The Irregular Heart Beat

“Doctor, my heart is”:

Racing

Pounding

Skipping

Flipping

Irregular

1) How long have you had the symptoms

2) What makes them better

3) What makes them worse

4) Worse at night

5) Worse with exercise

6) Lightheadedness or syncope

7) Family history of sudden death

Differential Diagnosis

1)Sinus rhythm

2)Sinus tachycardia

3)Premature atrial complexes (PAC’s)

4)Premature ventricular complexes (PVC’s)

5)Supraventricular tachycardia (SVT)

6)Atrial fibrillation

7)Ventricular tachycardia

Sinus rhythm

Sinus Tachycardia

Premature Atrial Contractions (PAC’s)

Premature Ventricular Contractions (PVC’s)

Supraventricular Tachycardia (SVT)

Atrial Fibrillation

Ventricular Tachycardia

When to Refer Out

Diagnostic Tools

Normal Echocardiogram

Diagnostic Tools

Diagnostic Tools

Diagnostic Tools

Treatment

Pharmaceuticals

Beta-blockers

Metoprolol

Atenolol

Carvedilol

Nadolol

Calcium channel blockers

Verapamil

Diltiazem

Digoxin

Anti-arrhythmics

Amiodarone

Sotalol

Propafenone

Flecainide

Dofetilide

50% success at 2 years for atrial fibrillation

Supplements

Magnesium (1,2)

Potassium (2)

Taurine (3)

Arginine (3)

Omega-3 (4)

Co Q 10 (5)

1) Arq Bras Cardiol. 2012 Jun;98(6):480-7. 2) J Am Coll Cardiol. 1997 Apr;29(5):1028-34. 3) Med Hypotheses. 2006;67(5):1200-4. 4) Heart Rhythm. 2012 Apr;9(4):483-91 5) Interact Cardiovasc Thorac Surg. 2015 Feb;20(2):254-9

Probiotics

Multivitamin

Digestive Enzymes

Greens

Omega-3

Stroke Risk

Case Study

27 year old female complains her heart stops

Worse at night and with caffeine or sugar

No hx of syncope or family history of sudden death

Exam is unremarkable

ECG is normal

What is the next move?