Return to Titanic: Irregular Heart Beats...• fusion beats - not so premature PVCs ... patients...
Transcript of Return to Titanic: Irregular Heart Beats...• fusion beats - not so premature PVCs ... patients...
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Return to Titanic: Irregular Heart Beats
Ric Samson, MDChildren’s Heart Center - Nevada
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The Titanic
RMS Titanic• largest ship ever built up
to that time• maiden voyage April 1912
travelling from Southampton to New York• 2,224 passengers/crew
• struck ice berg and sank• >1,500 died
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irreg HR
suddendeath
Irregular Heart Beats vs. Sudden DeathThe Dilemma
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Irregular HR vs. Sudden Death
irregular HR
sudden death
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Definitions
• ectopy: a departure of the heart rhythm from normal sinus rhythm
• sudden death: an unexpected death from natural causes which can occur instantaneously or within 24 hours of the patient�s initial symptoms
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Incidence of Sudden Death• Adults– competitive athletes: 4 per million per year– recreational athletes under 30: 10-25 per million per
year–US Air Force recruits - 1 per 3 million hours of
exercise (1 per 735,00 per year)• Children–Mayo clinic: ages 1-22 in Olmstead County, MN: 1.3
per 100,000 per year– Gajewski, Annals Ped Cardiol 2010» 0.6-6.2 per 100,000
• 30% of all non-traumatic deaths in people < 35• < 20% exhibit cardiac symptoms prior to death
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Patient Presentation #1• 3 year old toddler seen in clinic for well
child check is noted on exam to have an irregular heart rate
• Asymptomatic, completely healthy• No significant PMH, FH• HR 100 irregular, RR 20 O2 sat 98%• Physical exam otherwise unremarkable
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• Physiologic variation in HR related respiration–Speeds up during inspiration, slows down during expiration
• Normal finding in a healthy child or youngadult• P waves and QRS complexes all identical
Sinus Arrhythmia
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Wandering atrial pacemaker
• Physiologic variation in HR related respiration–Secondary pacemakers within the atria
• Also a normal finding in a healthy infant or child• P waves vary slightly; QRS complex identical
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Patient Presentation #2
• 12 hour old newborn is noted to have an irregular heart rate• uncomplicated pregnancy, labor and
delivery• HR 120 irregular, sats 98%• Physical exam otherwise normal
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ECG rhythm strip
Premature Atrial Contractions
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Premature Atrial Contractions
• early identifiable P wave• P wave has different morphology
from sinus P wave• conducted –normally (normal QRS)–aberrantly (wide QRS)–non-conducted (no QRS)
• frequently �resets� the sinus node
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Premature Atrial Contractions
• �resetting� of the sinus node–following PAC-P interval similar to
sinus P-P interval
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Premature Atrial Contraction
sinus nodeectopic focus
RA
RVLV
LA
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Premature Atrial ContractionsCauses
• Acute–mechanical - CVP line–metabolic - hypoxia, hypo/hyperkalemia,
hypercalcemia– drugs – sympathomimetics, digitalis
• Chronic– s/p atrial surgery– atrial enlargement (ASD, AV valve regurgitation)– atrial tumors (myxomas)– normal heart
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Premature Atrial Contractionsnormal heart
• Nagashima et al, Pediatr Cardiol 8:103, 1987
• 360 children studied by 24� Holter– ages: 1 day, 1-11 mos, 4-6 yrs, 9-12 yrs, 13-15 yrs
• PACs seen in 51-77%
• incidence of 5 PACs or more per 24� was highest in 1 day olds (26%) and 13-15 year olds (23%)
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Premature Atrial ContractionsTreatment/Prognosis
• Identify underlying causes• Typically no specific anti-arrhythmic
treatment required• If associated with symptoms– ß-blockers, other anti-arrhythmics
• Excellent Prognosis–Salice et al, Circ 68(III):395, 1983» 6900 normal newborns prospectively
studied by Holter» 1 had PAC persisting beyond 1 year» no development of symptoms,
arrhythmias
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Patient Presentation #3
• 4 year old admitted for asthma exacerbation, receiving albuterol nebs
• noted to have irregular rhythm on monitor
• HR 120, O2 sat 99%• Bilateral wheezes, o/w exam
unremarkable
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Patient Presentation #4
• 12 yo male presents for routine pre-sports participation physical exam
• Healthy and asymptomatic• Negative PMH, FH• On auscultation is noted to have
irregular HR• PE otherwise normal
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ECG – irregular HR
Premature Ventricular Contractions
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Premature Ventricular Contraction • Aberrant QRS, different from QRS in
sinus rhythm• No identifiable P wave• Compensatory pause• Fusion beats• Other terms– bigeminy, trigeminy– couplets, triplets– non-sustained ventricular tachycardia
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Premature Ventricular Contraction
• compensatory pause– helpful but not diagnostic– interval between previous and following sinus
beats = 2 x sinus interval
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Premature Ventricular Contraction
sinus node
ectopic focus
RA
RVLV
LA
AV node
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Premature Ventricular Contractions
sinus node
ectopic focus
RA
RVLV
LA
AV node/His/PurkinjeSystem
• fusion beats - not so premature PVCs– part of ventricle depolarized from PVC, the rest by
normal His-Purkinje System
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Premature Ventricular ContractionCauses
• Acute–mechanical - CVP line–metabolic»hypoxia»electrolyte abnormalities
–drugs»sympathomimetics»digoxin, anti-arrhythmics
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Premature Ventricular Contraction
Causes
• Chronic
–normal heart
»Southall et al, Br Heart J 43:14, 1980
Southall et al, Br Heart J 45:281, 1981
• 18% of normal newborns by Holter
• 26% in older children, esp. teenagers
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Premature Ventricular ContractionTreatment
• Identify any underlying cause• Determine whether PVCs are
suppressed by exercise• If exam is normal and patient is
asymptomatic, no treatment necessary
• If symptomatic, ß-blocker or anti-arrhythmic
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Premature Ventricular ContractionPrognosis: normal heart
• Southall et al, Pediatrics 68:58, 1981 Nagashima et al, Pediatr Cardiol 8:103, 1987–PVCs resolved by 8-12 weeks of age in all infants
• Jacobsen et al, J Pediatr 92:36, 1978– 17 asymptomatic children with nl hearts and frequent
PVC followed up to 13.8 yrs» 4 with bigeminy, 3 with trigeminy
–PVCs resolved in 9/17– all remained asymptomatic
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Premature Ventricular Contractions
• Less Benign –s/p heart surgery–myocarditis–tumors (tuberous sclerosis)–multiform PVCs–couplets, triplets or non-sustained
ventricular tachycardia
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Premature Ventricular Contraction
• Potentially Life Threatening
–PVCs in the setting of
»Long QT syndrome
»Hypertrophic Cardiomyopathy•Maron et al, Am J Cardiol 48:532, 1981
–presence of ventricular ectopy in patients with HCM was a strong predictor of sudden death
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Long QT syndrome• Torsade de Pointes ventricular tachycardia• corrected QT interval > 0.45
QTc = QT interval (sec)
preceding R-R interval (sec)
• Phoon, Pediatrics 100 (3): 439, 1997• if QT interval is < 1/2 of R-R interval, QTc < 0.45
• not valid if HR < 70 bpm
LQT1
LQT2
LQT3
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Corrected QT interval: short cut
QTc OK, (< 0.45)
Must calculate QTc
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Can’t Always Trust the Computer• Miller et al, Pediatrics 108:8;2001
Family of LQTS patients and automated ECG interpretation
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Examples – erroneous interpretationsWhat about the prolonged QT interval?!
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Long QT Syndrome
• Brought on by stress, anxiety, catecholamines
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Torsade de Pointes
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Long QT Syndrome
• Congenital
– Jervell-Lange-Nielsen - autosomal recessive
» associated with sensorineural hearing loss
–Romano-Ward - autosomal dominant
» associated with normal hearing
–Now characterized genetically as defects in cardiac
ion channels (channelopathies)
» LQTS 1-15
• Acquired
–medications
» tricyclic anti-depressants,ketoconazole
» erythromycin, TMP-SMX, famotidine
– https://crediblemeds.org
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Hypertrophic Cardiomyopathy
• abnormal hypertrophy of ventricular septum and LV free wall without extrinsic cause
• 60% inherited as autosomal dominant• most common cause of sudden death among
healthy young patients• multiple genetic defects identified – involving
sarcomeric proteins of heart• physical exam – SEM louder when upright
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Hypertrophic cardiomyopathy• Murmur of HCM: louder when upright–Supine: increased venous return → increased
end diastolic volume– Increased EDV → less stenosis, softer murmur
RV
septum
LV
LAAORA
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Hypertrophic CardiomyopathyECG
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Risks factors for HCM
• Genetics – family history of sudden death• Severe septal hypertrophy• Severe LV outflow obstruction• Blunted BP response on exercise
stress test• Ventricular ectopy on holter
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Approach to the Child with Irregular Heart Rate
• History– symptoms» palpitations, syncope, CHF» h/o cardiac surgery
–medications» bronchodilators
– family history» arrhythmias» syncope, sudden death
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Approach to the Child with
Irregular Heart Rate
• Physical Exam
– Cardiac Auscultation
» r/o underlying heart defect
» ectopy suppressed with exercise
• assess by performing 25 jumping jacks
• ECG
– diagnose arrhythmia
– r/o Long QT Syndrome, HCM
• 24� Holter
– longer period of recording
– quantitate ectopy
– document response of ectopy to increased
HR
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Who to Refer
• suspicious symptoms– palpitations, exercise intolerance, syncope
• abnormal cardiac exam• multiform PVCs• ventricular couplets or worse• ectopy not suppressed by exercise• positive family history
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