Palpitation electrocardiogram: Difference between revisions
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==Electrocardiogram== | ==Electrocardiogram== | ||
*A 12 lead ECG along with a detailed history and thorough physical examination form the '''cornerstone trio''' in initially approaching a patient presenting with palpitations. | |||
*It should be noted that a patient is rarely symptomatic at the time of presentation as palpitations are frequently a transitory symptom. | |||
*However, this should not take away from an ECG’s importance as an initial diagnostic procedure. *'''Nicolas Clementy et al''' at found that prehospital ECGs and ECGs at admission had the '''highest positivity rate'''. <ref name="pmid29995805">{{cite journal| author=Clementy N, Fourquet A, Andre C, Bisson A, Pierre B, Fauchier L | display-authors=etal| title=Benefits of an early management of palpitations. | journal=Medicine (Baltimore) | year= 2018 | volume= 97 | issue= 28 | pages= e11466 | pmid=29995805 | doi=10.1097/MD.0000000000011466 | pmc=6076186 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29995805 }} </ref> | |||
*Based on the presence or absence of ECG findings, a decision should then be made whether the underlying condition is cardiac or not and what further investigative modalities may be required. | |||
*Several studies have suggested that an aggressive diagnostic approach should be employed in patients who are : | |||
*#At a high risk of developing arrhythmias (presence of ECG changes on initial evaluation, H/O myocardial and structural heart disease, positive family history) <ref name="pmid28613787">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume= | issue= | pages= | pmid=28613787 | doi= | pmc= | url= }} </ref> | |||
*#Those who remain anxious to have a specific explanation regarding their symptoms. <ref name="pmid15742913">{{cite journal| author=Abbott AV| title=Diagnostic approach to palpitations. | journal=Am Fam Physician | year= 2005 | volume= 71 | issue= 4 | pages= 743-50 | pmid=15742913 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15742913 }} </ref> | |||
*#Patients with a history of warning symptoms such as presyncope, syncope, dizziness, dyspnea. | |||
*#Patients with a history of increase of palpitations on exertion. | |||
*#Patients with impaired hemodynamic function. | |||
*#Patients with an impaired quality of life attributable to palpitations. <ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L | display-authors=etal| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315 }} </ref> | |||
==Findings to be wary of on initial 12 Lead ECG Evalutation <ref name="pmid26739319">{{cite journal| author=Gale CP, Camm AJ| title=Assessment of palpitations. | journal=BMJ | year= 2016 | volume= 352 | issue= | pages= h5649 | pmid=26739319 | doi=10.1136/bmj.h5649 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26739319 }} </ref><ref name="pmid21766757">{{cite journal| author=Wexler RK, Pleister A, Raman S| title=Outpatient approach to palpitations. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 1 | pages= 63-9 | pmid=21766757 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21766757 }} </ref>== | |||
*[ | |||
{| class="wikitable" | |||
|+ | |||
! | |||
!Epidemiology | |||
!Rate | |||
!Rhythm | |||
!P waves | |||
!PR Interval | |||
!QRS complex | |||
!Response to maneuvers | |||
!Example (Lead 2) | |||
|- | |||
|'''Sinus Tachycardia''' | |||
|More common in children and elderly. | |||
|Greater than 100 bpm | |||
|Regular | |||
|Upright, consistent, and normal in morphology | |||
|0.12–0.20 sec and shortens with high heart rate | |||
|Less than 0.12 seconds, consistent, and normal in morphology | |||
|May break with [[vagal maneuvers]] | |||
|[[Image:sinustachy_small.svg|200px|Sinustachycardia - a normal p wave precedes every QRS complex]] | |||
|- | |||
|'''Atrial Fibrillation''' | |||
|More common in the elderly, following [[bypass surgery]], in mitral valve disease, [[hyperthyroidism]] | |||
|110 to 180 bpm | |||
|Irregularly irregular | |||
|Absent, fibrillatory waves | |||
|Absent | |||
|Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction | |||
|Does not break with [[adenosine]] or [[vagal maneuvers]] | |||
|[[Image:afib_small.svg|200px|Atrial fibrillation - irregular rate, no p waves]] | |||
|- | |||
|'''Atrial Flutter''' | |||
|More common in the elderly, after alcohol | |||
|75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) bpm, but 150 is more common | |||
|Regular | |||
|Sawtooth pattern of [[P waves]] at 250 to 350 beats per minute | |||
|Varies depending upon the magnitude of the block, but is short | |||
|Less than 0.12 seconds, consistent, and normal in morphology | |||
|Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm | |||
|[[Image:aflutt_small.svg|200px|Atrial flutter - sawtooth in lead II with 2:1 block]] | |||
|- | |||
|'''AV Nodal Reentry Tachycardia (AVNRT)''' | |||
|Accounts for 60%-70% of all SVTs. 80% to 90% of cases are due to antegrade conduction down a slow pathway and retrograde up a fast pathway. | |||
|In adults the range is 140-250 bpm, but in children the rate can exceed 250 bpm | |||
|Regular | |||
|The [[P wave]] is usually superimposed on or buried within the [[QRS complex]] | |||
|Cannot be calculated as the P wave is generally obscured by the [[QRS complex]] | |||
|Less than 0.12 seconds, consistent, and normal in morphology | |||
|May break with [[adenosine]] or [[vagal maneuvers]] | |||
|[[Image:avnrt_small.svg|200px|ANVRT - rSR' in lead V1]] | |||
|- | |||
|'''AV Reciprocating Tachycardia (AVRT)''' | |||
|More common in males, whereas [[AV nodal reentrant tachycardia|AVNRT]] is more common in females, occurs at a younger age. | |||
|More rapid than [[AV nodal reentrant tachycardia|AVNRT]] | |||
|Regular | |||
|A [[retrograde P wave]] is seen either at the end of the [[QRS complex]] or at the beginning of the ST segment | |||
|Less than 0.12 seconds | |||
|Less than 0.12 seconds, consistent, and normal in morphology | |||
|May break with [[adenosine]] or [[vagal maneuvers]] | |||
|[[Image:avrt_small.svg|200px|AVRT - inverted p wave behind every QRS complex]] | |||
|- | |||
|'''Inappropriate Sinus Tachycardia''' | |||
|The disorder is uncommon. Most patients are in their late 20s to early 30s. More common in women. | |||
|> 95 beats per minute. A nocturnal reduction in heart rate is present. There is an inappropriate heart rate response on exertion. | |||
|Regular | |||
|Normal morphology and precede the [[QRS complex]] | |||
|Normal and < 0.20 seconds | |||
|Less than 0.12 seconds, consistent, and normal in morphology | |||
|Does not break with [[adenosine]] or [[vagal maneuvers]] | |||
| | |||
|- | |||
|'''Junctional Tachycardia''' | |||
|Common after [[heart surgery]], [[digitalis toxicity]], as an escape rhythm in [[AV block]] | |||
|> 60 beats per minute | |||
|Regular | |||
|Usually inverted, may be burried in the [[QRS complex]] | |||
|The [[P wave]] is usually buried in the [[QRS complex]] | |||
|Less than 0.12 seconds, consistent, and normal in morphology | |||
|Does not break with [[adenosine]] or [[vagal maneuvers]] | |||
|[[Image:avnodal_small.svg|200px|AV junctional tachycardia - no or inverted p-waves within QRS complex]] | |||
|- | |||
|'''Multifocal Atrial Tachycardia (MAT)''' | |||
|High incidence in the elderly and in those with [[COPD]] | |||
|Atrial rate is > 100 beats per minute (bpm) | |||
|Irregular | |||
|P waves of varying morphology from at least three different foci | |||
|Variable [[PR interval]]s, [[RR interval]]s, and [[PP interval]]s | |||
|Less than 0.12 seconds, consistent, and normal in morphology | |||
|Does not terminate with [[adenosine]] or [[vagal maneuvers]] | |||
|[[Image:MAT.jpg|200px|Multifocal Atrial Tachycardia, p waves of 3 different morphologies]] | |||
|- | |||
|'''Sinus Node Reentry Tachycardia''' | |||
|Between 2% and 17% among individuals undergoing [[EKG]] for SVTs | |||
|100 to 150 bpm | |||
|Regular | |||
|Upright [[P waves]] precede each regular, narrow [[QRS]] complex | |||
|[[Short PR interval]] | |||
|Less than 0.12 seconds, consistent, and normal in morphology | |||
|Does often terminate with [[vagal maneuvers]] unlike [[sinus tachycardia]]. | |||
| | |||
|- | |||
|'''Wolff-Parkinson-White syndrome''' | |||
|Estimated prevalence of [[Wolff-Parkinson-White syndrome|WPW]] syndrome is 100 - 300 per 100,000 in the entire world. | |||
|Atrial rate is nearly 300 bpm and ventricular rate is at 150 bpm. | |||
|Regular | |||
|[[P wave]] generally follows the [[QRS]] complex due to a bypass tract | |||
|Less than 0.12 seconds | |||
|[[Delta wave]] and evidence of ventricular [[pre-excitation]] if there is conduction to the ventricle via ante-grade conduction down an [[accessory pathway]] | |||
|May break in response to [[procainamide]], [[adenosine]], [[vagal maneuvers]] | |||
|[[Image:WPW syndrome 2.jpg|200px|Wolff Parkinson White Syndrome with the characteristic delta wave]] | |||
|} | |||
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center" | |||
|+ | |||
! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Disease}} | |||
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF| ECG Findings}} | |||
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF| Example}} | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" | '''Left Ventricular Hypertrophy''' | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Increased R wave amplitude in the left-sided ECG leads (I, aVL and V4-6) and increased S wave depth in the right-sided leads (III, aVR, V1-3). | |||
|[[Image:LVH-ECG.jpg|200px|Left Ventricular Hypertrophy]] | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" | '''Extrasystolic Palpitations/Ventricular Tachycardia''' | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Frequent Premature ventricular contractions. | |||
|[[Image:PVCs.jpg|200px|Premature ventricular Contractions]] | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" |'''Ischemic Heart Disease''' | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Q waves, T wave inversions, ST segment elevations or depressions. | |||
|[[Image:Q waves.jpg|200px|Q waves]] | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Hypertrophic Cardiomyopathy]]''' | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Tall R waves in aVL, deep S waves in V3 and T waves changes. | |||
|[[Image:HCM.jpg|200px|Hypertrophic Cardiomyopathy]] | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" | '''Arrhythmogenic right ventricular cardiomyopathy''' | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Inverted T waves or Epsilon waves across right precordial leads (V1-V3) | |||
|[[Image:ARVC.JPG|200px|ARVC]] | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" | '''Long QT syndrome''' | |||
| style="padding: 5px 5px; background: #F5F5F5;" | QT interval longer than 460 msec in women and 440 msec for men. | |||
|[[Image:LONG QT.JPG|200px|Prolonged QT Interval seen in Long QT Syndrome]] | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" | '''Genetic Arrhythmia syndromes''' | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Long or Short QT interval, Brugada pattern, early repolarisation pattern. | |||
|[[Image:Brugada Syndrome.JPG|200px|Genetic Arrhythmia, Brugada Syndrome]] | |||
|- | |||
|} | |||
==Ambulatory Electrocardiography== | |||
*Ambulatory ECG devices can be divided into internal and external monitoring devices. | |||
*External Devices include Holter monitors, hospital telemetry devices, event recorders, external loop recorders and mobile cardiac outpatient telemetry. | |||
*Internal devices include pacemakers, implantable cardioverter defibrillators equipped with diagnostic features and implantable loop recorders. | |||
*In addition, modifications to monitoring devices have permitted automatic detection of arrythmia. | |||
*Data is wirelessly transmitted to a central monitoring station which then triggers off an alarm in case of an event. | |||
*This allows for prompt responses from the physician, facilitates early detection of episodes and provides information regarding the mechanism of the arrythmia. | |||
*It is important to note that while the specificity of ambulatory ECG monitoring is high in terms of differentiating between arrhythmogenic and non-arrhythmogenic causes of palpitations, it’s sensitivity depends on the duration of monitoring, patient compliance and the frequency of episodes. <ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L | display-authors=etal| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315 }} </ref> | |||
===ACC/AHA Guidelines for Ambulatory Electrocardiography<ref name="pmid10458728">{{cite journal| author=Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A | display-authors=etal| title=ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the guidelines for ambulatory electrocardiography). | journal=Circulation | year= 1999 | volume= 100 | issue= 8 | pages= 886-93 | pmid=10458728 | doi=10.1161/01.cir.100.8.886 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10458728 }} </ref>=== | |||
[[Image:AHA AEKG Indications.JPG|thumb|centre|500px|Indications for Ambulatory Electrocardiography]] | |||
===Different Ambulatory Electrocardiography Devices<ref name="pmid28613787">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume= | issue= | pages= | pmid=28613787 | doi= | pmc= | url= }} </ref><ref name="pmid31256490">{{cite journal| author=McLellan AJ, Kalman JM| title=Approach to palpitations. | journal=Aust J Gen Pract | year= 2019 | volume= 48 | issue= 4 | pages= 204-209 | pmid=31256490 | doi=10.31128/AJGP-12-17-4436 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31256490 }} </ref><ref name="pmid21766757">{{cite journal| author=Wexler RK, Pleister A, Raman S| title=Outpatient approach to palpitations. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 1 | pages= 63-9 | pmid=21766757 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21766757 }} </ref><ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L | display-authors=etal| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315 }} </ref>=== | |||
{| class="wikitable" | |||
|+ | |||
!Machine | |||
!Description | |||
!Indications | |||
!Advantages | |||
!Disadvantages | |||
!Picture | |||
|- | |||
|12 Lead ECG | |||
| | |||
|•Initial Step in the evaluation of patients of palpitations | |||
|•Inexpensive | |||
|•Rarely performed during the event | |||
| | |||
|- | |||
|Handheld ECG | |||
| | |||
|•Palpitations occurring for months to years | |||
|•High diagnostic yield | |||
•Always present with the patient | |||
|•Expensive | |||
•Time period from patient activation to event recording is long | |||
| | |||
|- | |||
|Exercise ECG Stress testing | |||
| | |||
|•Palpitations aggravated by exertion | |||
| | |||
| | |||
| | |||
|- | |||
|Holter Monitoring | |||
|•Continuous beat to beat monitoring system via 12 leads (attached via skin electrodes). | |||
•24-48 hour monitoring system. | |||
|•Symptoms occurring daily or every second day. | |||
|•Readily available. | |||
•Need not be activated during the event. | |||
•Low cost. | |||
•Provides information of asymptomatic episodes. | |||
|•Low diagnostic yield | |||
•Size may prevent trigger events | |||
•Clinical Diary completion (upon which symptom correlation depends upon) is a tedious process | |||
|[[Image:IMG 3369.jpg|thumb|250px|center|A person carries a holter monitor in his pocket.]] | |||
|- | |||
|Continuous- loop event recorder | |||
|•Worn for a few days (typically 30 days) | |||
•Older monitors are patient activated and store data once, whereas newer models continuously record data | |||
•Provides a one to three lead EKG tracing | |||
|•Symptoms occurring weekly or monthly | |||
•Short lasting palpitations associated with hemodynamic compromise | |||
|•Can be worn for longer periods of time when compared to Holter monitors | |||
•More cost effective | |||
•High diagnostic efficacy/yield as it is a patient activated process | |||
|•Not diagnostic for asymptomatic arrythmias as it is a patient activated system (older models | |||
•Devices are uncomfortable and require high maintenance | |||
•Requires patient to be compliant | |||
|[[Image:External Loop Recorder.JPG|thumb|centre|250px]] | |||
|- | |||
|Mobile cardiac outpatient telemetry | |||
|•External Loop Recorder + Portable Receiver | |||
•Data is wirelessly transmitted to a central monitoring station which then triggers off an alarm in case of an event | |||
| | |||
|•This allows for prompt responses from the physician, facilitates early detection of episodes and provides information regarding the mechanism of the arrythmia | |||
•Provides information of asymptomatic episodes. | |||
| | |||
| | |||
|- | |||
|Implantable Loop Recorder | |||
|•Placed subcutaneously through a small 2cm incision in the left precordial region | |||
•Provides a one lead electrocardiographic tracing | |||
|•Palpitations occurring for months to years | |||
•Rare episodes of palpitations associated with syncope/ hemodynamic compromise | |||
•When all other methods of Ambulatory ECG monitoring prove to be inconclusive | |||
|•High diagnostic yield | |||
• Long term monitoring (3 years) | |||
•Automatically records arrythmias in addition to patient triggered episodes | |||
•Subcutaneous approach avoids long term problems associated with surface electrodes | |||
•Does not require patient to be compliant. | |||
|•Invasive procedure may cause local complications | |||
•Expensive | |||
•Not readily available | |||
| | |||
|- | |||
|Pacemakers/Implantable Cardioverter Defibrillators | |||
|•Dual chamber Devices which are able to detect and store atrial and ventricular Intracardiac Electrograms. | |||
|•Conventional indications for pacemakers/ICDs | |||
|•Automatic Arrythmia recording | |||
•Able to discriminate between ventricular and supraventricular arrythmias | |||
|•Invasive | |||
•Increased risk of early/long term local/systemic complications | |||
|[[Image:PacemakerAEKG.jpg|thumb|centre|200px| Pacemaker insitu.]] | |||
|} | |||
*'''Allan Abbott et al''' found that transtelephonic event monitors had a greater diagnostic yield and were more cost effective when compared to Holter monitors. <ref name="pmid15742913">{{cite journal| author=Abbott AV| title=Diagnostic approach to palpitations. | journal=Am Fam Physician | year= 2005 | volume= 71 | issue= 4 | pages= 743-50 | pmid=15742913 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15742913 }} </ref> | |||
==References== | ==References== |
Revision as of 13:47, 5 August 2020
Palpitation Microchapters |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]
Overview
There are no ECG findings associated with [disease name].
OR
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
Electrocardiogram
- A 12 lead ECG along with a detailed history and thorough physical examination form the cornerstone trio in initially approaching a patient presenting with palpitations.
- It should be noted that a patient is rarely symptomatic at the time of presentation as palpitations are frequently a transitory symptom.
- However, this should not take away from an ECG’s importance as an initial diagnostic procedure. *Nicolas Clementy et al at found that prehospital ECGs and ECGs at admission had the highest positivity rate. [1]
- Based on the presence or absence of ECG findings, a decision should then be made whether the underlying condition is cardiac or not and what further investigative modalities may be required.
- Several studies have suggested that an aggressive diagnostic approach should be employed in patients who are :
- At a high risk of developing arrhythmias (presence of ECG changes on initial evaluation, H/O myocardial and structural heart disease, positive family history) [2]
- Those who remain anxious to have a specific explanation regarding their symptoms. [3]
- Patients with a history of warning symptoms such as presyncope, syncope, dizziness, dyspnea.
- Patients with a history of increase of palpitations on exertion.
- Patients with impaired hemodynamic function.
- Patients with an impaired quality of life attributable to palpitations. [4]
Findings to be wary of on initial 12 Lead ECG Evalutation [5][6]
Epidemiology | Rate | Rhythm | P waves | PR Interval | QRS complex | Response to maneuvers | Example (Lead 2) | |
---|---|---|---|---|---|---|---|---|
Sinus Tachycardia | More common in children and elderly. | Greater than 100 bpm | Regular | Upright, consistent, and normal in morphology | 0.12–0.20 sec and shortens with high heart rate | Less than 0.12 seconds, consistent, and normal in morphology | May break with vagal maneuvers | |
Atrial Fibrillation | More common in the elderly, following bypass surgery, in mitral valve disease, hyperthyroidism | 110 to 180 bpm | Irregularly irregular | Absent, fibrillatory waves | Absent | Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction | Does not break with adenosine or vagal maneuvers | |
Atrial Flutter | More common in the elderly, after alcohol | 75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) bpm, but 150 is more common | Regular | Sawtooth pattern of P waves at 250 to 350 beats per minute | Varies depending upon the magnitude of the block, but is short | Less than 0.12 seconds, consistent, and normal in morphology | Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm | |
AV Nodal Reentry Tachycardia (AVNRT) | Accounts for 60%-70% of all SVTs. 80% to 90% of cases are due to antegrade conduction down a slow pathway and retrograde up a fast pathway. | In adults the range is 140-250 bpm, but in children the rate can exceed 250 bpm | Regular | The P wave is usually superimposed on or buried within the QRS complex | Cannot be calculated as the P wave is generally obscured by the QRS complex | Less than 0.12 seconds, consistent, and normal in morphology | May break with adenosine or vagal maneuvers | |
AV Reciprocating Tachycardia (AVRT) | More common in males, whereas AVNRT is more common in females, occurs at a younger age. | More rapid than AVNRT | Regular | A retrograde P wave is seen either at the end of the QRS complex or at the beginning of the ST segment | Less than 0.12 seconds | Less than 0.12 seconds, consistent, and normal in morphology | May break with adenosine or vagal maneuvers | |
Inappropriate Sinus Tachycardia | The disorder is uncommon. Most patients are in their late 20s to early 30s. More common in women. | > 95 beats per minute. A nocturnal reduction in heart rate is present. There is an inappropriate heart rate response on exertion. | Regular | Normal morphology and precede the QRS complex | Normal and < 0.20 seconds | Less than 0.12 seconds, consistent, and normal in morphology | Does not break with adenosine or vagal maneuvers | |
Junctional Tachycardia | Common after heart surgery, digitalis toxicity, as an escape rhythm in AV block | > 60 beats per minute | Regular | Usually inverted, may be burried in the QRS complex | The P wave is usually buried in the QRS complex | Less than 0.12 seconds, consistent, and normal in morphology | Does not break with adenosine or vagal maneuvers | |
Multifocal Atrial Tachycardia (MAT) | High incidence in the elderly and in those with COPD | Atrial rate is > 100 beats per minute (bpm) | Irregular | P waves of varying morphology from at least three different foci | Variable PR intervals, RR intervals, and PP intervals | Less than 0.12 seconds, consistent, and normal in morphology | Does not terminate with adenosine or vagal maneuvers | ![]() |
Sinus Node Reentry Tachycardia | Between 2% and 17% among individuals undergoing EKG for SVTs | 100 to 150 bpm | Regular | Upright P waves precede each regular, narrow QRS complex | Short PR interval | Less than 0.12 seconds, consistent, and normal in morphology | Does often terminate with vagal maneuvers unlike sinus tachycardia. | |
Wolff-Parkinson-White syndrome | Estimated prevalence of WPW syndrome is 100 - 300 per 100,000 in the entire world. | Atrial rate is nearly 300 bpm and ventricular rate is at 150 bpm. | Regular | P wave generally follows the QRS complex due to a bypass tract | Less than 0.12 seconds | Delta wave and evidence of ventricular pre-excitation if there is conduction to the ventricle via ante-grade conduction down an accessory pathway | May break in response to procainamide, adenosine, vagal maneuvers | ![]() |
Disease | ECG Findings | Example |
---|---|---|
Left Ventricular Hypertrophy | Increased R wave amplitude in the left-sided ECG leads (I, aVL and V4-6) and increased S wave depth in the right-sided leads (III, aVR, V1-3). | ![]() |
Extrasystolic Palpitations/Ventricular Tachycardia | Frequent Premature ventricular contractions. | ![]() |
Ischemic Heart Disease | Q waves, T wave inversions, ST segment elevations or depressions. | Q waves |
Hypertrophic Cardiomyopathy | Tall R waves in aVL, deep S waves in V3 and T waves changes. | ![]() |
Arrhythmogenic right ventricular cardiomyopathy | Inverted T waves or Epsilon waves across right precordial leads (V1-V3) | |
Long QT syndrome | QT interval longer than 460 msec in women and 440 msec for men. | |
Genetic Arrhythmia syndromes | Long or Short QT interval, Brugada pattern, early repolarisation pattern. |
Ambulatory Electrocardiography
- Ambulatory ECG devices can be divided into internal and external monitoring devices.
- External Devices include Holter monitors, hospital telemetry devices, event recorders, external loop recorders and mobile cardiac outpatient telemetry.
- Internal devices include pacemakers, implantable cardioverter defibrillators equipped with diagnostic features and implantable loop recorders.
- In addition, modifications to monitoring devices have permitted automatic detection of arrythmia.
- Data is wirelessly transmitted to a central monitoring station which then triggers off an alarm in case of an event.
- This allows for prompt responses from the physician, facilitates early detection of episodes and provides information regarding the mechanism of the arrythmia.
- It is important to note that while the specificity of ambulatory ECG monitoring is high in terms of differentiating between arrhythmogenic and non-arrhythmogenic causes of palpitations, it’s sensitivity depends on the duration of monitoring, patient compliance and the frequency of episodes. [4]
ACC/AHA Guidelines for Ambulatory Electrocardiography[7]
Different Ambulatory Electrocardiography Devices[2][8][6][4]
- Allan Abbott et al found that transtelephonic event monitors had a greater diagnostic yield and were more cost effective when compared to Holter monitors. [3]
References
- ↑ Clementy N, Fourquet A, Andre C, Bisson A, Pierre B, Fauchier L; et al. (2018). "Benefits of an early management of palpitations". Medicine (Baltimore). 97 (28): e11466. doi:10.1097/MD.0000000000011466. PMC 6076186. PMID 29995805.
- ↑ 2.0 2.1 "StatPearls". 2020. PMID 28613787.
- ↑ 3.0 3.1 Abbott AV (2005). "Diagnostic approach to palpitations". Am Fam Physician. 71 (4): 743–50. PMID 15742913.
- ↑ 4.0 4.1 4.2 Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L; et al. (2011). "Management of patients with palpitations: a position paper from the European Heart Rhythm Association". Europace. 13 (7): 920–34. doi:10.1093/europace/eur130. PMID 21697315.
- ↑ Gale CP, Camm AJ (2016). "Assessment of palpitations". BMJ. 352: h5649. doi:10.1136/bmj.h5649. PMID 26739319.
- ↑ 6.0 6.1 Wexler RK, Pleister A, Raman S (2011). "Outpatient approach to palpitations". Am Fam Physician. 84 (1): 63–9. PMID 21766757.
- ↑ Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A; et al. (1999). "ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the guidelines for ambulatory electrocardiography)". Circulation. 100 (8): 886–93. doi:10.1161/01.cir.100.8.886. PMID 10458728.
- ↑ McLellan AJ, Kalman JM (2019). "Approach to palpitations". Aust J Gen Pract. 48 (4): 204–209. doi:10.31128/AJGP-12-17-4436. PMID 31256490.