Chapters Transcript Video Work Up of Palpitations Back to Symposium Hi, good morning. I'll be talking about palpitations. A lot of the things I'm going to talk about will be overlapping with what Doctor Patel has mentioned earlier. I have no disclosure. So palpitations is actually one of the most common symptoms that we encounter in primary care setting or us in cardiology or electrophysiology, and it's very subjective. And it can be described by the patient by like so many ways to describe it and actually it's very helpful. I asked the patient, is it like just a rapid beating? Is it forceful? Is it irregular? A skipped beat or a, you know, uh, a drop beat could tell us about a PAC or PVC. Is it fluttering? And, um, you know, there are different causes for palpitations. One is the classic cardiac cause because of arrhythmia, and the others are physiologic, you know, reasons, stressors, conditions that can make patients have a faster heart rate or the sensation of having a fast heart rate. And that's the same as with other chief complaints, we have a more structured and, you know, just to go through the um the complaint of the patient to have a more uh detailed way to approach palpitations. So like other chief complaints, we go with the history. So age of onset, it's actually quite helpful, especially for patients with um SVTs, you know, the WPWs, um, AVNRTs, they will tell us. Oh, I've had it since I was a child, and I've learned to hold my breath. So they've, that in itself can tell you, oh, this SVT is dependent on the vagal stimulation, right? The AV node, um, part of the circuit, um, versus someone who's 70 years old. Now we're thinking about, um, atrial fibrillation, um, the abruptness, the triggers. For example, someone had a drinking spree, now you're in an older patient, you're gonna be thinking about atrial fibrillation. Associated symptoms are also very helpful cause that would help you think of what type of workup you're going to do, right? So if someone tells you, I had a traumatic syncope, so later on, and that's what Doctor Patel has talked about earlier, there are types of monitors that are live. That someone is actually watching telemetry wise what your rhythm is. So if someone had a traumatic syncope or someone had a big stroke, you really want to pick up a very um advanced uh like a high grade AV block or an Afib so you can start anticoagulation early. Um, personal or family history, um, also helps. There are certain arrhythmias that goes in, you know, family, um, uh, that goes in family like, um, ARVC and you're thinking about VT or sometimes AFib can happen in younger patients. It could be familial, um, past medical history, as what I mentioned earlier, there are different types of physiologic stressors, conditions, medications that make, can make someone have palpitations. So for a physical exams very focused, obviously the clincher is the heart rate, right? If it's fast, then you would also see the blood pressure if it's hemodynamically affecting the patient, cardiovascular exam, um, breathing, and any sign of um endocrine abnormalities. So EKG when someone tells you about palpitations, obviously it's very helpful to have an EKG on the time of your visit, especially if the patient says I'm having. One right now and here is an example of an EKG sinus rhythm with PVCs. Now, our role when we see the patient and we see it in an EKG with PVCs, it doesn't end there. It would still very much help us in cardiology or EP world to have a halter. Why is that? Because we want to know the burden of the PVC, right? Because if the PVC only happened during that visit, but the actual burden is only less. Less than 1%, then we can't really talk about, you know, rhythm control strategies because, you know, I tell my patients PVC when we do ablation, it's like catching a firefly. If it doesn't light up, I can't catch it. So I have to have a specific burden before I talk about anti-arrhythmics, about ablation. Also, there are studies wherein if you have more than 25% burden of your PVC, then you are at risk for a PVC induced cardiomyopathy. So by the time we see the patient, we see the burden. Oh, then it's, we gotta get the echo, we going to prepare about all the rhythm, you know, strategies. Um, AFib, right? So even if you see, oh, patient's Afib, you start anticoagulation or rate control medications, it would still help us if the patient has a Holter monitor or any type of cardiac monitoring because one, it can tell us if it's paroxysmal or persistent. Why would it change? It doesn't change with the blood thinner. Well, when we talk to them about ablation, we can tell them the realistic goals of. What an ablation can do, right? If it's a paroxysmal afib, the success rate of keeping you in a normal rhythm could be as high as 85 to 90%. If it's persistent, it dramatically decreases to 50%. So that really helps us tell them like from the get-go, the goals and telling them the options for rhythm control like if someone is persistently or long standing persistent, meaning more than a year of being in AFib. Then I can tell them, you know what, it, and with the size of the left atrium, I can tell them that, you know, the ablation is probably not gonna work. So that will help us. Also, if we plan to do a rate control strategy, which is very rare, but sometimes we offer that for really older patients or not ablation candidates, we have to know the average heart rate when someone is in AFib, right? Do we have to add in more beta blockers? Do we have to hold back? Do, does the patient have long pauses, like more than 5.5 seconds when they're in AFib? Do we have to put in a pacer? So again, seeing an AFib on an EKG, it doesn't end there. It would also help us, you know, more with the monitoring. Um, this EKG shows a delta wave, you know, a sign of a pre-excitation. So if someone comes to us and who's younger, 20s, 30s, teenager, and tells you about a palpitation, then yeah, with this pre-excitation, you can think about AVRT and um talk about ablation and other um rhythm control strategies. So in terms of laboratory testing, blood tests, there's really no evidence-based guidelines on what blood tests we're going to order, unless, of course, you're, you're highly thinking about anemia or thyroid problems. Other than that, we don't routinely do blood tests for um palpitations. So palpitation is approximately 30 to 43% as an indication for your um outpatient monitoring. And again, uh, and I'm going to pound on what Doctor Patala mentioned earlier, um, it's very important to know how often the symptoms are, right? If the patient tells you, I have palpitations once a week, it doesn't make sense to order a 48 hour monitor. So I would say 2-week monitor. If it's once a month, then go 28 days. So, it's all about making your bin bigger to catch that certain episode. Um, again, the need for the real-time monitoring, right? If someone had a syncope, you want to avoid the traumatic syncope, then you would want to have a live monitor, um, and how involved the patient is. If someone has some dementia, you wouldn't want to order a triggered like an event, uh, recorder. Um, so what are the outcomes if you have a monitor? So, if you have someone with a typical palpitation symptoms and this coincides or you find a cardiac arrhythmia, so it's most useful, right? We talk about strategies to avoid them, you know, ablation or medication. If you have typical symptoms, palpitations, you see the monitor with 50 triggered events, but all of them correlate with sinus rhythm, it's also quite helpful. Actually, and later I'll show you, I sit down with the patient, I show them their monitor. I show them that every time they triggered it, it's a normal rhythm, and that actually helps a lot with them. It's just a matter of reassurance that telling them that, oh, you know what, you're just feeling the forceful contraction, but the good news is it is a normal rhythm, so that helps them too. No symptoms, but you have a cardiac arrhythmia. Really, it depends. If it's sustained, then you still have to, um, especially for an AFib that's fast, even if the patient does not have symptoms, you want to trigger it because the last thing you want is a tachycardia-induced cardiomyopathy. And the last finding, which is not helpful if the patient has no symptoms and there's no arrhythmia found. So, your, uh, the way you keep on looking for the reason does not end there. So, I, the first thing I ask my patients when they wear a monitor is that, did you have symptoms while you were wearing it? Because if they say, Oh, I never had the same symptom like before, then it doesn't really tell you anything, right? It doesn't give you the go signal to say, oh, OK, you're cleared, it's negative. So you have to keep, um, ordering. Maybe it will come to a point that you might need a loop recorder, something that is far longer than any, you know, um, non-invasive type of monitoring. I'm gonna go over this quickly because Doctor Patel has gone over them. Again, Holter monitor is about 1 to 3 days. It's non-live. It's the bulky, um, monitoring. Um, it, you can't avoid getting wet, continues, um, recording. The external event, uh, recorder, um, you have to activate the recording when you have the symptom and it does not record, um, continuously. Usually, it's for patients when they're very rare symptoms and you just want to trigger and then you look at that, um, rhythm during that time. The patch recorders, um, you know, this is one of the most, you know, common that we use familiar with the Zaya patch or Vital Connect, and there's, um, others more, but basically it's like halter, um, the difference is it's longer, it can last until 24 weeks. And um it's non-live and it will capture both the symptomatic and non-symptomatic episodes. Um, and this is the uh MCOT is the live telemetry where the higher risk patients would um be here for, and it will catch both symptomatic and asymptomatic um events. Um, these are the different types of MCOT and again the implantable loop recorder, the invasive way, but it, it goes as long as 4 years. So, um, I'll just go over some studies that or even poster presentation that actually shows that, um, 42, and this is a retrospective cohort, about 18,000 patients, about 42% had their first symptomatic arrhythmia beyond 48 hours. So that just tells you for us, usually 4 to 8 hour Holter does not really give a good diag I mean diagnostic yield. So again, 14 day monitoring, we will, um, is what we would recommend. There was a study in 2020 wherein they compared a 24 hour halter to the 14 day monitoring and in here you can see in that graph that you know one week monitoring it's almost half already of getting an arrhythmia detected versus in only 24 hours it's only 13%. Um, and below you would also see the marked difference between the two being 66% for any type of arrhythmia picked up by a two week monitor versus only a 9% for a 24 hour, um, and that is also reflected for a specific arrhythmia for AFib. This was published last year in about 1.1 million devices and like the previous studies, and now it is a bigger one, right? 1.1 million. It just shows that most arrhythmias occur after um 48 hours and the median time to detection is about 3 to 4 days. Um, here, um, when they tried to study the, the, you know, the symptom of the patient that's actually correlating with an arrhythmia, you can see here that the, um, atrial fibrillation, the, the one in the first, um, PAC and PVCs, those are the most common types of arrhythmia that we're correlating with patients having symptoms during the time of monitoring. Doctor Patel saw this the moment I entered and she was showing this too, so I'm just going to go over it quickly. Part one is, uh, the first part is like, uh, the patient's identifier, like how long the patient wore it, what is the indication. The two in the middle are just samples of all the arrhythmias that were picked up, not necessarily clinically significant, but any type of arrhythmia. Number 3 here, the patient triggered events. I always wanna look at it. I always wanna show it to the patient that makes them feel like they are that you are listening to their symptoms that you're actually looking at each one and not just looking at the preliminary findings, which is just, um, you know, findings generated by algorithm and, um, cardiac technicians. So, um, and we are all working in it in our cardiology field to have a good final interpretation basically. A lot of us are trying to have, you know, at least 3 to 4 final, uh, recommendation or final conclusion saying that the predominant rhythm is blank with an average heart rate of blank, um, sustained arrhythmias clinically significant. Usually for SVT we would have a cutoff about 6 minutes, 30 seconds for VT PVC burden more than 10%. That's when we're going to mention it as a sustained arrhythmia and of course we always have to mention what the symptoms were correlating with. So again, this is an example of a triggered event of a patient wearing Zoatch, and this tells you um that for 90 seconds I always go back with that, you know, that circle one I go prior to that because obviously the patient cannot immediately like trigger when she has a symptom and the fact that you go over it with a patient, tell them that, hey, this is a normal rhythm, normal heart rate already, you know, especially for younger patients who are also on the anxious side, it really helps them. Um, this is an example of a live telemetry by Vital Connect. So anytime if my patient is wearing a monitor and she calls us and says, hey, I got a significant symptom. So the moment we log in, um, the Vital Connect, we see all our patients there. Um, they will tell us the heart rate and, um, all the different, um, ongoing telemetry, the, the ongoing monitors whether the patient is ours or not, which is very helpful because compared to the non-live you don't wanna wait for about a month to even see what's going on here at that exact moment you can actually click and see what's going on this. This is an example of a specific patient. So, you know, below the heart rate and they're in the left of 60, you would see the notifications. Those are preset, um, kind of notification triggers, the patient's symptoms. And once you click on that, you would see here below the symptom, and then you can actually look at the EKG like real time when, um, it's happened. So here in Centerra and Epic, so what we would order is I, and it's a wearable cardiac monitor. I usually just put card 1051, and once you put that in, that's the only option. And this is the pop-up box that will open up so you have a live non-live which we've hammered when do we use live versus non-live 14 days usually and then the vendor we use. So we were instructed that, uh, in our system just to let you know if we want 28 days, the only option we have is live, um, it's vital Connect. Um, it, it doesn't mean that it's not the Zio cannot be done, but it's, we're not doing it. Here in Centera just because if we order 214 days it's gonna cause some insurance problem it's not gonna, the insurance won't cover it. So just to let you know, live 28 monitors, the only option we have is vital connect. If it's a non-live 14 days, we have both the Zio and Vital Connect placement location. Usually it really depends on the patient. I usually prefer the clinic just because if you ask the patient to have it at home, sometimes it's, you know, the lead is reversed or it's not properly positioned. Um, this is an example of a loop recorder. So if the patient's symptom is, say, once or twice a year, or it's very significant that the traumatic syncope caused like subarachnoid bleed or, you know, subdural bleed, you definitely, even it's once, you definitely wanna catch that, and no amount of, of external monitors can catch it. It's once a year, but you can always start and if it's negative, then you have to talk about the loop. Quarter or the cryptogenic strokes um it's same day procedure um it's under local anesthesia we put it here um by the 4th parasternal, uh, border 1 cm from the parasternal border 4th intercostal space and here you could below you would see the counters we put, um, the preset criteria when it will be triggered so the good thing is. It will trigger lifetime and it will trigger so every month, um, the EP or whoever has put it in would see um would download from the patient like remotely and we would put in usually our tacky setting is more than 170. It really depends, but we can um alter the, you know, the, the cutoff on when it's going to be triggered, um. There and this is um an example of a study wherein they uh they compared a loop recorder for a um compared with a conventional diagnostic strategy wherein it's either a 24 halter or a 14 day halter and as you can see for a recurrent unexplained palpitations, um, they followed patients for as long as 1 year and you would see that the loop recorder has a significant um amount of uh diagnosis like 73% versus only 21%. So Doctor Patella also talked about smartwatches. This is very common these days. A lot of patients go to us just because of, um, any reading from smartwatch, and this was last, about 3 years ago, but I'm sure you know the watches have become more savvy. You know, it's not Apple Watch 6 anymore, it's what, 9. And um if you can like those findings are um put in the graph and you would see that once you exclude the inconclusive trading uh tracings, it's very high. The sensitivity and specificity are quite high. It's almost like 95%. Um, and every time the patient tells me about that, I always wanna look at the tracings, and that increases the sensitivity and specificity further because sometimes watches what I've seen is if it has a patient has a lot of PAC or PVC, it would automatically say irregular, then that's your role as a physician to confirm it. Um, again, to conclude, so the workup of palpitations actually always starts with a careful history, physical exam, so that you know what to target, what type of monitor, what type of workup, um, and it's always important to correlate the frequency, the duration, and the type of the cardiac monitor you're gonna have. So the yield of the EKG and short-term monitoring is low, but it can already provide clues on how much workup you're going to do. And as what Doctor Patel was saying, digital health will play an increasing role in the diagnosis and workup of palpitations and syncope over time. Thank you. Published Created by Related Presenters Constancia Macatangay-Geronilla, M.D. Cardiology, Internal Medicine View full profile
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