Palpitation electrocardiogram
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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.