PALPITATIONSChildren & Young people

Outline Scenario.

Quiz.

What causes palpitations.

Capturing the diagnosis.

Risk stratification.

Answers to Quiz.

Key messages.

Clinical scenario

Ngaire,age 8,complains that her heart “beeps”.

These episodes have increased over 4 months and now occur twice per week. They last up to 20 minutes and are associated with pallor and chest discomfort.

Physical examination between episodes is normal.

Her ECG during a symptomatic episode is shown

An 8-year-old girl with brief episodes of tachycardia,

terminated with Valsalva maneuver

VALSALVAE MANUEVRE

“Playing Trumpets”

QUIZ

Q1 The most likely diagnosis is AVNRT.

Q2 Thyroid function testing is useful.

Q3 She should avoid caffenated beverages

Q4 In the presence of a normal ECG, her risk of sudden death is not increased?

Q5 A physiotherapy assessment of breathing patterns may be useful in the evaluation and management.

Q6 She should avoid strenuous exercise.

Definition

Palpitations are an unpleasant subjective awareness of one’s own heartbeats.This usually occurs as a sensation of rapid, irregular, or unusually strong heartbeats.

The patient describes it as beeping, pounding, jumping, racing, irregularity or fluttering of the heart beat.

Palpitation can be felt in the chest, throat, or neck.

The term palpitation is used so loosely that specific questions must be asked to determine the exact nature of the symptom.

Aetiology of Palpitations PEDIATRICS 113(2)248-51;2004

Children with palpitations(420),chest pain(43),presyncope or syncope(32) evaluated with TTM event recorders

Mean age 10 yrs; Girls=Boys, CHD in 20%.

Monitored for median of 83 days (1-1021).

Aetiology of PalpitationsPEDIATRICS 113(2)248-51;2004

Only 48% ever transmitted an ECG during symptoms.

Thirty-five (15%) of 238 patients with events had SVT.

All children with SVT had palpitations.

Three with SVT also had pre-syncope or syncope.

No child with isolated chest pain or syncope had SVT.

No other significant arrhythmia,(VT),was identified.

Outside or Inside Sinus Tachycardia vs SVT

Garson’s PearlsCLINICAL PEDIATRIC ARRHYTHMIAS 1999

1.How many times have palpitations occurred?

2.How often have the episodes occurred?

3.How long did the episodes last?

4.What brings on the episode?

5.What does the child look like during an episode?

6.Where do you feel the palpitations?

7.What makes the tachycardia disappear?

QUESTION PROBABLE SVT ARRHYTHMIA UNLIKELY

How many times? Several Once

How Often? Monthly Daily

How long is each episode? 5-30 minutes Seconds

Circumstances? Anytime Falling asleep, After exercise

Appearance? Pale, sweaty Red

Where felt? Chest, neck Chest

What makes it disappear? Gag, swallow, vomit Rest

DIFFERENTIAL DIAGNOSIS OF NARROW COMPLEX TACHYCARDIAS

Diagnosis

“ SVT “

Appearance

Orthodromic AVRT ** P wave in the ST segment

AV nodal re-entry * P wave not seen or in QRS

Atrial Flutter Often 2:1 or higher AV block

EAT Incessant.Variable rate. L or R atrial P waves

CAT Irregular. Many non-conducted P waves

PJRT Long RP. Inverted P waves in 2,3, and AVF

JET Incessant, Irregular, VA block

Investigation of Palpitations

Standard 12 lead ECG (Pre-Excitation)

Holter ECG ( Frequency >2 x week)

Open letter/Rapid ECG (Episodes >20 min)

Neimejen questionnaire (Hyperventilation)

Event recorders for 4 weeks most cost effective. _Sensitivity 60% _NPV 96%

Echocardiogram and exercise testing neither sensitive nor cost effective

Time (SVT will increase in duration or frequency)

SVT + Preexcitation =Wolf Parkinson White Syndrome

)

Prognosis of SVT

Age < 1 year 90% resolve, but 1/3 recur.

Age > 6 year “Permanent”. Grow into SVT.

WPW have risk of SCD of 2% per 10 years so if symptomatic need definitive Rx.

Children with concealed APW are not at risk of dying but also unlikely to outgrow SVT so Rx is based on symptom “burden”.

Salerno, J. C. et al. Arch Pediatr Adolesc Med 2009;163:268-274.

Schematic representation of a supraventricular tachycardia circuit and targets of common therapies

Chronic SVT Management

Reassurance & Normal activities

Vagal maneuvers eg Playing trumpets

“Pill in the Pocket”_Sotolol or Flecainide

Cryo or Radiofrequency ablation cures

SVT in 85_95% children aged 4 +

An 8-year-old girl with brief episodes of tachycardia,

terminated with Valsalva maneuver

QUIZ

Q1 The most likely diagnosis is AVNRT. T

Q2 Thyroid function testing is useful. F

Q3 She should avoid caffenated beverages. T

Q4 In the presence of a normal ECG, her risk of T

sudden death is not increased?

Q5 A physiotherapy assessment of breathing T

patterns may be useful in the evaluation.

Q6 She should avoid strenuous exercise. F

SUMMARYKey messages

Palpitations are a common symptom in children.

Most children do not have an identifiable cause.

Over 50% will abate following clinical assessment.

The only significant arrhythmia presenting with palpitations in children & youth is AVRT & AVNRT.

The key objective of the diagnostic evaluation is to identify the small number with WPW syndrome.

SVT is commonest arrhythmia of childhood with a prevalence of ~ 1:250 For most this is a nuisance rather than being life threatening

Anxiety disorders often presents with palpitations in the young. This is more common than SVT.

PALPITATIONS

Radio Frequency Ablation (RFA)

SVT Shock Present?

IV accessquicker than

DEFIB?

Vagal manoeuvre

Consider:Adenosine 400-500 mcg/kg

Synchronous DC shockAmiodarone

Or SEEK ADVICE

Adenosine 100 mcg/kg

Adenosine 200 mcg/kg

Adenosine 300 mcg/kgSynchronous

DC shock 1J/kg

Vagal manoeuvre(If no delays)

Synchronous DC shock 2J/kg

Yes No

Yes

No

2 min

2 min

Consider Amiodarone

Copyright restrictions may apply.

Salerno, J. C. et al. Arch Pediatr Adolesc Med 2009;163:268-274.

Example of Typical School Plan

The AV Node could be likened to a drafting pen.

It slows and controls atrial activation of venticular muscle.

An accessory P/W is analagious to sheep ‘jumping the fence’

Answers

1. Diagnosis AVNRT or “SVT”

2. TFT are unhelpful unless sustained ST

3. Caffeine associated with PALP’s(OR 1.8)

4. True but preexcitation increases risk of SCD to 2% over next 10 years.

5. The commonest Non cardiac cause of palpitations is anxiety.This shows as BPD.

6. False but expect more SVT with sport