Heart Disease: Faculty The Number One Health Brigitta C. Brott, MD Problem for Women Assistant Professor of Medicine Rresearch Assistant Professor of Satellite Conference Biomedical Engineering University of Alabama at Birmingham Thursday, February 24, 2005 9:00-11:00 a.m. (Central Time) Sharon M. Dailey MD FACC Medical Director, Cardiographics

Produced by the Alabama Department of Public Health Associate Professor of Medicine Video Communications Division University of Alabama at Birmingham

Faculty Objectives

Suzanne Oparil, MD • To review new information regarding Professor of Medicine estrogen replacement and risk of University of Alabama at Birmingham CHD and stroke in women. • To review coronary disease in women including the different presentation symptoms and the various responses to therapy.

Objectives in Women • To review the evaluation and treatment of cardiac arrhythmias in Sharon M. Dailey MD FACC women. Associate Professor of Medicine • To review the modification of risk factors for coronary heart disease in women.

1 There Really Are Gender Basis For Gender Differences In Arrhythmias Differences Unclear • Resting HR in women is higher. • Autonomic tone differences • Corrected QT interval is longer in –women may have higher baseline women. sympathetic tone • Higher female incidence of certain genes for long QT syndrome. • Hormonal effects • Higher female incidence of AVNRT vs –menstural cycle effects WPW. –pregnancy • Risk of torsades de pointes higher • Ion channel differences with antiarrhythmic drugs in women.

Do Women Perceive Evaluation of Patients with Arrhythmias Differently From Men? • Symptoms and associated circumstances –Detailed history • Diagnostic evaluation –Physical exam –Diagnostic testing –Ambulatory monitoring devices • Management

Flip-Flopping Rapid Fluttering • Can result from any sustained • Heart seems to stop and start - VT, SVT, sinus causing pounding or flipping tachycardia. sensation. • Patients can sometimes see shirt • Usually caused by PACs or PVCs. moving rapidly. • Pause following ectopic beat causes • Sinus tach often occurs with activity sensation that heart has stopped and and resolves gradually with rest in pounding or flipping caused by deconditioned patients. SVT or VT forceful contraction after ectopic will stop suddenly if spontaneously beat. terminating.

2 Pounding In The Neck Circumstances

• Usually caused by AV dissociation • Anxiety or panic reactions –Reentrant SVTs (AVNRT or WPW) • Periods of catecholamine excess • Associated with position – or sometimes PVCs • Associated with syncope or near- syncope • Cannon A waves can be seen • Poor sleep, bad habits • Feeling of being unable to catch –excess caffeine, alcohol, drugs one’s breath (even otc)

Anxiety Or Panic Catecholamine Excess • Cause or effect? • Idiopathic ventricular • Average of 3.3 years between onset particularly RVOT of symptoms and diagnosis of SVT • Atrial fibrillation due to meeting DSM criteria for panic disorder (67%). • Torsades with startling • Diagnosis of panic should not be • Inappropriate sinus tachycardia accepted until true arrhythmic cause excluded.

Palpitations Associated Palpitations Associated With Position With Syncope

• Patients with AVNRT may notice • Should prompt a search for onset when standing up after ventricular tachycardia bending over. • Not common, but can occur with SVT • PVCs and PACs are more noticeable particularly at onset of tachycardia when lying in bed, since they are often more frequent with slower likely due to acute vasodilatation, heart rates. rapid HR with low CO

3 Diagnostic Evaluation Diagnostic Evaluation Detailed History Detailed History • Age of onset • Mode of onset and termination – Childhood or adolescent onset suggests WPW, perhaps AVNRT, • Complete ROS and social history idiopathic VT, long QT – Atrial tachycardias or afib generally later onset • Description of palpitations – helpful to have patient tap out rhythm with fingers

Diagnostic Evaluation Diagnostic Evaluation Physical Exam Physical Exam

• Helps define cardiac abnormalities • Seldom will exam occur during that can serve as substrate for episode of palpitations (except in ER) arrhythmias but findings such as irregularly –murmur of IHSS irregular rhythm may be present –S3 gallop, displaced PMI, elevated (afib) JVP –echocardiogram to confirm

Diagnostic Evaluation Diagnostic Testing 12 Lead ECG Who Should Have? • Short PR and delta wave (WPW) • Initial evaluation suggests an . • Marked LVH, deep septal Q waves in • Patients at high risk for an I, AVL, V4-6 (IHSS) arrhythmia • LAE - substrate for afib –organic heart disease or • Q waves characteristic of prior MI - abnormality that can cause serious arrhythmias possibility of VT –strong family hx of sudden death • Long QT, findings of Brugada • Anxious patients who want syndrome explanation for their symptoms

4 Ambulatory Monitoring Management Devices • Referral of most sustained • Holter monitor arrhythmias to an electrophysiologist –24-48 hrs. Saves data continuously. either for drug or ablation/device Not good if infrequent symptoms. therapy • Event recorders • PACs, PVCs –“Beeper” - records in real time when – Reassurance pt activated. – Beta-blocker therapy –“Looper” - records few minutes – Avoid antiarrhythmic drug therapy before and after patient activated (continuous-loop). – Lifestyle modification (i.e., caffeine, sleep, stress –Can use for one month.

Inappropriate Sinus Summary Tachycardia • The cause of palpitations in the vast • Diagnosis made only when causes majority of outpatients is benign, such as hyperthyroidism, anemia therefore extensive and costly investigation isn’t warranted but ruled out. • Patients may desire a specific • Beta blockers, calcium channel diagnosis for their symptoms blockers first line of therapy. • Most important to identify those at • Sinus node modification often an high risk for serious causes of unrewarding form of therapy. palpitations

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