Symptom Finder - Cardiac Arrhythmias
CARDIAC ARRHYTHMIAS
With few exceptions, the etiologies of cardiac arrhythmias like those of bradycardia can best be recalled using the mnemonic VINDICATE. The exceptions are from one pathophysiologic cause: obstruction and consequent dilatation of one or more of the chambers of the heart. Thus, mitral stenosis with obstruction and dilatation of the left atrium is a prominent cause of atrial arrhythmias, especially of auricular fibrillation.
Hypertension and aortic stenosis may cause a number of atrial and ventricular arrhythmias. Pulmonary hypertension resulting from pulmonary emphysema, fibrosis, or pneumonia with consequent right ventricular and atrial obstruction and dilatation cause arrhythmias, especially atrial arrhythmias. Getting back to VINDICATE completes the
recall of the causes of arrhythmias.
V—Vascular diseases include myocardial infarction, coronary insufficiency, and coronary artery emboli.
I—Inflammatory diseases include viral myocarditis, diphtheria, syphilis, tuberculosis, and Chagas disease.
N—Neoplasms include atrial myxomas, but the N also stands for neuropsychiatric causes. Paroxysmal atrial tachycardia is especially likely to result from emotional causes.
D—Degenerative diseases include Friedreich ataxia, myotonic dystrophy, myocardial fibroelastosis, and other myocardiopathies.
I—Intoxication suggests the largest number of causes of arrhythmia: Alcohol, caffeine, tobacco, digitalis, quinidine, propranolol, and procainamide are just a few. Diuretics cause electrolyte disturbances that may cause or contribute to cardiac arrhythmias.
C—Congenital disorders recall congenital heart diseases, many of which cause recurrent arrhythmias. The Wolff–Parkinson–White syndrome predisposes to atrial tachycardia. Muscular dystrophy may cause myocardiopathy and arrhythmias. Von Gierke disease and gargoylism also need to be remembered.
A—Autoimmune disorders suggest the arrhythmias of amyloidosis, sarcoidosis, scleroderma, periarteritis nodosa, and rheumatic fever.
T—Trauma suggests the arrhythmias in shock, burns, stab wounds to the heart, and head injuries. Electric shock is a cause of ventricular fibrillation.
E—Endocrinopathies should remind one of hyperthyroidism, a prominent cause of atrial fibrillation, Addison disease, and aldosteronism, which disturb the electrolytes sufficiently to cause arrhythmias. Pheochromocytomas may cause atrial tachycardia from
the tremendous output of epinephrine.
Approach to the Diagnosis
The diagnosis depends a lot on the type of arrhythmia. Atrial premature contractions are usually benign, and an extensive workup is unnecessary unless other physical signs indicate the need for it. Infrequent ventricular premature contractions (VPCs) in otherwise healthy individuals probably can be handled the same way. When VPCs are frequent or multifocal, an exercise tolerance test, echocardiogram, and perhaps coronary angiography are indicated. Runs of ventricular tachycardia require an extensive workup, including coronary angiography, but usually there will be other signs to indicate the need for this.
Atrial tachycardia and fibrillation require a workup of hyperthyroidism and pulmonary disease, systemic hypertension, and congestive heart failure (CHF). Atrial obstruction and dilatation should be excluded by echocardiography. Carotid sinus massage will distinguish rapid atrial arrhythmias from sinus tachycardia.
Any arrhythmia warrants an electrocardiogram (ECG) and possibly repeated ECGs. The Holter monitor should be used if there is doubt about the type of arrhythmia.
Other Useful Tests
1. Complete blood count (CBC) (anemia)
2. Thyroid profile (hyperthyroidism, hypothyroidism)
3. Urinalysis (renal disease)
4. Chemistry panel (uremia, electrolyte imbalance)
5. Sedimentation rate (infection)
6. Serial cardiac enzymes (myocardial infarction)
7. Serum and urine osmolality (CHF)
8. Exercise tolerance test (coronary insufficiency)
9. Serial ECGs (myocardial infarction)
10. Signal-averaging ECG and electrophysiologic testing (localize site
of irritable focus)
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11. Pulmonary function tests (CHF, emphysema)
12. Echocardiogram (CHF, valvular heart disease)
13. Coronary angiogram (coronary insufficiency)
14. Drug screen (chronic drug abuse)
15. Hold all drugs (drug intoxication)
16. B-type natriuretic peptide (BNP) (CHF)
With few exceptions, the etiologies of cardiac arrhythmias like those of bradycardia can best be recalled using the mnemonic VINDICATE. The exceptions are from one pathophysiologic cause: obstruction and consequent dilatation of one or more of the chambers of the heart. Thus, mitral stenosis with obstruction and dilatation of the left atrium is a prominent cause of atrial arrhythmias, especially of auricular fibrillation.
Hypertension and aortic stenosis may cause a number of atrial and ventricular arrhythmias. Pulmonary hypertension resulting from pulmonary emphysema, fibrosis, or pneumonia with consequent right ventricular and atrial obstruction and dilatation cause arrhythmias, especially atrial arrhythmias. Getting back to VINDICATE completes the
recall of the causes of arrhythmias.
V—Vascular diseases include myocardial infarction, coronary insufficiency, and coronary artery emboli.
I—Inflammatory diseases include viral myocarditis, diphtheria, syphilis, tuberculosis, and Chagas disease.
N—Neoplasms include atrial myxomas, but the N also stands for neuropsychiatric causes. Paroxysmal atrial tachycardia is especially likely to result from emotional causes.
D—Degenerative diseases include Friedreich ataxia, myotonic dystrophy, myocardial fibroelastosis, and other myocardiopathies.
I—Intoxication suggests the largest number of causes of arrhythmia: Alcohol, caffeine, tobacco, digitalis, quinidine, propranolol, and procainamide are just a few. Diuretics cause electrolyte disturbances that may cause or contribute to cardiac arrhythmias.
C—Congenital disorders recall congenital heart diseases, many of which cause recurrent arrhythmias. The Wolff–Parkinson–White syndrome predisposes to atrial tachycardia. Muscular dystrophy may cause myocardiopathy and arrhythmias. Von Gierke disease and gargoylism also need to be remembered.
A—Autoimmune disorders suggest the arrhythmias of amyloidosis, sarcoidosis, scleroderma, periarteritis nodosa, and rheumatic fever.
T—Trauma suggests the arrhythmias in shock, burns, stab wounds to the heart, and head injuries. Electric shock is a cause of ventricular fibrillation.
E—Endocrinopathies should remind one of hyperthyroidism, a prominent cause of atrial fibrillation, Addison disease, and aldosteronism, which disturb the electrolytes sufficiently to cause arrhythmias. Pheochromocytomas may cause atrial tachycardia from
the tremendous output of epinephrine.
Approach to the Diagnosis
The diagnosis depends a lot on the type of arrhythmia. Atrial premature contractions are usually benign, and an extensive workup is unnecessary unless other physical signs indicate the need for it. Infrequent ventricular premature contractions (VPCs) in otherwise healthy individuals probably can be handled the same way. When VPCs are frequent or multifocal, an exercise tolerance test, echocardiogram, and perhaps coronary angiography are indicated. Runs of ventricular tachycardia require an extensive workup, including coronary angiography, but usually there will be other signs to indicate the need for this.
Atrial tachycardia and fibrillation require a workup of hyperthyroidism and pulmonary disease, systemic hypertension, and congestive heart failure (CHF). Atrial obstruction and dilatation should be excluded by echocardiography. Carotid sinus massage will distinguish rapid atrial arrhythmias from sinus tachycardia.
Any arrhythmia warrants an electrocardiogram (ECG) and possibly repeated ECGs. The Holter monitor should be used if there is doubt about the type of arrhythmia.
Other Useful Tests
1. Complete blood count (CBC) (anemia)
2. Thyroid profile (hyperthyroidism, hypothyroidism)
3. Urinalysis (renal disease)
4. Chemistry panel (uremia, electrolyte imbalance)
5. Sedimentation rate (infection)
6. Serial cardiac enzymes (myocardial infarction)
7. Serum and urine osmolality (CHF)
8. Exercise tolerance test (coronary insufficiency)
9. Serial ECGs (myocardial infarction)
10. Signal-averaging ECG and electrophysiologic testing (localize site
of irritable focus)
194
11. Pulmonary function tests (CHF, emphysema)
12. Echocardiogram (CHF, valvular heart disease)
13. Coronary angiogram (coronary insufficiency)
14. Drug screen (chronic drug abuse)
15. Hold all drugs (drug intoxication)
16. B-type natriuretic peptide (BNP) (CHF)