CARDIAC ARRHYTHMIA

Ask the following questions:

1. Is it acute or chronic? An acute cardiac arrhythmia should make one consider a myocardial infarction first.
2. Is the heart rate slow, normal, or fast? A rapid cardiac arrhythmia may be associated with hyperthyroidism, congestive heart failure, or drug toxicity. A slow cardiac arrhythmia is more likely to be associated with heart block and syncope. A myocardial infarction may produce either the rapid or slow cardiac arrhythmia.
3. Is the rhythm regular or irregular? A tachycardia with a regular rhythm is more likely to be a supraventricular tachycardia or ventricular tachycardia. A tachycardia with an irregular rhythm is more likely to be atrial fibrillation, but atrial flutter can also cause a rapid irregular rhythm. Irregular premature contractions and ventricular premature contractions may be associated with rapid, slow, or normal cardiac rates. A slow, fairly regular heart rate is associated with complete heart block.
4. Is there chest pain associated with the cardiac arrhythmia? Chest pain should make one think of myocardial infarction, pericarditis, or coronary insufficiency.
5. Is there fever? If there is fever, one should consider rheumatic fever, subacute bacterial endocarditis, and thyroid storm.
6. Is there a heart murmur associated with the arrhythmia? A heart murmur associated with arrhythmia should make one think of rheumatic fever or subacute bacterial endocarditis, myocardiopathy, or acute congestive heart failure.
7. Are there signs of congestive heart failure? Hepatomegaly, jugular vein distention, and pitting edema of the extremities would make one think that congestive heart failure was the cause of the arrhythmia.
8. Is there a thyroid enlargement? An enlarged thyroid gland would certainly make one think of thyrotoxicosis.
9. Is there hypertension? Hypertension is another important cause of cardiac arrhythmias that should not be forgotten.

DIAGNOSTIC WORKUP

All patients should have an EKG, chest x-ray, and a CBC to rule out anemia. A thyroid profile should be done to look for both hyperthyroidism and hypothyroidism. In acute arrhythmias, serial EKGs and tests for cardiac enzymes need to be done to exclude an acute myocardial infarction. Venous pressure and circulation time should be determined to rule out congestive heart failure; pulmonary function tests may be helpful, as they may rule out both congestive heart failure and emphysema. Echocardiograms should be done to rule out valvular disease and cardiomyopathy. If there are paroxysmal arrhythmias, Holter monitoring needs to be done. An exercise tolerance test may allow the recording of an arrhythmia that is only induced on exercise. Signal-averaged EKG and electrophysiologic testing should also be considered. Patients on digitalis, quinidine, or other cardiac drugs should have blood levels of these drugs measured to determine if their levels are toxic. If there is a fever, blood culture should be done to rule out bacterial endocarditis. Referral to a cardiologist can be made at any point in the diagnostic workup.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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