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Palpitation

By Group 14
dr. Reeny Purnamasari, Sp.B
Members
ANDI RETNO AFIFAH (11020170001)
MARYAM QARINAH RABBANI (11020170022)
GHITA SHUPIYESA. S (11020170140)
M. AVIZENA ILHAMI. S (11020170078)
RIRIN RAMADHANI RIDWAN (11020170070)
VANIA ALMIRA (11020170121)
WARDAYANI (11020170072)
MUFTHIAR MUHTAR (11020170128)
ANDI MUH NASYWAN (11020170106)
AZIMAR KHATIMAH Z (11020170170)
Scenario 2
A 22-year-old man came to the hospital with chief complaining of palpitations. It
have been felt since a long time, especially after doing activity and sometimes
accompanied by dizziness and like nearly faint. Lately, the palpitations going increased
everytime doing activity and accompanied with a feeling of tightness and fatigue. From the
history of the disease, the patient had been treated regularly in poly endocrine during the
last 3 years and consumed PTU
Physical examination of 90/60 mmHg TD, heart rate (+/-)120x/minute irregularly,
respiration rate 28x/minute and body temperature 37.20C temperatur. There is a lump in
front of the neck, symmetrical, mobile.
Difficult Word

PTU Propylthiouracil
• is the main treatment for antithyroid drug hyperthyroidism).
The main mechanism for antithyroid drugs is blockade
synthesis of thyroid hormones through inhibition of the
enzyme system thyroid peroxidase from the thyroid gland.
PTU inhibits peripheral conversion of T4 to T3
Keyword
22 years old men

Complaining of palpitation since a long time


Contents

Palpitation especially after doing activity accompanied by


dizziness and like nearly faint

Feeling of tightness and fatigue

History had been treated regularly during the last 3 years


and consumed PTU

Blood pressure 90/60 mmHg. Heart rate 120x/minutes


irregular. Respiration 28x/minutes. Temperature 37,2oC

There is lump in front of the neck, symmetrical, and


mobile.
QUESTIONS

1. A. What the definition of palpitation ?


B. What the mechanism of palpitations ?
2. What heart disease can cause palpitation ?
3. What the relation between hypertiroidsm based on the scenario ?
4. What are the risk factors of atrial fibrillation ?
5. What mechanism of low blood pressure of atrial fibrillation ?
6. Why the activity trigger the atrial fibrillation?
7. What the diagnose steps ?
8. What are the differential diagnoses on the scenario ?
9. What is first treatment to the patient in the scenario ?
10.What is perspective islam in the scenario ?
Definition of
Palpitation
Palpitation

Sensations of a rapid or irregular heartbeat

This sensation can be either


intermittent or sustained and
either regular or irregular

Reference : 1. Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. Am J Med. 1996;100:138–48.
2. Knudson MP. The natural history of palpitations in a family practice. J Fam Pract. 1987;24:357–60.
Palpitation

Sensory receptors are


myocardial, pericardial, and Brain centres involved in
peripheral the elaboration of afferent
stimuli are the sub
mechanoreceptors, and/or
peripheral baroreceptors with cortical areas (thalamus, Palpitation
their afferent amygdala) and the base
parasympathetic and of the frontal lobes.
sympathtic pathways.

Reference : Raviele, Antonio Et Al. 2011. Management Of Patients With Palpitations. European Heart Rhythm Association.
Causes of Palpitation due to
Cardiac and Non-Cardiac
Reference: Abbott AV. Diagnostic approach to palpitations. Am Fam Physician. 2005;71(4):743–750
ALLAN V. ABBOTT, M.D., Keck School of Medicine of the University of Southern California, Los Angeles, California
Am Fam Physician. 2005 Feb 15;71(4):743-750
Relation between
Hypertiroidsm based on
the Scenario
Hyperthyroidism

Changes in thyroid hormone levels have


significant effects on the cardiovascular
system, even in the subclinical stage.
Hyperthyroid conditions significantly increase
oxygen consumption, which requires increased
blood and pump function at rest Free T3
hormones can result in rapid relaxation of
smooth muscle cells in culture media.

Reference: Hersunarti, Nani. 2017. Buku ajar kardiovaskular. Sagung Seto. Hal 646
Hyperthyroidism

Reference: Hersunarti, Nani. 2017. Buku ajar kardiovaskular. Sagung Seto. Hal 646
The Risk Factors of Atrial
Fibrillation
Risk Factors of AF
Basically the risk factor associated with atrial fibrillation is divided into several
factors, including:
a. Increased pressure or atrial resistance e. Endocrine disorders
• Increased heart valve Hyperthyroidism, Feochromotisoma
• Abnormalities in filling and emptying the f. Neurogenic
atrial space g. Atrial Ischemia
• Cardiac hypertrophy Myocardial infarction
• Cardiomyopathy h. Drugs
• Pulmonary hypertension (chronic Alcohol, Caffeine
obstructive pulmonary i. Descendants or Genetics
• chronic disease and cor pulmonary
• Intracardiac tumor
b. Infiltrative and Inflammatory Processes
• Pericarditis or myocarditis
• Amyloidosis and sarcoidosis
• Increasing age factor
c. Infection Process
Fever and all kinds of infections
Mechanism of Low Blood
Pressure of Atrial
Fibrillation
Mechanism of Low Blood Pressure of Atrial Fibrillation

In atrial fibrillation, the upper chambers of your heart (atria)


experience chaotic electrical signals. As a result, they quiver. The AV node
the electrical connection between the atria and the ventricles is bombarded
with impulses trying to get through to the ventricles.
The ventricles also beat rapidly, but not as rapidly as the atria, as
not all the impulses get through. The reason is that the AV node is like a
highway on-ramp only so many vehicles can get on at one time.
The result is a fast and irregular heart rhythm.
Ordinarily, your body increases your heart rate and constricts certain blood
vessels to help maintain normal blood pressure. But in some people these
mechanisms fail, leading to dizziness, faintness and falls.
The Activity Trigger The Atrial Fibrillation

Structural remodeling, particularly fibrosis, is the main


stay in many forms of AF.
Dilation of the atria can be due to almost any structural
abnormality of the heart that can cause a rise in the pressure
with in the heart.
Recently, mutation of the lamin AC gene has been found
to be associated with fibrosis of the atria that can lead to atrial
fibrillation.

Reference: Hersunarti, Nani. 2017. Buku ajar kardiovaskular. Sagung Seto. Hal 646
Diagnose steps
Anamnesis Identity that needs to be known, namely: Identity of patients known as
gender and age, the patient is a 22-year-old man. In the possibility of this
identity there is no possibility of a suspected risk of atrial fibrilation so that
other history questions are needed. Because atrial fibrilation has risk factors
in the form of sex and age, the high risk of developing atrial fibrilation is that
it attacks men more often at an average age of >60 years.

Main complaint in FA Some symptoms are possible patients complained, among others:
- Palpitations. Expressed expressed by patients as: drum beat, thunder
roar, or fried fish in the chest.
- Tired or low on physical activity
- Presinkop or syncope
- General weakness, dizzinessin the scenario of patients experience the
several main symptoms of atrial fibrilation, the patient complaining of
palpitation. It have been felt since a long time, especially after doing
activity and sometimes accompanied by dizziness and like nearly faint.
accompanied with a feeling of tightness and fatigue
Diagnosis Criteria 1. History
2. ECG:
• The ventricular rate is irregularo
• there is no clear P waveo
• P gel is replaced by F waveirregular and random, followed by the QRS
complexwhich is irregular too.
• in general: General heart rateranging from 110-140x / minute, but rarelyexceed 160-
170x / minute.
• Beats can be found by conductionaberan (wide QRS) after a short interval of R-R
interval (Ashman phenomenon)
• Left ventricular hypertrophy
Torax photos:Chest X-ray examination is usually normal, but sometimes evidence of
heart failure or signs of parenchymal or vascular lung pathology (eg pulmonary
embolism, pneumonia) can be found.
Supporting Investigation 1. Laboratory of blood:Routine hematology, coagulation factors, thyroid
function, HBsAg, HCV, kidney function and electrolytes.
2. TTE echocardiography for:
• Evaluate valve heart diseaseo
• Evaluation of the size of the atria, ventricles andwall dimensionso
• Estimated ventricular function and evaluationventricular thrombus
3. Electrophysiology studies:Identification of the mechanism of wide QRS
tachycardia, predisposing arrhythmias, or determination of the curative
ablation site.
Reference:
-ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias, European Heart Journal 2003;34:1857-1897.
-Ziad Issa, John M. Miller, Douglas P. Zipes.— Clinical Arrhythmology and Electrophysiology: A Companion to Braunwald’s Heart Disease, Saunders, 2009.
-Yuniadi Y et al. Pedoman Tatalaksana Fibrilasi Atrium, PERKI 2014.
2D echocardiography: mitral valve prolapse,
large central jet, enlarged left atrium
rapid irregular R-R intervals and mimic AF. Most
atrial tachycardias and flutters show longer atrial
cycle lengths ≥200 ms
Differential Diagnose
Atrial Fibrillation Ventricular Fibrillation
Epidemiology 50% (men) to 90% (women) increased risk Ventricular fibrillation is the most common
for overall mortality over 40 years. cause of sudden death. Its occurrence is a
direct reflection of underlying causes,
especially ischemic heart disease.
Patophysiology Structural atrial abnormalities consist of areas Ventricular tachycardia may be focal or
of patchy fibrosis, enhanced connective tissue macroreen trant. Focal VT has a point source
deposits juxtaposed with normal atrial fibres, of earliest ventricular activation, with a
inflammatory changes, intracellular substrate spread of activation away in all directions
accumulation, and disruption of cell coupling from that site
at gap junctions with remodelling of The mechanism can be triggered activity,
connexions. automaticity, microreentry, or focal
endocardial breakthrough from an epicardial
reentry circuit.
Differential Diagnose
Atrial Fibrillation Ventricular Fibrillation
Laboratory Examination Basic laboratory investigations (full blood Complete blood count, cardiac enzymes,
count; renal, liver, and thyroid function; serum electrolytes (including magnesium),
electrolytes, including calcium and creatinine, BUN, and liver and thyroid
magnesium, glucose, and lipid profile. function tests should be checked. Additional
specific tests, such as iron studies and HIV,
should also be obtained when clinically
indicated.
EGC Examination Atrioventricular nodal conduction may Ventricular fibrillation is rapid, usually more
present with rapid irregular R-R intervals and than 333 bpm (cycle length ≤ 180 ms),
mimic AF. Most atrial tachycardias and grossly irregular ventricular rhythm with
flutters show longer atrial cycle lengths ≥200 marked variability in QRS cycle length,
ms.14 morphology, and amplitude. Fine VF is low
amplitude VF that can be perceived as
asystole.
Differential Diagnose
Atrial Fibrillation Ventricular Fibrillation

Thorax Radiology Chest X-ray examination is usually normal, This can assess whether the heart has any
but sometimes evidence of heart failure or swelling, or if there is anything unusual in the
signs of parenchymal or vascular lung heart's blood vessels.
pathology (eg pulmonary embolism,
pneumonia) can be found.

EGC examination in VF

EGC examination in AF

Reference:Demosthenes G. Katritsis, Bernard J. Gersh, A. John Camm. 2015. Clinical Cardiology. Oxford University Press is a department of the
1. Prof. Bulent Gorenek , FESC. Cardioversion in atrial fibrillation described. An article from the e-journal of the ESC Council for Cardiology Practice. 2014
2. Prof. Dr. Peter Kabo PhD, MD. Bagaimana menggunakan obat-obat kardiovaskular secara rasional. Fakultas Kedokteran Universitas Indonesia. 2017.
First Treatment
AF management includes anti-arrhythmic drugs, ablation
and Cox-maze III surgery.AF treatment always starts with treating
precipitating factors, such as reducing preload in patients with heart
failure, reducing afterload in patients with hypertension, increasing
blood supply in ischemic heart disease, returning hyperthyroid
patients to euthyroid status, stopping excessive coffee and tea
consumption or using drugs - sympathomimetic drug, giving a minor
traquilizer to anxious patient.
Two drugs that can restore the rhythm of AF to sinus
rhythm are sulfas kinidine and amiodarone. The importance of AF
returned to sinus rhythm is to improve cardiac output and prevent
thromboembolism.
Kinidine (sulfate or gluconate) is usually given orally at doses
ranging from 300-600 mg every 6 hours.
Amiodarone is a unique anti-arrhythmia drug
Low-dose amiodarone has been reported to be effective in returning
AF rhythms to sinus rhythm (in an emergency can be given per
intravenously). The success rate for new AF is +/- 80%
1. Prof. Bulent Gorenek , FESC. Cardioversion in atrial fibrillation described. An article from the e-journal of the ESC Council for Cardiology Practice. 2014
2. Prof. Dr. Peter Kabo PhD, MD. Bagaimana menggunakan obat-obat kardiovaskular secara rasional. Fakultas Kedokteran Universitas Indonesia. 2017.
Islamic Perspective
Surah Al Haqqah verses 45 and 46 Allah says:

٤٥ ‫ين‬ِ ‫م‬ِ َ ‫ي‬‫ل‬ْ ‫ٱ‬ ‫ب‬


ِ ُ ‫ه‬‫ن‬ْ ‫م‬
ِ ‫ا‬َ ‫ن‬‫ذ‬ْ َ
‫خ‬ َ ‫أ‬
َ ِ‫ث ُ َّم لَقَ َط ْعنَا ِم ْنهُ ٱ ْل َوت‬
٤٦‫ين‬
"We surely hold him in his right hand. Then really we cut the veins of the
heart. “

The purpose of the verse is if the Prophet Muhammad lied against Allah,
the sanction that would be given was cutting the blood vessels coming out
of his heart (aorta) so that death was the end result.