Office Evaluation of Palpitations in Pediatric Patients

Educational Objectives

The goal of this program is to improve management of palpitations in pediatric patients. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate among sinus tachycardia, supraventricular tachycardia, and ventricular tachycardia.
2. Recommend diagnostic modalities for arrhythmias in pediatric patients.

Summary

Nonarrhythmias: include sinus tachycardia (ST; fast heart rate [HR]) and hyperdynamic precordium (strong pulsation); can be associated with, eg, anxiety, caffeine, stimulants, anemia, fever, hypoglycemia, heart failure (HF); a history of panic attacks may be related to true tachyarrhythmic events (with HR 250 bpm and poor perfusion)

Transient arrhythmias: include premature atrial contractions (PACs) and premature ventricular contractions (PVCs); patients may perceive a pause in heart beats or “the heart stopping”; PACs and PVCs can be intercalated between 2 normal sinus beats, giving the impression of a run of beats; blocked beats with a prolonged PR interval followed by a dropped beat can also cause pauses; transient arrhythmias are usually not clinically significant, unless there are sustained or recurrent episodes with, eg, second-degree atrioventricular (AV) block, atrial or ventricular bigeminy (ie, pulsus alternans)

Sinus tachycardia (ST), supraventricular tachycardia (SVT), and ventricular tachycardia (VT)

History: evaluate speed, intensity, and duration of symptoms; consider activity-related triggers and onset and termination patterns; gather family and social history

Examination: examine the jugular venous pulse for Cannon A waves; auscultate for murmurs; look for signs of HF or hyperdynamic precordium; look for rashes or café au lait spots

Differential diagnosis: primary concerns include VT (eg, long QT syndrome, catecholaminergic polymorphic VT, arrhythmogenic right ventricular [RV] cardiomyopathy, Brugada syndrome), Wolff-Parkinson-White syndrome, complete heart block, and pacemaker malfunction; secondary concerns include second-degree AV block, SVT, and frequent PVCs

Evaluation: in cases with limited or low-risk symptoms (eg, vasovagal presyncope), doing nothing may be appropriate, although electrocardiography (ECG) is generally recommended to assess for underlying cardiac issues or arrhythmias; eg, echocardiography, stress testing, Holter or event monitors, provide further insight with limitations; cardiologists can perform advanced evaluations (eg, tilt table testing, implantable loop recorders, electrophysiologic studies); smartwatch monitoring is gaining popularity

Referral to cardiology: appropriate with an uncertain diagnosis, with symptoms requiring specialized treatment, to identify risk for morbidity (with, eg, Wolff-Parkinson-White [WPW] syndrome, atrial flutter, VT, cardiomyopathies), and in the presence of comorbidities (eg, anxiety, depression, obesity, attention-deficit/hyperactivity disorder, drug interactions)

Treatment: includes conservative approaches, (eg, avoiding stimulants), vagal maneuvers (for SVT), and medication management; advanced interventions include, eg, cardioversion, ablation, pacemakers, implantable cardioverter-defibrillators

Event monitoring: ECG recordings during events are diagnostic, but since these events are often sporadic, extended monitoring is beneficial; patch-type monitors are effective and reduce the need for multiple leads; Holter monitors record all rhythms over a 24-hr period, while event monitors only capture triggered events; Holter monitors require return to the manufacturer for evaluation, while some event monitors allow reporting through a delayed cell phone link

Role of echocardiography: appropriate-use criteria include a known history of SVT, VT, or cardiomyopathy, or family history of sudden death; Sheth et al (2021) determined that echocardiography provides low diagnostic yield in pediatric patients with palpitations but without chest pain or syncope

Wolff-Parkinson-White (WPW) syndrome: although often asymptomatic, carries a risk for sudden death because of rapid conduction of atrial fibrillation (AF) or flutter across the accessory pathway; diagnosing this condition is crucial to prevent potential life-threatening complications; medications which block the AV nodes (eg, digoxin, calcium-channel blockers, β-blockers) are relatively contraindicated in patients with WPW; treating SVT alone does not eliminate risk for sudden death; high-risk patients may require potent medications (eg, flecainide, amiodarone, sotalol; carry a risk for arrhythmia) or ablation; limited methods exist to determine level of risk; ablation is recommended for all patients with WPW unless low risk or taking medications

Long QT syndrome: concern for patients experiencing palpitations, chest pain, or syncope during exercise (symptoms occurring after exercise and during rest are more likely to be vagally mediated and unassociated with long QT syndrome); associated with VT and sudden death (presentation in 30% of patients); indicators include family history of syncope, seizures, or sudden death, or symptoms triggered by, eg, exercise, emotional stress, loud noises; correcting the QT interval is important, as computer calculations may be inaccurate

Dysautonomia (eg, postural orthostatic tachycardia syndrome): patients may report heart pounding that is reproducible with change in position; ECG is normal; may be associated with syncope or presyncope; per von Alvensleben et al (2020), strict protocol is necessary for orthostatic vital signs to avoid false-positive results; per Benditt et al (1996), tilt table testing is less commonly used for diagnosis in pediatric patients (in whom risks for false-positive results and confirmation bias are very high) vs adults; deferring orthostatic vital signs and tilt table testing may be prudent to mitigate the risk for confirmation bias

Atrial flutter: atrial rate is 2-fold faster than the ventricular rate

Monitoring: implantable loop recorder — recommended for sustained monitoring; batteries last ≤3 yr; permits continuous remote monitoring; patients can also press a button when symptomatic to trigger event recordings; particularly beneficial for individuals with malignant arrhythmias or bothersome palpitations that are challenging to diagnose with other monitoring methods; smartwatch tracings — Perez et al (2019) showed high sensitivity and specificity of smartwatch tracings in detection of AF in adults; Garikapati et al (2022) demonstrated the 15 different devices being used to detect AF and arrhythmias in the general population; Paech et al (2022) demonstrated 100% classification of correct smartwatch-produced ECG rhythm by a pediatric cardiologist in preterm neonates, including those with extreme prematurity (with weight 0.65-3 kg); Garikapati et al (2022) noted the need for additional studies, a lack of systematic data regarding accuracy and utility, and challenges regarding quality standards and privacy with use of smartwatches; smartwatch tracings can aid in diagnosis, especially for AF, but may yield false-positive results for sinus arrhythmia in children; caution is needed in clinical decision-making

Diagnosis and treatment: obtaining a full 12-lead ECG is crucial for accurate diagnosis; radiofrequency ablation or cryoablation can be curative

Readings

Benditt DG, Ferguson DW, Grubb BP, et al. Tilt table testing for assessing syncope. American College of Cardiology. J Am Coll Cardiol. 1996;28(1):263-75. doi:10.1016/0735-1097(96)00236-7; Frommeyer G, Eckardt L, Breithardt G. Panic attacks and supraventricular tachycardias: the chicken or the egg? Neth Heart J. 2013;21(2):74-7. doi:10.1007/s12471-012-0350-2; Garikapati K, Turnbull S, Bennett RG, et al. The role of contemporary wearable and handheld devices in the diagnosis and management of cardiac arrhythmias. Heart Lung Circ. 2022;31(11):1432-1449. doi:10.1016/j.hlc.2022.08.001; Gheorghiade M, Adams KF Jr, Colucci WS. Digoxin in the management of cardiovascular disorders. Circulation. 2004;109(24):2959-64. doi:10.1161/01.CIR.0000132482.95686.87; Mahtani AU, Nair DG. Supraventricular tachycardia. Med Clin North Am. 2019;103(5):863-879. doi:10.1016/j.mcna.2019.05.007; Olshansky B, Cannom D, Fedorowski A, et al. Postural Orthostatic Tachycardia Syndrome (POTS): a critical assessment. Prog Cardiovasc Dis. 2020;63(3):263-270. doi:10.1016/j.pcad.2020.03.010; Paech C, Kobel M, Michaelis A, et al. Accuracy of the Apple Watch single-lead ECG recordings in pre-term neonates. Cardiol Young. 2022;32(10):1633-1637. doi:10.1017/S1047951121004765; Perez MV, Mahaffey KW, Hedlin H, et al. Large-scale assessment of a smartwatch to identify atrial fibrillation. N Engl J Med. 2019;381(20):1909-1917. doi:10.1056/NEJMoa1901183; Shah M, Silka M, Silva J, et al. 2021 PACES expert consensus statement on the indications and management of cardiovascular implantable electronic devices in pediatric patients. Cardiol Young. 2021;31(11):1738-1769. doi:10.1017/S1047951121003413; Sheth S, Fares M, Kikano S, et al. Appropriate use of echocardiography for palpitations in paediatric cardiology clinics. Cardiol Young. 2021;31(1):60-62. doi:10.1017/S104795112000325X; von Alvensleben JC. Syncope and palpitations: a review. Pediatr Clin North Am. 2020;67(5):801-810. doi:10.1016/j.pcl.2020.05.004.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Wetzel’s lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Wetzel was recorded at the 49th Annual Pediatric Trends, virtually held May 9-12, 2023, and presented by the Johns Hopkins University School of Medicine. For information about upcoming CME activities from this presenter, please visit https://hopkinscme.cloud-cme.com. Audio Digest thanks the speakers and the Johns Hopkins University School of Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

PD693302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.