Establishing a Smartphone Ambulatory ECG Service for Patients Presenting to the Emergency Department with Pre-Syncope and Palpitations

Background and Objectives: The IPED study showed that a smartphone-based event recorder increased the number of patients in whom an ECG was captured during symptoms over five-fold to more than 55% at 90 days compared to standard care [1] and concluded that this safe, non-invasive and easy to use device should be considered part of on-going care to all patients presenting acutely with unexplained palpitations or pre-syncope. This study reports the process of establishing a smartphone palpitation and pre-syncope service. Materials and Methods: A clinical Standard Operating Procedure (SOP) was devised, and funding was secured through a business case for the purchase of 40 AliveCor devices in the first instance. The clinic was launched on 22nd July 2019. Results: Between 22nd July 2019 and 31st October 2019, 68 patients seen in the ED with palpitations or pre-syncope were referred to SPACC. 30 were male and 38 female and mean age was 45.8 (SD 15.1) with a range from 18 to 80 years. 50 (74%) patients underwent full investigation. 7 (11%) patients were deemed on first assessment to have non-cardiac palpitations and were not fitted with the device. All patients who underwent full investigation achieved symptomatic rhythm correlation most with sinus rhythm, ventricular ectopics or bigeminy. A symptomatic cardiac dysrhythmia was detected in 6 (8.8%) patients. 3 patients had supraventricular tachycardia; SVT (4%), 2 had atrial fibrillation (3%) and 1 atrial flutter (2%). Qualitative feedback from the SPACC team suggested several areas where improvement to the clinic could be made. Conclusion: We believe a smartphone palpitation service based in ambulatory care is simple to implement and is effective at detecting cardiac dysrhythmia in ED palpitation patients.

Benefits of effective multidisciplinary teamwork: catheter ablation of premature ventricular ectopics

The case concerns a difficult but successful right ventricular outflow tract ectopy catheter ablation in a fit and well 33-year-old man with a 16-year history of symptomatic premature ventricular contractions (PVCs). Beta blockade medication had become ineffective in suppressing the PVCs, and a 24-hour Holter monitor revealed a high burden of ectopy (10%). An echocardiogram and cardiac MRI showed a structurally normal heart. During the procedure, it became impossible to uncurve the catheter, and it lodged in the patient’s right femoral artery. Immediate collaboration with interventional cardiology and interventional radiology was required to resolve the issue. The case demonstrates that excellent teamwork and calling rapidly on input from subspecialties are integral to overcoming unexpected events and to achieve a safe and successful outcome. The patient involved was a medical student at the time and as one of the coauthors offers a unique insight.

A case report on clozapine-induced ventricular ectopics: a fatal adverse drug reaction

BackgroundClozapine is one of the most efficacious antipsychotic drug used for the treatment-resistant schizophrenia; it is sometimes associated with serious adverse reactions like agranulocytosis, myocarditis, cardiac rhythm disturbances, etc.Case presentationA 30-year-old patient with a primary diagnosis of paranoid schizophrenia (ICD code - F20.05) was on regular prescription for 6 years. Due to refractoriness, the patient was initiated on tablet clozapine. After 45 days of clozapine therapy, he presented with the complaints of worsening of positive symptoms and sudden falls associated with a brief period of unresponsiveness for which the patient was admitted for evaluation. After stabilization of the patient, it was concluded that he was suffering from ventricular ectopics based upon cardiac investigations like electrocardiogram (ECG) and Holter monitoring. Upon causality assessment between the adverse drug reaction (ADR) and the suspected drug using Naranjo Scale and WHO causality assessment scale, the ADR was found to be probable.ConclusionsThis case report will help to keep physicians vigilant about the rare cardiac side effects of clozapine and to do regular ECG monitoring of the patients who are on clozapine. Moreover, this case report generates the evidence of clozapine-induced arrhythmia, which is needed to be quantified with aggressive study design and there is a need to study the dose-dependent relationship of clozapine-induced arrhythmia.

A Study for dexmedetomidine for Fibreoptic intubation

Trauma is a major fitness hassle of modern-day society and maxillofacial injuries because of high-pace trauma from avenue visitors accidents, sports activities accidents or falls require airway renovation with cervical spine stabilisation and manage of bleeding along a unique set of problems.Compromised airway is lifestyles-threatening both within the early and later levels leading to hypoxia or obstruction. Awake fibreoptic bronchoscope (FOB)-guided endotracheal intubation (AFOI) is an powerful method for coping with patients with tough airway, and is presently taken into consideration the gold standard(eleven). Dexmedetomidine at a dose of 0.75 mcg/kg and 1.0 mcg/kg over 20 mins turned into drastically found to be powerful in maintaining sufferers comfy at some point of Awake fibre optic intubation. While 0.5 mcg/kg of loading dose had strong haemodynamics and did no longer have any adverse occasions, 1 mcg/kg of loading dose precipitated high blood pressure in 2 sufferers and 0.75 mcg/kg of loading dose triggered cardiac rhythm abnormality (ventricular ectopics) in one patient. Dexmedetomidine at a loading dose of 0.5 mcg/kg is secure, whereas loading doses of zero.75 mcg/kg and 1 mcg/kg gives better patient consolation. More quantity of research ought to be finished the use of a packing dose of 0.75 mcg/kg to set up its protection.

Vasopressin-Induced Ventricular Arrhythmia

Long QT and ventricular tachyarrhythmias can occur due to a number of causes including dyselectrolytemia, drugs, and intracranial lesions, predominantly subarachnoid hemorrhage. Here the authors report a rare case of acquired long QT with R on T ventricular ectopics due to vasopressin in the setting of intracerebral bleed, which reverted on withdrawal of vasopressin.

The Value of Holter Monitoring in the Assessment of Non-Specific Symptoms

Background: To assess the importance of Holter monitoring in evaluation of non-specific symptoms (like presyncope, dizziness, palpitations, syncope, etc.). Patients and Methods: This is an observational , prospective descriptive study which was conducted at Shaheed Al-Mihrab cardiac centre at Babylon City - Iraq in which 100 patients referred from the consultation department for the assessment of non-specific compliants were included in this study . Holter monitoring was done for all patients after initial evaluation. Holter monitoring was accomplished using GE Holter system with two channels and five leads, attached to the anterior chest wall. The recorder was attached to a strap, which was attached to the patient shoulder. The recording was started in the morning at hospital working hours and the patient was allowed to go home and to resume his normal activities. He was advised to maintain his activity and asked to return back at the same time next day. Results: 87% of patients have less than 10% premature ventricular ectopics as an isolated event while 90% of the patients have Supraventricular arrythmias less than 10% as isolated events. The mean minimum heart rate was 47 , mean maximum heart rate was 117 and mean average heart rate was 65 . 18 % of patients have ST segment Shift in which 4% were ST-segment elevation and 14% were ST segment depressions. Conclusion: Holter monitoring was found to have no important role for the early diagnosis of arrhythmias or ischaemia as a cause of compliant in patients with non-specific symptoms

Unusual association between spinal cord tumour and perioperative arrhythmia

There are multiple causes of perioperative arrhythmias. Some have underlying cardiac disease while others accompany systemic pathology. Use of anaesthetic agents in the intraoperative period is also a known cause of rhythm abnormalities. Preoperative benign arrhythmias may progress to serious ones in intraoperative period. The trigger may be a transient insult such as hypoxemia, cardiac ischaemia, catecholamine excess or electrolyte abnormality. Thus, presence of arrthymia in the preoperative period adds to preoperative work-up and especially in the elective surgery settings, they call for additional opinion and patient evaluation. However, not all arryhthmias are amenable to drug treatment and modalities like pacing, some require just careful watch in the perioperative period. We report a patient with thoracic intramedullary space occupying lesion who presented to us with multiple ventricular ectopics on electrocardiography, which eventually disappeared with tumour removal. The case highlights the association of multiple ectopics with spinal tumour and their management.