Ambulatory arrhythmia monitoring: Use frequency of palpitations to guide your diagnostic modality as an outpatient. The three main modalities to assess for arrhythmia in the ambulatory setting are
- Holter monitor or Ziopatch: Holter monitor is bit more of a pain since it require leads and is uncomfortable. This is good for patients with frequent symptoms and you can have it on for just a couple of days. A Ziopatch is similar but a newer device that is a small sticker that you stick to the chest and is way more convenient. Lasts 2 weeks (therefore higher yield), can shower with it and when done can just mail it in!
- Event recorder: lasts 2-3 weeks and is better for infrequent palpitations. Requires a patient to press a button when they feel palpitations coming on.
- Implantable loop recorder: office procedure to implant this device. Can be left in for months and is the best modality for picking up an arrhythmia. Best used if you are very suspicious that there is indeed an arrhythmia at play but have not been able to identify it thus far.
Ambulatory pearl: when someone complains of palpitations, ask them to tap out the rhythm like a drummer. This will help clarify what the patient means by “palpitations”. This technique that YY uses can tell you if it’s regular or irregular, fast or slow, and if there are pauses or extra beats.
Noncompaction cardiomyopathy (see here: http://circ.ahajournals.org/content/109/24/2965.full)
- Uhhh… I have never heard of this? This is a disorder in embryogenesis when the sponge-like myocardium during development fails to progress and “compact” into normal adult myocardium that is more solid and smooth. As a result, there are lot of trabeculations that remain, and are seen particularly in the LV apex. The result is abnormal myocardium (heart failure) and turbulent flow which can cause LV thrombi. This is considered a genetic cardiomyopathy and there are many identified mutations.
- Classic presentation: heart failure, arrhythmias, embolic events from mural thrombi. However, there is a wide spectrum of presentations and outcomes.
- Are accessory pathways associated with noncompaction? This came up in the case, and from the above article, it seems like WPW was seen in one case series in up to 15% of patients. However, other larger case series did not have any patients with WPW.
Tip for ultrasound aficionados: When assessing for LA enlargement on TTE, a quick rule of thumb is that the LA and the aorta should be about the same size in diameter in the parasternal long view.