Cardiac arrhythmias and syncope

Swayampakula AK, et al. Arrhythmogenic causes of syncope. Pediatr Emerg Care. 2014 Dec;30(12):894-5.

Syncope is one of the common presenting complaints in the pediatric emergency department. The evaluation may begin with consideration of the most common causes. However, it is important to exclude the rare causes, including cardiac arrhythmias that may lead to sudden death in young patients. Brugada syndrome and catecholaminergic polymorphic ventricular tachycardia are some of the rare causes of primary electrical disorders of the heart. High suspicion of these disorders in the evaluation, and appropriate referral to a cardiologist may prevent sudden deaths in these patients. Here, we report 2 children with arrhythmogenic causes of syncope.

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Kakavand B, et al. Frequent ventricular premature beats in children with a structurally normal heart: a cause for reversible left ventricular dysfunction? Pediatr Cardiol. 2010 Oct;31(7):986-90.

Ventricular premature beats (VPBs) in a structurally normal heart generally are a benign condition. Rarely, however, reversible cardiomyopathy may develop. This study aimed to evaluate the incidence of cardiomyopathy among pediatric patients in a cohort with frequent VPBs and to examine the characteristics of the ventricular ectopic beats as well as therapeutic options. This study reviewed the charts of all pediatric patients between the ages of 1 day and 18 years seen at the University of Kentucky with the diagnosis of VPBs between 2003 and 2007. Frequent VPBs were defined as an ectopy burden of 5% or more in 24 h. Electrocardiograms, Holter monitors, and echocardiograms were reviewed. The review identified 28 patients (17 boys, age 13.3 ± 5.9 years, and 11 girls, age 13 ± 5.2 years) with frequent VPBs. The echocardiograms of four patients (2 boys, 14%) showed cardiomyopathy. Cardiac function normalized in all four patients, with spontaneous resolution of the VPBs (2 patients) or with antiarrhythmic therapy (2 patients). During a follow-up period of 2.7 ± 2.3 years, 32% of the patients without cardiomyopathy showed a marked spontaneous improvement in arrhythmia burden. Most of the patients showed VPBs with a left bundle branch block (LBBB) and inferior axis morphology. The most commonly associated symptoms were chest pain (17.8%) and dizziness and syncope (21.4%). Generally, VPBs in structurally normal hearts are considered benign. Rarely, a reversible cardiomyopathy can develop, requiring therapeutic intervention.

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Black, KD, et al. (2011). Cardiogenic causes of pediatric syncope. Clinical Pediatric Emergency Medicine, 12(4), 266-277.

Syncope is a common presentation for children in the emergency department (ED). Cardiac causes of pediatric syncope are rare but may be life threatening and have the highest risk of morbidity and mortality. An extensive workup for syncope is usually unnecessary. All children presenting to the ED with syncope should have a detailed history, physical examination, and electrocardiogram performed. These components should be used to guide further diagnostic studies and subspecialty referrals. Cardiology consultation or referral should be considered if a cardiac etiology is suspected due to “red flags” identified during the history, physical examination, or electrocardiogram. An algorithmic approach to the evaluation of pediatric syncope in the ED is recommended.

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Rivera, RF, et al. (2011). Evaluation of children with palpitations. Clinical Pediatric Emergency Medicine, 12(4), 278-288.

Palpitations are a common symptom in children and adolescents presenting to the emergency department. The differential diagnosis can range from benign etiologies to life-threatening dysrhythmias. Although the most common causes of palpitations in pediatric patients are benign, the emergency department physician is charged with determining which patients would require immediate management, workup, and referral to a cardiologist. This article will specifically address the symptom of palpitations in pediatric patients, isolating it from the more frequently reviewed subject of chest pain.

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Mace, S. (2010). Syncope in pediatric patients. Pediatr Emerg Med Reports, 15, 13-20.

Dysrhythmias. Because cardiac syncope can be a harbinger for sudden death, the possibility should be considered in every patient with syncope. The number one etiology of dysrhythmias in pediatric patients is probably congenital heart disease.[17] Sudden cardiac death is associated with both noncorrected congenital heart disease patients and those who are status post corrective cardiac surgery. Sudden death from dysrhythmias is known to occur particularly in congenital heart disease patients status post corrective cardiac surgery for tetralogy of Fallot, transposition of the great vessels (after a Mustard or Senning procedure for a baffle), and single ventricle (after a Fontan procedure).[17-22] Patients with noncorrected congenital heart disease who are especially vulnerable to sudden death include patients with Eisenmenger’s syndrome, Ebstein anomaly, atrioventricular canal, aortic stenosis, coronary artery abnormalities, and mitral valve prolapse.[17-22] Secondary or acquired cardiovascular disease can also be associated with sudden death from dysrhythmias and includes myocarditis/ cardiomyopathies (for example, hypertrophic obstructive cardiomyopathy, primary/ secondary myocarditis), pulmonary hypertension, and Kawasaki’s disease.[17-26]

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Alexander ME, Berul CI. Ventricular arrhythmias: when to worry. Pediatr Cardiol. 2000 Nov-Dec;21(6):532-41.

Although isolated premature ventricular contractions may be seen in as many as 15% of normal newborns, one third of normal adolescents, and two thirds of adolescents and adults with repaired heart disease, sustained ventricular arrhythmias are relatively rare in young normal hearts. Sudden cardiac health is rare in young normal hearts, although there is an increased incidence in dilated cardiomyopathies and following repair of particular congenital heart lesions. Noninvasive and invasive techniques imperfectly stratify these patients. Patients with cardiomyopathy often have ventricular arrhythmias, although the risk of mortality is more closely linked to ventricular function. There are many infants and pediatric patients with apparently normal hearts who have combinations of asymptomatic nonsustained ventricular tachycardia and potentially serious symptoms. The clinical concern is to identify diagnoses such as long QT syndrome associated with recurrent cardiac syncope and premature mortality so that appropriate choices can be made regarding drug and device therapy. Although this broad range of disease places a premium on careful evaluation, selective therapy, and continued research, serious symptoms, even in the absence of ectopy, are concerning in any patient.

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More PubMed results on arrhythmias and syncope.

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