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Chapter 81: Approach to the Patient with Cardiac Arrhythmias

A 40-year-old woman presents to your clinic complaining of palpitations that have become more frequent in the last few years, having occurred three times in the last year. They are described as rapid, regular, of sudden onset and sudden offset, with no clear precipitant. Three years ago, a supraventricular tachycardia was noted on EKG, which terminated abruptly with adenosine administration in the emergency department. Her transthoracic echo at that time revealed a structurally normal heart. She regularly drinks 1 to 2 cups of coffee per day, and she does not ingest other caffeinated products. With regard to caffeine intake, what advice do you give her?

A. She should limit her caffeine intake to 1 cup of coffee per day

B. She should stop all caffeine consumption

C. Caffeine is not clearly linked with paroxysmal SVT

D. She should increase her intake to assess whether caffeine is a precipitant for her palpitations

E. She should drink tea instead

The answer is C. (Hurst’s The Heart, 14th Edition, Chap. 81). Neither alcohol nor caffeine is clearly linked with paroxysmal SVT or sustained ventricular tachycardias. The link between caffeine and arrhythmias is unclear, and perhaps more clear for sinus tachycardia than supraventricular tachycardias (SVT).1 Options A and B suggest reducing or discontinuing caffeine intake, but there are no data to suggest that this will reduce her symptoms or arrhythmia burden.

Which of the following is most in favor with cardiac syncope as opposed to a seizure?

A. Waking with a cut tongue

B. Loss of consciousness with emotional stress

C. Head turning to one side during loss of consciousness

D. Prolonged standing prior to event

E. Abnormal behavior noted

The answer is D. (Hurst’s The Heart, 14th Edition, Chap. 81). Scoring systems exist to separate cardiac syncope from seizures (see Table 81-1 in Hurst’s The Heart, 14th Edition).2 It is essential to document neurological prodromes or sequelae that may suggest the aura or postictal state of seizures or focal neurological abnormalities that may point to a nonarrhythmic etiology, including waking with a cut tongue (option A), loss of consciousness with emotional stress (option B), head turning to one side during the loss of consciousness (option C), the presence of abnormal behavior (option E), postictal confusion, and prodromal deja vu. Criteria more in favor of a syncopal episode include any presyncope, loss ...

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