=====Palpitations=====

^'Traffic light system' for risk stratification of palpitations ||
^ <WRAP safety box> • skipped beats\\ • thumping beats\\ • short fluttering\\ • slow pounding AND\\ • normal ECG AND\\ • No FHx AND\\ • no structural disease</WRAP>  ^ <WRAP caution>• Hx suggests recurrent tachyarrhythmia\\ • palpitations with assoc symptoms AND/OR\\ • abnormal ECG AND/OR\\ • structural heart disease</WRAP> ^ <WRAP danger>• palpitations during exercise\\ • palpitations with syncope/near syncope\\ • high risk structural heart disease\\ • FHx of inheritable heart disease/SADS\\ • high degree AV block</WRAP> |

^<WRAP notice>ECG findings </WRAP> ^<WRAP notice> Implication/consideration </WRAP> |
^Pre-excitation/delta wave |WPW – AVRT |
^Left atrial enlargement, frequent PACs, sinus bradycardia |[[wiki:cardiovascular:af|Atrial fibrillation]] |
^Left ventricular hypertrophy |[[wiki:cardiovascular:af|Atrial fibrillation]], ventricular tachycardia |
^Frequent PVCs |Ventricular tachycardia |
^Q waves |Ischaemic heart disease – [[wiki:cardiovascular:af|Atrial fibrillation]], ventricular tachycardia |
^Widespread T wave inversion across precordial leads,\\ LVH, Q waves and ST-segment changes |Hypertrophic cardiomyopathy – risk of atrial fibrillation, ventricular tachycardia |
^Long or short QT interval, Brugada pattern,\\ early repolarisation pattern |Genetic arrhythmia syndromes – risk of sudden cardiac death |
^Inverted T waves or Epsilon waves across right precordial leads (V1–V3)* |[[wiki:cardiovascular:arrhythmogenic_rv_dysplasia#arrhythmogenic_right_ventricular_cardiomyopathy|ARVC]] – <wrap em>risk of sudden cardiac death</wrap> |
|//*in patients without RBBB//\\ ARVC - Arrhythmogenic Right Ventricular Cardiomyopathy ||

====Idiopathic Fascicular VT====
[[https://litfl.com/idiopathic-fascicular-left-ventricular-tachycardia/|LITFL - idiopathic fascic VT]]\\ 
[[https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-9/Idiopathic-fascicular-left-ventricular-tachycardia|European Soc Cardiol idiopathic fascic VT 2010]]\\ 
  *usually in young healthy adults 15-40yo, predominantly male resulting from ventricular ectopic focus
  *a re-entrant tachy causing palpitations usually at rest but may be with exercise, stress, other catecholamine triggers etc
  *often mis-diagnosed as SVT - look for dissociated P waves and narrow complex 'capture beat'
  *good prognosis
  ***Monomorphic ventricular tachycardia** eg. fusion complexes, AV dissociation, capture beats
  *90% of monomorphic VT = result of structural cardiac disease, usually IHD and others etc
  *10% therefore NOT assoc with structural disease & therefore known as idiopathic VT with >75% of these arising in RV and the remainder in the L with most of these in L posterior fascicle
  *QRS duration 100 – 140ms — ie. narrower than other forms of VT
  *Short RS interval (onset of R to nadir of S wave) of 60-80 ms — the RS interval is usually > 100 ms in other types of VT
  *RBBB Pattern
  *Axis deviation depending on anatomical site of re-entry circuit (see classification)
  *first line treatment = <wrap em>Verapamil</wrap> 
  *Classification:
    *Posterior fascicular VT (90-95%): RBBB morphology + left axis deviation; arises close to the left posterior fascicle
    *Anterior fascicular VT (5-10%): RBBB morphology + right axis deviation; arises close to the left anterior fascicle
    *Upper septal fascicular VT (rare): atypical morphology – usually RBBB but may resemble LBBB instead; cases with narrow QRS and normal axis have also been reported. Arises from the region of the upper septum

==Management==
  *characteristically responds to verapamil
  *does not respond to adenosine, vagal manoeuvres, lignocaine

==References include:==
https://bjcardio.co.uk/2009/07/10-steps-before-your-refer-for-palpitations/\\ 
https://www1.racgp.org.au/ajgp/2019/april/approach-to-palpitations\\