How do you manage an abnormal pulse?

Management of Abnormal Pulse

The management of an abnormal pulse requires a systematic approach including ECG documentation, identification of the underlying rhythm, and treatment based on the specific arrhythmia diagnosed. 1

Initial Assessment

• Physical examination may reveal an abnormal pulse through irregular pulse rhythm, irregular jugular venous pulsations, and variation in the loudness of the first heart sound 1
• Pulse deficit (difference between apical and peripheral pulse rates) should be assessed when irregular rhythm is detected 2
• Determine if the patient is hemodynamically stable or unstable, as this will guide immediate management decisions 1

Diagnostic Evaluation

Minimum Required Testing

• Electrocardiogram (ECG): Essential for documenting the arrhythmia - at least single-lead ECG recording during the dysrhythmia 1

• History and physical examination to determine:

  • Presence and nature of symptoms associated with the arrhythmia 1
  • Clinical type (first episode, paroxysmal, persistent, or permanent) 1
  • Onset, frequency, duration, precipitating factors, and modes of termination 1
  • Response to previous treatments 1
  • Presence of underlying heart disease or reversible conditions (e.g., hyperthyroidism, alcohol consumption) 1, 3

• Blood tests: Thyroid function tests, especially for first episodes, difficult rate control, or unexpected recurrence after cardioversion 1

Additional Testing Based on Clinical Presentation

• Holter monitoring or event recording if:

  • Diagnosis of arrhythmia type is unclear 1
  • Episodes are infrequent (event recorder preferred) 1
  • Evaluation of rate control is needed 1

• Echocardiogram to identify:

  • Valvular heart disease 1
  • Atrial and ventricular size and function 1
  • Pulmonary hypertension 1
  • Left ventricular hypertrophy 1
  • Pericardial disease 1

• Chest radiograph when clinical findings suggest pulmonary or vascular abnormalities 1

• Exercise testing for:

  • Evaluating rate control in permanent atrial fibrillation 1
  • Reproducing exercise-induced arrhythmias 1
  • Excluding ischemia before treatment with certain antiarrhythmic drugs 1

• Transesophageal echocardiography to:

  • Identify left atrial thrombus 1
  • Guide cardioversion 1

• Electrophysiological study to:

  • Clarify mechanism of wide-QRS-complex tachycardia 1
  • Identify predisposing arrhythmias 1
  • Locate sites for ablation 1

Management Approach

For Unstable Patients

• Immediate synchronized cardioversion for unstable tachycardia 1
• Atropine for unstable bradycardia 3

For Stable Patients

Management of Specific Arrhythmias

1. Atrial Fibrillation/Flutter:

   • Two fundamental approaches: restore and maintain sinus rhythm OR allow AF to continue with controlled ventricular rate 1
   • Consider anticoagulation to prevent thromboembolism 1
   • Review medication history to identify potential drug-induced causes 1

2. Premature Atrial Contractions (PACs):

   • Eliminate reversible causes (electrolyte abnormalities, hyperthyroidism) 3
   • For symptomatic PACs: beta blockers; consider ablation in selected cases 3

3. Premature Ventricular Contractions (PVCs):

   • Exclude reversible causes (electrolyte abnormalities, hyperthyroidism, stimulant use) 3
   • Echocardiogram to detect underlying heart disease 3
   • Treatment options: beta blockers, non-dihydropyridine calcium channel blockers, or antiarrhythmics 3
   • Consider ablation for patients with PVCs and left ventricular dysfunction 3

4. Supraventricular Tachycardia:

   • Stable patients: consider catheter ablation or antiarrhythmic medications 3
   • For regular wide-complex tachycardias of uncertain origin: IV adenosine may be reasonable for both diagnosis and treatment 1

5. Ventricular Tachyarrhythmias:

   • Sotalol 1.5 mg/kg IV over 5 minutes (avoid in patients with prolonged QT) 1
   • Amiodarone 150 mg IV over 10 minutes, repeated as needed to maximum 2.2g/24 hours 1

6. Sinus Node Dysfunction:

   • Discontinue bradycardia-causing drugs when possible 3
   • Consider pacemaker for symptomatic patients 3

Special Considerations

• Drug-induced arrhythmias: Identify and discontinue offending drugs when possible; if not possible, reduce dose and monitor closely 1
• Autoimmune rheumatic diseases: Be aware of specific arrhythmia patterns - sinus tachycardia in SLE, PVCs in systemic sclerosis, and conduction disorders in RA 4
• Metabolic stress: Address underlying oxidative stress which may contribute to arrhythmogenesis 5

Follow-up

• Regular monitoring of response to treatment 1
• Adjustment of therapy based on symptom control and arrhythmia recurrence 1
• Patient education regarding pulse monitoring, especially for those taking medications with potential to cause arrhythmias 1