Approach to palpitation family medicine case discussion 2010

Approach to palpitation family medicine case discussion 2010

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  Palpitation Department of Family Medicine Case Discussion Puan Rahimah a 54 years old Malay lady comes with her son to see you in the clinic with the complaint of palpitation for the past 6 months. She is married with 4 children and her husband is a pensioner Questions 1) What question would you ask in assessing patient who presented with palpitation. 2) Based on safe diagnostic strategy, state differential diagnoses. 3) What is your diagnosis for this lady? 4) What investigation would you do for her? 5) How would you treat her?
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  What is Palpitation Anuncomfortable or abnormal awareness of the heart beat, are common in primary care patients. In one study, recurrent symptoms occurred in 75% of patients and 33% reported lower quality of life, but the 1-year mortality rate was 1.6% [Robert B. Taylor] Usually felt over the precordium or in the throat or neck. The patient may describe them as pounding, jumping, turning, fluttering, or flopping or as missing or skipping beats. Palpitations may be regular or irregular, fast or slow, paroxysmal or sustained. [Handbook of Signs & Symptoms 3rd ed] Palpitation can be caused by cardiac and non cardiac origin. The most common cardiac causes of palpitation is atrial fibrillation. However, less than half of the total patient presented to GP with palpitation has significant cardiac problem. Others are benign and most of it are due to psychological problem especially anxiety. The initial task is to detect a life-threatening cause of the PPTs. Studies have shown a 7% to 40% incidence of potentially serious arrhythmias in these patients, although the cause in up to 31% is psychiatric [Robert B. Taylor] In woman, palpitation occur at any age especially during the luteal phase of the menstrual cycle, pregnancy and perimenopausal syndrome. In perimenapausal period, it is usually benign and related to increased sympathetic activity caused by the menopause. In order not to miss the causes of palpitation, a mnemonic VITAMIN CDE can be used. Vascular - (aortic aneurysms, arteriovenous fistulas, anemia, postural hypotension, migraine, and cardiac disorders such as aortic regurgitation, aortic stenosis, tricuspid insufficiency, CH) Inflammation/infection - (fever, pericarditis, bacterial endocarditis, rheumatic fever.) Trauma (due to increase release of catecholamines) Anxiety / Autoimmune. Metabolic – electrolyte disorder. Idiopathic / intoxication - alcohol, tobacco, coffee, soft drinks, and tea Neoplasm – rarely causes palpitation Congenital – heart problem Drugs – digitalis, aminophylline, sympathomimetics, ganglionic blocking agents, nitrates Endocrine - thyrotoxicosis, pheochromocytoma, menopausal syndrome, and hypoglycemia.
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  Red Flag inpalpitation Like what have been written previously, most of the causes for palpitation are benign and less than half of it are due to cardiac origin. However, once should pay an attention for Red flag of palpitation. 1. Syncope 2. Associated cardiac manifestation Patient with high risk of cardiac etiology could be predicted based on few characteristic which includes 1. Male gender 2. Irregular heart beat 3. History of heart disease 4. Event duration more than 5 minutes Since, cardiac arrhythmia is one of the causes for palpitation, one should look for cardinal sign of unstable patient which includes 1. Altered Mental Status 2. On going chest pain 3. Hypotension 4. Acute Pulmonary Edema
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  Question to beasked in assessing patient who presented with palpitation 1) Characteristic of the palpitation a) Rapid, irregular (AF, multifocal artrial tachycardia, artrial flutter) b) Rapid, regular (supraventricular tachycardias, Sinus tachycardia and ventricular tahycardia) c) A “stop-start,” “flip-flop,” or “turning over” sensation in the chest (premature ventricular contractions or premature atrial contractions d) Palpitation perceived at neck (AV nodal reentrant tachycardia, premature ventricular contractions) e) Constant – suggest tachycardia, and that would suggest hyperthyroidism or overuse of caffeine and other drugs. may also point out fever of unknown origin. f) Intermittent palpitations -cardiac arrhythmia, particularly extrasystoles. 2) What patient did during the attack occur? a) Anxiety or somatization disorders b) Catecholamine release (exercise, emotional stress) c) At rest - benign condition d) In changes of posture - SVT or PVCs 3) Onset and termination a) abrupt onset and termination of PPTs suggests PSVT b) Anxiety can lead to sinus tachycardia following an arrhythmia, precluding the patient from sensing an abrupt cessation. 4) Associated symptoms a) Ruled out sustained or nonsustained VT if syncope, presyncope, or dizziness occurs b) weight loss, increased appetite, and polyuria – hyperthyroidism c) shortness of breath and pitting edema - congestive heart failure 5) Others relevant history a) Occurs after taking some drugs or changing into another type of drugs b) Association with food c) Any known medical illness like Diabetes mellitus, thyroid problem,congenital heart problem etc d) Menstrual history in woman.
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  Safe Diagnostic Strategy ASafe Diagnostic strategy was designed by John Murtagh and the method was publish in Australian Family Physician Journal, volume 19 in the year of 1990. It outlines a diagnostic model applicable to all common problems encountered in general practice. It has an inbuilt safety strategy to help the busy practitioner consider life threatening conditions and other serious illnesses during the diagnostic process. A health care personnel must bear in their mind that there are 5 questions need to be answered when dealing with a patient who presented to them. The strategy is to demonstrate that you have a logical and safe approach to making diagnoses. What is the most likely diagnosis? Case Study What serious disorders must not be missed? 54 years old Malay lady with complaint of palpitation for What conditions are often the past 6 months missed? Could the patient have a masquerading illness? List at least 7 Is the patient trying to say something? Differential diagnosis 1) Most likely diagnosis – Perimenopausal syndrome 2) Serious disorder not to miss – Unstable Atrial fibrillation 3) Condition often miss – Diabetes mellitus, hyperthyroidism, pheochromocytoma 4) Masquerading illness – alcohol intoxication, caffeine abuse, stess and anxiety 5) Is the patient try to say something – most likely related with psychological aspect.
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  What is yourdiagnosis for this lady? The most probable diagnosis for this patient based on limited data given (age, sex, onset and duration) is mainly benign and non cardiac related. I’m confidently say that based on data provided by Hoefman E, et al Therefore my most probable differential diagnosis would be 1. Perimenopausal syndrome Palpitations associated with menopause and the perimenopausal period are usually related to sinus tachycardia or to simple arrhythmias because of increased sympathetic drive. The menopausal state is characterized by a marked decrease in ovarian estradiol production and an associated increase in adrenergic activity. In menopausal women, cardiovascular control shifts toward a sympathetic predominance. Estrogen replacement therapy improves this altered control and can improve the cardiovascular symptoms such as hot flushes and papitations. Of note, some progestins given in conjunction with estrogen replacement may trigger cardiac arrhythmias in patients; however, this effect is usually remedied by decreasing the progestin dose or by using a natural progestational agent. [Elizabeth R. Keeler et al] 2. Anxiety disorder. Management for this patient 1) 12 lead ECG for cardiac problem screening 2) Re assurance for the patient. 3) Psychological councelling to relieve anxiety. 4) Severe anxiety may require further referral to psychiatrist for anti anxiety management.
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  Evidence Based Medicine 1)Relationship between pulse palpation and atrial fibrillation Georga Cooke et al has analysed three studies by Morgan & Mant, Somerville et al and Sudlow et all that compared pulse palpation with ECG. The estimated sensitivity of pulse palpation ranged from 91% to 100%, while specificity ranged from 70% to 77%. Pooled sensitivity was 94% (95% confidence interval [CI], 84%–97%) and pooled specificity was 72% (95% CI, 69%– 75%). The pooled positive likelihood ratio was 3.39, while the pooled negative likelihood ratio was 0.10. Therefore the author conluded that pulse palpation has a high sensitivity but relatively low specificity for atrial fibrillation. It is therefore useful for ruling out atrial fibrillation. It may also be a useful screen to apply opportunistically for previously undetected atrial fibrillation. Assuming a prevalence of 3% for undetected atrial fibrillation in patients older than 65 years, and given the test’s sensitivity and specificity, opportunistic pulse palpation in this age group would detect an irregular pulse in 30% of screened patients, requiring further testing with ECG. Among screened patients, 0.2% would have atrial fibrillation undetected with pulse palpation. 2) Goal standard in accessing cardiac arrhythmia Obtaining a 12-lead echocardiogram (ECG) at the onset of symptoms is the gold standard in diagnosing cardiac arrhythmias. The resting 12-lead ECG offers valuable information regarding the presence of pre-existing conditions such as pre-excitation and ischaemic heart disease. Event recorders used over a 2-week period offer an effective way to capture cardiac arrhythmias. Holter monitors are also used in patients who have frequent symptoms. With the advent of new transcatheter cardiac ablation techniques and depending on the rhythm disturbance, management has become more successful (Ramzi YK & Mark D) 3) Differential diagnosis for palpitation The majority of patients presenting with palpitations are suffering from either anxiety or ectopic beats. In anxious patients, a recording of their ECG showing sinus rhythm while they have symptoms is reassuring for patient and doctor alike. The majority of ectopics are also benign, but in the case of ventricular ectopics it is important to ensure that there are not more serious ventricular arrhythmias occurring at other times. Again a recording of the rhythm while the patient is symptomatic is very helpful.Palpitations can be a reflection of dangerous cardiac arrhythmias. In one study of 190 patients with palpitations, 1.6% died and 1.1% had a stroke within 1 year of presentation (Ramzi YK & Mark D)
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  4) Accurate predictionby GPs of the presence of a (relevant) arrhythmia in patients presenting with palpitations and/or lightheadedness This study by Emmy Hoefman et al confirmed that an accurate prediction by GPs of the presence of a (relevant) arrhythmia in patients presenting with palpitations and/or lightheadedness and an inconclusive standard ECG is not possible at this moment. GPs do not have an accurate instrument at hand to predict which patients might profit from further diagnostic evaluation. As our sample was small, further research is needed to develop accurate triage rules. In cases where a standard ECG does not lead to a diagnosis, evidence suggests that a continuous event recording (CER) might be very helpful in the decision to treat or refer a patient. Reassuring a patient without using this diagnostic test might be premature.Therefore, a low threshold for further diagnostic testing seems adequate. 5) Non-cardiac chest pain and benign palpitations in the cardiac clinic in 94 consecutive referrals by general practitioners to a cardiac clinic with the presenting disorder of chest pain or palpitations. Fifty one patients were given no major physical diagnosis. Although all were new referrals to the clinic, many had already received considerable medical care for their symptoms. Conclusion: A substantial proportion of the consecutive referrals continued to describe symptoms and disability throughout the three years after clinic attendance. Outcome was poor for those who had negative investigations and were reassured that they had no cardiac disorder or other serious physical finding. These results have implications for defining the role of psychological assessment and for the formulation of cost effective clinical measures to (a) minimise disability associated with cardiac disorder; and (b) prevent and treat handicaps in those without major physical diagnoses [Richard Mayou et al] 6) Characteristics of patients presenting to a cardiac clinic with palpitation Most patients presenting to secondary care with palpitation do not have serious underlying cardiovascular conditions. Concurrent psychological problems are common and persistent. Aetiology may be seen as an interaction of pathology, awareness of normal physiology, and psychological variables. Few patients require specialist cardiological treatment, but simple reassurance is of limited effectiveness. A stepped care approach may improve outcomes and needs rigorous evaluation.[R. Mayou et al]
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  7) Laboratory Evaluationof palpitation based on article by Elizabeth R. Keeler et al A few basic hematological and chemistry studies should be performed to assess for anemia, hyperthyroidism, electrolyte disturbances (especially in patients taking digitalis), and hypoglycemia. If there is evidence suggesting a pheochromocytoma, a 24-hour urine assessment for vanillylmandelic acid is helpful All patients complaining of palpitations should have an electrocardiogram to distinguish supraventricular from ventricular tachycardias and to help to identify the type of SVT during the arrhythmia If the history, physical examination, and a 12-lead electrocardiogram fail to point to an etiology of the palpitations, further investigation should be performed. If palpitations occur on a daily basis, 24-hour continuous ambulatory electrocardiographic monitoring may be helpful (Holter monitors) When palpitations are associated with exertion, an exercise stress testing should be done because ventricular tachycardia may be uncovered An echocardiogram should be done when the history, physical exam, or EKG raise suspicion of valvular disease or cardiomyopathy Electrophysiological studies (EPS), either via the transesophageal or intracavitary route, are able to identify some arrhythmias. Because this technique is invasive, EPS should be limited to individuals who have asymptomatic nonsustained VT and either evidence of underlying heart disease or a reduced ejection fraction (< 40%) 8) Prevalence of palpitations, cardiac arrhythmias and their associated risk factors in ambulant elderly, by Lok NS, Lau CP, Int J Cardiol. 1996 Jun;54(3):231-6. To determine the prevalence of palpitations, cardiac arrhythmias and associated cardiovascular risk factors in an ambulatory elderly population, 1454 ambulatory elderly people (219 men and 1235 women, age range 60-94 years) were assessed in a territory-wide health survey including anthropometric measurements, biochemical blood tests, questionnaire interview and resting surface ECG examination. Prevalence of palpitations and ECG abnormalities were determined and correlated with coronary risk factors and biochemical blood tests. Palpitations were present in 121 subjects (8.3%) and cardiac arrhythmias were found in 183 subjects (12.6%). Conduction abnormalities and sinus bradycardia were the commonest findings (9.8%). Premature beats (atrial 2.3%; ventricular 1%) were the next most frequent arrhythmia. Atrial fibrillation was the commonest sustained arrhythmia that was present in 19 subjects (1.3%). Compared with those
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  without arrhythmia onECG, people with arrhythmias were predominantly males and were older (72 +/- 8 years vs. 70 +/- 6 years, P < 0.05), had a higher prevalence of smoking (12.9% vs. 5%, P < 0.05) and coronary heart disease (30.7% vs. 11.4%, P < 0.05). The prevalence of palpitations between subjects with documented arrhythmias (excluding conduction disturbance) and those without arrhythmias on surface ECG was similar (9% vs. 7.7%, P = N.S.). We conclude that cardiac arrhythmias are common in the elderly and are often asymptomatic. Subjects with ECG documented arrhythmias are more common in males, and are associated with smoking and ischaemic heart disease. Palpitation was a frequent complaint in the ambulatory elderly with no bearing on arrhythmias recorded on resting ECG. Reference: 1) Elizabeth R. Keeler, Robert K. Morris,Dolar S. Patolia & Eugene C. Toy," The Evaluation and Management of Palpitation", Prim Care Update Ob/Gyns, Volume 9, Number 6, 2002 © 2002 Elsevier Science Inc 2) Georga Cooke, Jenny Doust & Sharon Sanders, " Is pulse palpation helpful in detecting atrial fibrillation? A systematic review", The Journal of Family Practice ©2006 Quadrant HealthCom Inc. 3) Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins. 4) Hoefman E, Boer KR, van Weert HCPM, Reitsma JB, Koster RW and Bindels PJE. Predictive value of history taking and physical examination in diagnosing arrhythmias in GP. Family Practice 2007; 24: 636–641. 5) Lok NS, Lau CP, "Prevalence of palpitations, cardiac arrhythmias and their associated risk factors in ambulant elderly, Int J Cardiol. 1996 Jun;54(3):231-6. 6) Ramzi Y Khamis & Mark Dancy, " Palpitations", MEDICINE 37:2, © 2008 Elsevier Ltd. 7) Robert B. Taylor, "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time- Limited Encounter ", Copyright © 2000 Lippincott Williams & Wilkins. 8) R. Douglas Collins, "Algorithmic Diagnosis of Symptoms and Signs", Copyright © 2003 Lippincott Williams & Wilkins. 9) R Mayou, B Bryant, C Forfar, et al, "Non-cardiac chest pain and benign palpitations in the cardiac clinic", Br Heart J 1994 72: 548-553 10) R. Mayou, D. Springings, J. Birkhead & J. Price, "Characteristics of patients presenting to a cardiac clinic with palpitation", Q J Med 2003; 96:115–123