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Palpitations
Palpitations are defined as an uncomfortable awareness of the heartbeat. They can be caused by cardiac arrhythmias, psychiatric conditions like anxiety, or other miscellaneous factors like drugs or hyperthyroidism. The goal in evaluating patients with palpitations is to determine if they are caused by a potentially life-threatening arrhythmia. The physician takes a history on the nature of the palpitations and performs an examination and initial testing like an ECG or holter monitor. Depending on the results, further testing with echocardiogram, event recorder, or mobile cardiac telemetry may be used to diagnose the underlying cause, which is important to guide management and reassurance of the patient.
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Palpitations
- 1. PALPITATIONS Dr POLAMURI TABITHA PG FIRST YR
- 2. DEFINITION Uncomfortable awareness of heart beat or undue awareness of heart action. Defined as thumping , pounding or fluttering sensation in the chest. This sensation can be either intermittent or sustained and either regular or irregular
- 3. Most patients interpret palpitations as unusual awareness of the heart beat and become concerned when they sense that they had skipped or missing heartbeats. They are often noted when the patient is quietly resting , during which time other stimuli are minimal.
- 4. PHYSIOLOGY Palpitation is dueto Alteration in heart rate Eg: sinus tachycardia & bradycardia Alteration in heart rhythm Eg: Atrial fibrillation Augmentation of myocardial contraction Eg: anxiety states & drugs
- 5. NATURE OF PALPITATIONS FEATURE SUGGESTS HEART MISSES AND THUMPS ECTOPIC BEATS WORSE AT REST ECTOPIC BEATS VERY FAST REGULAR SVT / VT SUDDEN ONSET SVT / VT OFFSET WITH VAGAL MANOEUVRES SVT FAST AND IRREGULAR AF and ATRIAL FLUTTER with varying block FORCEFUL AND REGULAR – NOT FAST AWARENESS OF SINUS RHYTHM (ANXIETY) SEVERE DIZZINESS OR SYNCOPE VT or BRADYARRHYTHMIAS PRE-EXISTING HEART FAILURE VT
- 6. CAUSES OF PALPITATIONS CARDIAC PSYCHIATRI C 43% 31% MISCELLANEOU UNKNOWN S 10% 16%
- 7. Cardiovascular Causes Arrhythmias Prematureatrial and ventricular contractions Supraventicular and ventricular arrhythmias WPW syndrome Atrial fibrillation Atrial flutter with varying block Brady-arrhythmias : complete heart block Sick-sinus syndrome
- 8. Non-arrhythmic cardiac causes Mitralvalve prolapse (with or without associated arrhythmias) Aortic insufficiency Atrial myxoma Pulmonary embolism Congenital heart ds Systemic hypertension Pericarditis Pacemaker induced tachycardia
- 9. Psychiatric Causes Panicattacks Anxiety states Somatization Patients with psychiatric causes for palpitations more commonly report a longer duration of sensation >15min & multiplicity of symptoms than do patients with other causes
- 10. The physician must remember that panic disorder and significant arrhythmias are not mutually exclusive, and that cardiac evaluation still may be necessary in patients with suspected panic disorder. Arrhythmic causes must be ruled out before the diagnosis of anxiety or panic disorder can be accepted as the cause of the palpitations.
- 11. Miscellaneous Causes Hyperkineticcirculatory states : Anaemia , Fever , Thyrotoxicosis , Hypoglycemia , Phaechromocytoma Drugs : Aminophylline , Atropine , Thyroxine , Tricyclic antidepressants , Vasodilators , Digitalis Others : Caffeine , Cocaine , Amphetamines , Tobacco , Ethanol
- 12. Spontaneous skeletalmuscle contractions of the chest wall Systemic mastocytosis Physiological : exertion , excitement , pregnancy Neurocirculatory asthenia or Da costa’s syndrome or Effort syndrome or Soldier’s heart Vaso-vagal attack
- 13. APPROACH TO THEPATIENT WITH PALPITATIONS “Principal goal in assessing patients with palpitations is to determine if the symptom is caused by a life threatening arrhythmia”
- 14. History “Patients with coronaryartery disease or risk factors for CAD are at greater risk for ventricular arrhythmias as a cause for palpitations” In addition , the association of palpitations with other symptoms suggesting haemodynamic compromise including syncope or lightheadedness supports this diagnosis
- 15. Remember “All palpitations arenot arrhythmias and many arrhythmias do not palpitate”
- 16. HOW TO EVALUATE PALPITATION STEP 1 Is palpitation continuous or intermittent ? Intermittent P. are commonly caused by premature atrial or ventricular contractions : the post extrasystolic beat is sensed by the patient owing to the increase in ventricular end-diastolic dimension following the pause in the cardiac cycle and the increased strength of contraction (post-extrasystolic potentiation)
- 17. STEP 2 Is heartbeat regular or irregular ? Regular , sustained palpitations can be caused by SVT and VT Irregular , sustained palpitations can be caused by Atrial fibrillation
- 18. STEP 3 : What is the ~ heart rate ? STEP 4 : Does palpitations occur in discrete attacks ? Is onset abrupt? How do attacks terminate? -Ventricular arrhythmias are of sudden onset -Holding breath or vagal manoeuvres decrease palpitations in SVT
- 19. STEP 5 Are thereany associated symptoms ? Chest pain : Arrhythmogenic MI Dyspnoea : Heart failure due to arrhythmias Syncope : low cardiac output during arrhythmias , hypoglycemia , phaechromocytoma Polyuria : SVT Sweating : Anxiety ,hypoglycemia Diarrhoea : Thyrotoxicosis
- 20. STEP 6 : Are there any precipitating factors ? exercise , stress (hyperdynamic cardiovascular states caused by catecholaminergic stimulation) alcohol intake , drugs STEP 7 : Is there a history of structural heart disease ? coronary heart ds , valvular heart ds
- 21. “It is oftenuseful either to ask the patient to tap out the rhythm of the palpitations or to take his / her pulse while experiencing palpitations”
- 22. Palpitations that arepositional generally reflect a structural process within heart Eg : Atrial myxoma or adjacent to the heart Eg : Mediastinal mass
- 23. SIMPLE APPROACH TODIAGNOSIS OF PALPITATION Is heart beat regular ? YES NO Are there any discrete attacks of tachycardia >120/min Irregular heart beat YES NO Ectopic beats SVT Sinus tachycardia AF VT High stroke volume
- 24. Physical examination Key featuresof physical examination that will help confirm the presence of arrhythmia as a cause for the palpitations include Measurement of vital signs Assessment of the jugular venous pressure and pulse Auscultation of the chest and precordium
- 25. INVESTIGATIONS A restingECG If exertion is known to induce arrhythmia and accompanying palpitations , exercise ECG is useful 2D-ECHO When patients complaining of palpitations undergo 24-hour, ambulatory ECG monitoring, 39 to 85 percent manifest a rhythm disturbance (most being benign and clinically insignificant).
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- 27. If arrhythmia issufficiently infrequent , other methods must be used like Continuous ECG (Holter) monitoring , Telephonic monitoring , Loop recordings (external or implantable) & Mobile cardiac outpatient telemetry. Event recorder
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- 30. Mobile cardiac outpatienttelemetry
- 31. Recent data suggests holter monitoring is of limited clinical utility while implantable loop recorder and mobile cardiac outpatient telemetry are safe and more cost effective in assessment of patients with recurrent , unexplained palpitations
- 32. MANAGEMENT Occasional benign atrial or ventricular premature contractions can often be managed with beta blocker therapy if sufficiently troubling to the patient
- 33. Palpitations incited by alcohol , tobacco , illicit drugs need to be managed by abstention , while those caused by pharmacological agents should be managed by considering alternate therapies when possible
- 34. Psychiatric causes of palpitations may benefit from cognitive or pharmacotherapies Once serious causes for the symptom have been excluded , the patient should be reassured that palpitations will not adversely affect prognosis
- 35. Management in aNutshell 1. Re-assurance 2. Lifestyle modification 3. Correction of co-morbid diseases 4. Anxiolytics and Beta-blockers 5. Anti-arrhythmic drugs / electrical conversion Recurrent life-threatening ventricular arrhythmias are currently being treated with Implantable Cardioverter-defibrillitor devices
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