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Understanding Palpitations: Causes, Evaluation and Management
- 1. GOOD MORNING DR. FARJAD IKRAM House Officer, Cardiology Shalamar Hospital
- 2. PALPITATIONS
- 3. Objectives Understand the definition Know the possible etiologies How to assess the patient
- 4. Case scenario • Miss Amna Zafar / 28 years / Female • Non-traumatic ER presentation • C/O PALPITATIONS that were sudden in onset, started 15 minutes ago, associated with atypical chest pain, sweating and breathlessness • H/O similar attacks (3 times in last week), exercise intolerance, PND • No H/O nausea, vomiting, syncope, headache, fever, ABH, or dysuria
- 5. Case scenario • Non-smoker, non-alcoholic, no drug intake • No known co-morbidities, no known allergies • No family history of IHD or sudden cardiac death • LMP 15 days ago, cycle 5/28, no IMB Latest vitals • Pulse – 150 beats / min, regular • Blood pressure – 120 / 60 mm HG • Respiratory rate – 24 breaths / min • SpO2 – 96 % on room air, Afebrile • BSR – 110 mg/dl
- 6. Case scenario On examination • No pallor, cyanosis, pedal edema • Apex beat is in left 5th intercostal space in MCL • S1 + S2 + mid systolic click and late systolic murmur at MV area • On standing the mid systolic click moves closer to S1 • Rest of the examination is non-significant An 12 lead ECG was ordered Blood samples for baseline investigations were taken
- 8. Case scenario What is the most likely diagnosis? Mitral Valve Prolapse What is the next best diagnostic test? Echo cardiography What is the next best step in therapy? Beta blocker
- 10. PALPITATION “ uncomfortable awareness of the heartbeat ”
- 11. Often the most common symptom of a life threatening arrhythmia
- 12. Description of Sensation Rapid fluttering /racing in the chest Jumping / flip-flopping of the chest Pounding sensation in chest or neck Skipping of the heartbeat (pauses)
- 13. When it happens? Due to... Alteration in the heart rate Alteration in the rhythm Augmentation of contraction
- 14. 16% of OPD visitsrepresent 5.8/1000 ED visits, admission rate of 25% 43% are cardiac in nature in a study of 190 people with chief complaint of palpitation 3rd common complaint presenting to cardiologists, after chest pain and SOB
- 16. Classification 43% CARDIAC 31% PSYCHIATRIC 10% MISCELLANEOUS 16% IDIOPATHIC
- 17. PATHOPHYSIOLOGY MECHANSIM CAUSES PARASYMPATHETIC OVERDRIVE (Diastolic) Anxiety, Stress (increase cortisol and adrenaline causing vagal stimulation), Indigestion, Bloating SYMPATHETIC OVERDRIVE (Systolic) Panic disorders, Hypoglycemia, Anemia, Hypoxia, Anti-histamines, Heart Failure, Mitral Valve Prolapse HYPERDYNAMIC CIRCULATION Valvular incompetence, Thyrotoxicosis, Hypercapnia, Hyperthermia, Anemia, Pregnancy ABNORMAL HEART RHYTHM Ectopic beats, PACs, PVCs, Junctional escape, A. fib, A. flutter, SVT, VT, V. fib, Heart block
- 18. CARDIAC CAUSES (43 %) Rhythm Disorders (most common) Structural cardiac causes Mixed
- 19. RHYTHM DISORDERS ▪ Premature contractions (PAC, PVC) ▪ Atrial fibrillation ▪ Atrial flutter ▪ Supraventricular tachycardia (SVT) ▪ Ventricuar tachycardia (VT) ▪ Wolff-Parkinson-White syndrome (WPW) ▪ Ectopics (extrasystole) ▪ Sick sinus syndrome (SSS) ▪ Bradyrrhythmias (heart blocks)
- 20. NON_ARRHYTHMIC CARDIAC CAUSES ▪ Systemic hypertension ▪ Mitral valve prolapse ▪ LVOT obstruction (atrial stenosis, HOCM) ▪ Aortic insufficiency ▪ RV dysfunction (PE, ASD, VSD) ▪ Myocarditis, Pericarditis ▪ Atrial myxoma
- 21. MISCELLANEOUS CAUSES ▪ Stress (increased cortisol and adrenaline) ▪ Hypoglycemia ▪ Vasovagal bradycardia ▪ Infections (fever can cause tachycardia) ▪ Hyperdynamic circulation: dehydration, anemia, pregnancy ▪ Thyrotoxicosis ▪ Pheochromocytoma ▪ Drugs: caffeine, cocaine, alcohol, psuedo-ephedrine ▪ Prescription drugs: digoxin, beta-agonists, theophylline
- 22. PSYCHIATRIC CAUSES ▪ Panic disorder (most common) ▪ Generalized anxiety disorder (GAD) ▪ Post-traumatic stress disorder (PTSD) ▪ Specific phobias ▪ Clinical depression ▪ Somatization ▪ Conversion disorder ▪ Hypochondriasis
- 23. Evaluation • History and physical • Diagnostic approach 3
- 25. HISTORY ▪ Is it true palpitation or some other symptom simulating it? - Chest discomfort or dyspnea can be confused for palpitation ▪ Is it paroxysmal or persistent? - Paroxysmal – arrhythmias - Persistent – volume overload, persistent arrhythmias ▪ If paroxysmal, what is mode of onset and offset? - Abrupt onset +/- abrupt termination – usually an SVT, VT, or sick sinus syn. - Gradual onset +/- gradual termination – usually other benign causes ▪ Any relief with vagal maneuvers? – usually an SVT ▪ Does it worsen at night? – usually ectopic beats
- 26. CHARACTER ▪ What is the character of the sensation? - “Flip-flopping” (start & stop), missing a beat, thump in the heart – premature contractions i.e. PVC - Rapid regular “racing” or “fluttering” in the chest – sinus tachycardia, SVT, VT - Rapid irregular “fluttering” or “jumping about” – atrial fibrillation - Pounding in the chest – hyperdynamic circulation
- 27. RADIATION ▪ Does the palpitation radiate into the neck? - AV nodal tachycardias simultaenous contraction of both atria and ventricles cause reflux of blood into superior vena cava) - PVCs also cause atrioventricular dissociation, resulting in pounding sensations in the neck and often a finding of “cannon” A waves in JVP that occur when right atria contracts against a closed tricuspid valve.
- 28. ASSOCIATED SYMPTOMS • Syncope – low C.O in arrhythmias (VT) or bradycardia, hypoglycemia • Dyspnea (before palpitation) – acute MI or PE, valvular dysfunction • Dyspnea (after palpitation) – heart failure due to arrhythmias (i.e. VT) • Chest pain (before palpitaion) – acute MI or PE • Chest pain (after palpitaion) – angina due to palpitation (i.e AS, MVP) • Polyuria – atrial fib. / flutter, SVT (release of atrial natriuretic peptide) • Sweating – acute MI, hypoglycemia, anxiety, thyrotoxicosis • Diarrhea – hypokalemia, thyrotoxicosis • Melena, heavy menstrual bleeding – anemia • Heat intolerance, weight loss, increased appetite – thyrotoxicosis
- 29. PAST HISTORY ▪ Any known heart disease? - IHD, RHD, valvular disorders, cardiomyopathy, heart failure ▪ Any other known conditions? - Pregnancy, fever, anemia, hyperthyroidism, asthma ▪ Any recent drug intake, caffeine and alcohol consumption? - Sympathomimetics i.e beta agonists used by asthmatics ▪ Family history of sudden cardiac death? - Palpitations is a symptom of many common conditions
- 30. Regular Heart Beat Yes Discrete attacks of tachycardia? Yes SVT, VT No Sinus tachycardia, High stroke volume No Ectopics, PVC, Atrial Fibrillation
- 32. VITALS ▪ Bradycardia – Vasovagal syncope, heart blocks ▪ Tachycardia – MAT, SVT, VT, AVNT, atrial flutter, anxiety, MI, PE ▪ Hypotension – Vasovagal syncope, SVT, VT ▪ Bounding pulse – SVT, anemia, dehydration, hypoglycemia ▪ Irregular pulse – atrial fibrillation, ectopic “skip beats” (PVC) ▪ Pyrexia – thyrotoxicosis, infections, rheumatic fever, PE
- 33. EXAMINATION ▪ Pallor – Anemia ▪ Goitre, exopthalmos, fine tremors – Thyrotoxicosis ▪ Raised JVP – SVT, AVNT, PVC, atrial flutter, PE ▪ Diminished carotid upstroke, carotid bruit – VT, AVNT ▪ Murmurs – valvular disorders ▪ Other: S3 gallop (HF), S4 (LVH), loud P2 (PE), bibasal fine rales (HF), wheeze (asthma), bipedal edema (HF), calf tenderness (PE)
- 34. INVESTIGATIONS ▪ 12 lead ECG ▪ Blood sugar random ▪ Serum electrolytes ▪ Serum Ca, Mg, PO4 ▪ CBC ▪ RFTs SUPPORTIVE - Thyroid function tests – Thyrotoxicosis - Cardiac biomarkers – Suspected MI - D-dimer – suspected PE - Echocardiography structural heart disease - Treadmill exercise testing for palpitations precipitated by exercise
- 35. HOLTER MONITORING ▪ Helpful, if palpitation is paroxysmal and occurs on a regular basis ▪ Electrodes with a monitoring device are attached to the patient for a 1 to 14 days ▪ Patient is asked to continue and record his activities in a diary ▪ Rhythm strips are then analyzed ▪ If palpitation occurs but there is no arrhythmia, cardiac cause is less likely
- 36. IMPLANTABLE LOOP RECORDER (ILR) ▪ ILR is a small device that is implanted under the chest skin. ▪ Helpful if palpitations are paroxysmal but not very regular to be captured by Holter. ▪ It records and stores heart activity as ECG and has battery life over several years. ▪ Patients are instructed to activate the recorder whenever palpitations are felt and visit the physician.
- 37. DIAGNOSIS ▪ A careful and through history and examination is important. ▪ A definitive diagnosis can be obtained by carrying out an ECG during an attack, or by ambulatory monitoring. Ambulatory monitoring ▪ Holter monitoring ▪ Implantable loop recorders (ILR)
- 38. Is there a P wave? Yes Is P wave always related to QRS? Yes Measure PR interval Normal Multiple P wave morphologies in a single lead No Sinus Yes PACs, M.A.T Short Pre-excitation i.e. WPW syn. Long 1st AV block No Sometimes 2nd AV block Never 3rd AV block Abnormal HR 300/m saw-toothed Atrial flutter Inverted P waves Junctional rhythm ALGORITHM FOR DIAGNOSING ARRHYTHMIAS ON ECG
- 39. Is there a P wave? No QRS Narrow Regular Accelerated junctional Irregular Atrial fibrillation Wide Regular Ventricular tachycardia Irregular Ventricular fibrillation Occasionally wide PVCs None Asystole
- 40. WHEN TO ADMIT? Palpitations associated with syncope or pre-syncope Having an abnormal ECG with any of the following - Age 75 years or older - Hematocrit less than 30% - Shortness of breath - Respiratory rate higher than 24/min - A history of heart failure - Left ventricular outflow tract obstruction Patients with high risk factors for a serious arrhythmia
- 41. THANKS! Any questions? Find me @ slideshare.net/FarjadIkram 😉 Presentation template by SlidesCarnival