Introduction to one of the more common symptoms of cardiac, psychiatric and metabolic disease. Palpitation is the uncomfortable awareness of heart beat and can often be the only symptom of underlying fatal arrhythmias.
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4. Case scenario
âą Miss Amna Zafar / 28 years / Female
âą Non-traumatic ER presentation
âą C/O PALPITATIONS that were sudden in onset, started 15 minutes ago,
associated with atypical chest pain, sweating and breathlessness
âą H/O similar attacks (3 times in last week), exercise intolerance, PND
âą No H/O nausea, vomiting, syncope, headache, fever, ABH, or dysuria
5. Case scenario
âą Non-smoker, non-alcoholic, no drug intake
âą No known co-morbidities, no known allergies
âą No family history of IHD or sudden cardiac death
âą LMP 15 days ago, cycle 5/28, no IMB
Latest vitals
âą Pulse â 150 beats / min, regular
âą Blood pressure â 120 / 60 mm HG
âą Respiratory rate â 24 breaths / min
âą SpO2 â 96 % on room air, Afebrile
âą BSR â 110 mg/dl
6. Case scenario
On examination
âą No pallor, cyanosis, pedal edema
âą Apex beat is in left 5th intercostal space in MCL
âą S1 + S2 + mid systolic click and late systolic murmur at MV area
âą On standing the mid systolic click moves closer to S1
âą Rest of the examination is non-significant
An 12 lead ECG was ordered
Blood samples for baseline investigations were taken
7.
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
11. Often the most common symptom
of a life threatening arrhythmia
12. Description of
Sensation
ïRapid fluttering /racing in the chest
ïJumping / flip-flopping of the chest
ïPounding sensation in chest or neck
ïSkipping 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
25. HISTORY
âȘ Is it true palpitation or some other symptom simulating it?
- Chest discomfort or dyspnea can be confused for palpitation
âȘ Is it paroxysmal or persistent?
- Paroxysmal â arrhythmias
- Persistent â volume overload, persistent arrhythmias
âȘ If paroxysmal, what is mode of onset and offset?
- Abrupt onset +/- abrupt termination â usually an SVT, VT, or sick sinus syn.
- Gradual onset +/- gradual termination â usually other benign causes
âȘ Any relief with vagal maneuvers? â usually an SVT
âȘ Does it worsen at night? â usually ectopic beats
26. CHARACTER
âȘ What is the character of the sensation?
- âFlip-floppingâ (start & stop), missing a beat, thump in the heart
â premature contractions i.e. PVC
- Rapid regular âracingâ or âflutteringâ in the chest
â sinus tachycardia, SVT, VT
- Rapid irregular âflutteringâ or âjumping aboutâ
â atrial fibrillation
- Pounding in the chest
â hyperdynamic circulation
27. RADIATION
âȘ 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 âcannonâ A waves in JVP
that occur when right atria contracts against a closed tricuspid valve.
28. ASSOCIATED
SYMPTOMS
âą Syncope â low C.O in arrhythmias (VT) or bradycardia, hypoglycemia
âą Dyspnea (before palpitation) â acute MI or PE, valvular dysfunction
âą Dyspnea (after palpitation) â heart failure due to arrhythmias (i.e. VT)
âą Chest pain (before palpitaion) â acute MI or PE
âą Chest pain (after palpitaion) â angina due to palpitation (i.e AS, MVP)
âą Polyuria â atrial fib. / flutter, SVT (release of atrial natriuretic peptide)
âą Sweating â acute MI, hypoglycemia, anxiety, thyrotoxicosis
âą Diarrhea â hypokalemia, thyrotoxicosis
âą Melena, heavy menstrual bleeding â anemia
âą Heat intolerance, weight loss, increased appetite â thyrotoxicosis
29. PAST HISTORY
âȘ Any known heart disease?
- IHD, RHD, valvular disorders, cardiomyopathy, heart failure
âȘ Any other known conditions?
- Pregnancy, fever, anemia, hyperthyroidism, asthma
âȘ Any recent drug intake, caffeine and alcohol consumption?
- Sympathomimetics i.e beta agonists used by asthmatics
âȘ 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
34. INVESTIGATIONS
âȘ 12 lead ECG
âȘ Blood sugar random
âȘ Serum electrolytes
âȘ Serum Ca, Mg, PO4
âȘ CBC
âȘ RFTs
SUPPORTIVE
- Thyroid function tests â Thyrotoxicosis
- Cardiac biomarkers â Suspected MI
- D-dimer â suspected PE
- Echocardiography
structural heart disease
- Treadmill exercise testing
for palpitations precipitated by exercise
35. HOLTER
MONITORING
âȘ Helpful, if palpitation is paroxysmal and
occurs on a regular basis
âȘ Electrodes with a monitoring device are
attached to the patient for a 1 to 14 days
âȘ Patient is asked to continue and record
his activities in a diary
âȘ Rhythm strips are then analyzed
âȘ If palpitation occurs but there is no
arrhythmia, cardiac cause is less likely
36. IMPLANTABLE LOOP
RECORDER (ILR)
âȘ ILR is a small device that is implanted
under the chest skin.
âȘ Helpful if palpitations are paroxysmal but
not very regular to be captured by Holter.
âȘ It records and stores heart activity as ECG
and has battery life over several years.
âȘ Patients are instructed to activate the
recorder whenever palpitations are felt
and visit the physician.
37. DIAGNOSIS
âȘ A careful and through history and examination is important.
âȘ A definitive diagnosis can be obtained by carrying out an
ECG during an attack, or by ambulatory monitoring.
Ambulatory monitoring
âȘ Holter monitoring
âȘ 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?
ï§ Palpitations associated with syncope or pre-syncope
ï§ 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
ï§ Patients with high risk factors for a serious arrhythmia