approach to 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 due to
 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
 Premature atrial 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
 Mitral valve prolapse (with or without
associated arrhythmias)
 Aortic insufficiency
 Atrial myxoma
 Pulmonary embolism
 Congenital heart ds
 Systemic hypertension
 Pericarditis
 Pacemaker induced tachycardia

9. Psychiatric Causes
 Panic attacks
 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
 Hyperkinetic circulatory states :
Anaemia , Fever , Thyrotoxicosis ,
Hypoglycemia , Phaechromocytoma
 Drugs :
Aminophylline , Atropine , Thyroxine
, Tricyclic antidepressants , Vasodilators
, Digitalis
 Others :
Caffeine , Cocaine , Amphetamines
, Tobacco , Ethanol

12.  Spontaneous skeletal muscle
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 THE PATIENT 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 coronary artery 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 are not 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 heart beat 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 there any 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 often useful 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 are positional
 generally reflect a structural process
within heart
Eg : Atrial myxoma
 or adjacent to the heart
Eg : Mediastinal mass

23. SIMPLE APPROACH TO DIAGNOSIS 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 features of 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 resting ECG
 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).

26. Premature ventricular contraction-
Bigeminy

27. If arrhythmia is sufficiently infrequent , other
methods must be used like
 Continuous ECG (Holter) monitoring ,
 Telephonic monitoring ,
 Loop recordings (external or implantable)
&
 Mobile cardiac outpatient telemetry.
 Event recorder

28. Holter monitor

29. Implantable loop recorders

30. Mobile cardiac outpatient telemetry

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 a Nutshell
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

37. Thank You