Palpitation diagnostic study of choice: Difference between revisions

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== Overview ==
== Overview ==
There is no single diagnostic study of choice for [[palpitations]].


== Diagnostic Study of Choice ==
== Diagnostic Study of Choice ==


=== Study of choice ===
*There is no single diagnostic study of choice for the [[diagnosis]] of [[palpitations]], but [[palpitations]] can be diagnosed based on a through initial evaluation (a detailed [[history]], [[physical examination]] and 12 lead [[ECG]]).
[Name of the investigation] is the gold standard test for the diagnosis of [disease name].
*Following this, investigative [[modalities]] such as an [[echocardiography]], [[electrophysiologic]] study, a different forms of ambulatory [[ECG]] monitoring and laboratory investigations such as a [[renal function test]], [[thyroid function tests]] and [[serum drug levels]] may be employed.
*The following algorithm can be employed when approaching a patient presenting with [[palpitations]]. <ref name="pmid15742913">{{cite journal| author=Abbott AV| title=Diagnostic approach to palpitations. | journal=Am Fam Physician | year= 2005 | volume= 71 | issue= 4 | pages= 743-50 | pmid=15742913 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15742913  }} </ref><ref name="pmid31256490">{{cite journal| author=McLellan AJ, Kalman JM| title=Approach to palpitations. | journal=Aust J Gen Pract | year= 2019 | volume= 48 | issue= 4 | pages= 204-209 | pmid=31256490 | doi=10.31128/AJGP-12-17-4436 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31256490  }} </ref><ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L | display-authors=etal| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="pmid23177608">{{cite journal| author=Jamshed N, Dubin J, Eldadah Z| title=Emergency management of palpitations in the elderly: epidemiology, diagnostic approaches, and therapeutic options. | journal=Clin Geriatr Med | year= 2013 | volume= 29 | issue= 1 | pages= 205-30 | pmid=23177608 | doi=10.1016/j.cger.2012.10.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23177608  }} </ref> <ref>{{cite web |url=https://www.aafp.org/afp/2017/1215/p784.html |title=Palpitations: Evaluation in the Primary Care Setting - American Family Physician |format= |work= |accessdate=}}</ref>


OR
===Different Ambulatory Electrocardiography Devices<ref name="pmid28613787">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=28613787 | doi= | pmc= | url= }} </ref><ref name="pmid31256490">{{cite journal| author=McLellan AJ, Kalman JM| title=Approach to palpitations. | journal=Aust J Gen Pract | year= 2019 | volume= 48 | issue= 4 | pages= 204-209 | pmid=31256490 | doi=10.31128/AJGP-12-17-4436 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31256490  }} </ref><ref name="pmid21766757">{{cite journal| author=Wexler RK, Pleister A, Raman S| title=Outpatient approach to palpitations. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 1 | pages= 63-9 | pmid=21766757 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21766757  }} </ref><ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L | display-authors=etal| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref>===


The following result of [gold standard test] is confirmatory of [disease name]:
{| class="wikitable"
* [Result 1]
|+
* [Result 2]
!Machine
 
!Description
OR
!Indications
 
!Advantages
[Name of the investigation] must be performed when:
!Disadvantages
* The patient presents with [symptom/sign 1], [symptom/sign 2], and [symptom/sign 3].
!Picture
* A [name of test] is positive for [sign 1], [sign 2], and [sign 3] in the patient.
|-
 
|[[12 Lead ECG]]
OR
|
 
|•Initial Step in the evaluation of patients of [[palpitations]]
[Name of the investigation] is the gold standard test for the diagnosis of [disease name].
|•Inexpensive
 
|•Rarely performed during the event
OR
|
 
|-
The diagnostic study of choice for [disease name] is [name of the investigation].
|[[Handheld ECG]]
 
|
OR
|•[[Palpitations]] occurring for months to years
 
|•High diagnostic yield
There is no single diagnostic study of choice for the diagnosis of [disease name].  
•Always present with the patient
 
|•Expensive
OR
•Time period from patient activation to event recording is long
 
|
There is no single diagnostic study of choice for the diagnosis of [disease name], but [disease name] can be diagnosed based on [name of the investigation 1] and [name of the investigation 2].
|-
 
|Exercise [[ECG Stress testing]]  
OR
|
 
|•[[Palpitations]] [[aggravated]] by [[exertion]]
[Disease name] is primarily diagnosed based on the clinical presentation.
|
 
|
OR
|
 
|-
Investigations:
|[[Holter Monitoring]]
* Among the patients who present with clinical signs of [disease name], the [investigation name] is the most specific test for the diagnosis.
|•Continuous beat to beat monitoring system via 12 leads (attached via skin electrodes).  
* Among the patients who present with clinical signs of [disease name], the [investigation name] is the most sensitive test for diagnosis.
•24-48 hour monitoring system.
* Among the patients who present with clinical signs of [disease name], the [investigation name] is the most efficient test for diagnosis.
|•[[Symptoms]] occurring daily or every second day.  
 
|•Readily available.
==== The comparison of various diagnostic studies for [disease name] ====
•Need not be activated during the event.
{|
•Low cost.
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
•Provides information of [[asymptomatic episodes]].  
! style="background: #4479BA; color: #FFFFFF; text-align: center;" | Test
|•Low [[diagnostic]] yield
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Sensitivity
•Size may prevent trigger events
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Specificity
•Clinical Diary completion (upon which [[symptom]] correlation depends upon) is a tedious process
|[[Image:IMG 3369.jpg|thumb|250px|center|A person carries a holter monitor in his pocket.]]
|-
|[[Continuous- loop event recorder]]
|•Worn for a few days (typically 30 days)
•Older monitors are patient activated and store data once, whereas newer models continuously record data
•Provides a one to three [[lead EKG tracing]]
|•[[Symptoms]] occurring weekly or monthly
•[[Short lasting palpitations]] associated with [[hemodynamic compromise]]
|•Can be worn for longer periods of time when compared to [[Holter monitors]]
•More cost effective
•High [[diagnostic efficacy/yield]] as it is a patient activated process
|•Not diagnostic for [[asymptomatic arrythmias]] as it is a patient activated system (older models
•Devices are uncomfortable and require high maintenance
•Requires patient to be compliant
|[[Image:External Loop Recorder.JPG|thumb|centre|250px]]
|-
|[[Mobile cardiac outpatient telemetry]]  
|•External Loop Recorder + Portable Receiver
•Data is wirelessly transmitted to a central monitoring station which then triggers off an alarm in case of an event
|
|•This allows for prompt responses from the physician, facilitates early detection of episodes and provides information regarding the mechanism of the [[arrythmia]]
•Provides information of [[asymptomatic episodes]].
|
|
|-
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Test 1
|[[Implantable Loop Recorder]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
|•Placed [[subcutaneously]] through a small 2cm [[incision]] in the left [[precordial region]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
•Provides a one lead [[electrocardiographic tracing]]
|•[[Palpitations]] occurring for months to years
•Rare episodes of [[palpitations]] associated with [[syncope]]/ [[hemodynamic compromise]]
•When all other methods of [[Ambulatory ECG monitoring]] prove to be inconclusive
|•High diagnostic yield
• Long term monitoring (3 years)
•Automatically records [[arrythmias]] in addition to patient triggered episodes
•[[Subcutaneous]] approach avoids long term problems associated with [[surface electrodes]]
•Does not require patient to be compliant.
|•[[Invasive procedure]] may cause [[local complications]]
•Expensive
•Not readily available
|
|-
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Test 2
|[[Pacemakers]]/[[Implantable Cardioverter Defibrillators]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
|•[[Dual chamber Devices]] which are able to detect and store [[atrial and ventricular Intracardiac Electrograms]].
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
|•Conventional indications for [[pacemakers/ICDs]]
|•Automatic [[Arrythmia]] recording
•Able to discriminate between [[ventricular and supraventricular arrythmias]]
|•[[Invasive]]
•Increased risk of early/long term [[local/systemic complications]]
|[[Image:PacemakerAEKG.jpg|thumb|centre|200px| Pacemaker insitu.]]
|}
|}
<small> [Name of test with higher sensitivity and specificity] is the preferred investigation based on the sensitivity and specificity</small>
===== Diagnostic results =====
The following finding(s) on performing [investigation name] is(are) confirmatory for [disease name]:
* [Finding 1]
* [Finding 2]
===== Sequence of Diagnostic Studies =====
The [name of investigation] must be performed when:
* The patient presented with symptoms/signs 1, 2, and 3 as the first step of diagnosis.
* A positive [test] is detected in the patient, to confirm the diagnosis.
OR
The various investigations must be performed in the following order:
* [Initial investigation]
* [2nd investigation]
=== Name of Diagnostic Criteria ===
'''It is recommended that you include the criteria in a table. Make sure you always cite the source of the content and whether the table has been adapted from another source.'''
[Disease name] is primarily diagnosed based on clinical presentation. There are no established criteria for the diagnosis of [disease name].
OR
There is no single diagnostic study of choice for [disease name], though [disease name] may be diagnosed based on [name of criteria] established by [...].
OR
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
OR
The diagnosis of [disease name] is based on the [criteria name] criteria, which includes [criterion 1], [criterion 2], and [criterion 3].
OR
[Disease name] may be diagnosed at any time if one or more of the following criteria are met:
* Criteria 1
* Criteria 2
* Criteria 3
OR
'''IF there are clear, established diagnostic criteria'''
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
OR
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
OR
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].


OR
*'''Allan Abbott et al''' found that [[transtelephonic event monitors]] had a greater [[diagnostic yield]] and were more cost effective when compared to [[Holter monitors]]. <ref name="pmid15742913">{{cite journal| author=Abbott AV| title=Diagnostic approach to palpitations. | journal=Am Fam Physician | year= 2005 | volume= 71 | issue= 4 | pages= 743-50 | pmid=15742913 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15742913  }} </ref>


'''IF there are no established diagnostic criteria'''
==Ammerican Heart Association, Approach to Palpitations==


There are no established criteria for the diagnosis of [disease name].
[[Image: AHA Approach to Palpitations.JPG|thumb|centre|500px|<ref name="pmid14557344">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ | display-authors=etal| title=ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias). | journal=Circulation | year= 2003 | volume= 108 | issue= 15 | pages= 1871-909 | pmid=14557344 | doi=10.1161/01.CIR.0000091380.04100.84 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14557344  }} </ref>]]


==References==
==References==
{{reflist|2}}
{{reflist|2}}
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{{WikiDoc Sources}}


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Latest revision as of 04:19, 1 February 2021

Palpitation Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

Overview

There is no single diagnostic study of choice for palpitations.

Diagnostic Study of Choice

Different Ambulatory Electrocardiography Devices[6][2][7][3]

Machine Description Indications Advantages Disadvantages Picture
12 Lead ECG •Initial Step in the evaluation of patients of palpitations •Inexpensive •Rarely performed during the event
Handheld ECG •Palpitations occurring for months to years •High diagnostic yield

•Always present with the patient

•Expensive

•Time period from patient activation to event recording is long

Exercise ECG Stress testing •Palpitations aggravated by exertion
Holter Monitoring •Continuous beat to beat monitoring system via 12 leads (attached via skin electrodes).

•24-48 hour monitoring system.

•Symptoms occurring daily or every second day. •Readily available.

•Need not be activated during the event. •Low cost. •Provides information of asymptomatic episodes.

•Low diagnostic yield

•Size may prevent trigger events •Clinical Diary completion (upon which symptom correlation depends upon) is a tedious process

A person carries a holter monitor in his pocket.
Continuous- loop event recorder •Worn for a few days (typically 30 days)

•Older monitors are patient activated and store data once, whereas newer models continuously record data •Provides a one to three lead EKG tracing

•Symptoms occurring weekly or monthly

•Short lasting palpitations associated with hemodynamic compromise

•Can be worn for longer periods of time when compared to Holter monitors

•More cost effective •High diagnostic efficacy/yield as it is a patient activated process

•Not diagnostic for asymptomatic arrythmias as it is a patient activated system (older models

•Devices are uncomfortable and require high maintenance •Requires patient to be compliant

Mobile cardiac outpatient telemetry •External Loop Recorder + Portable Receiver

•Data is wirelessly transmitted to a central monitoring station which then triggers off an alarm in case of an event

•This allows for prompt responses from the physician, facilitates early detection of episodes and provides information regarding the mechanism of the arrythmia

•Provides information of asymptomatic episodes.

Implantable Loop Recorder •Placed subcutaneously through a small 2cm incision in the left precordial region

•Provides a one lead electrocardiographic tracing

•Palpitations occurring for months to years

•Rare episodes of palpitations associated with syncope/ hemodynamic compromise •When all other methods of Ambulatory ECG monitoring prove to be inconclusive

•High diagnostic yield

• Long term monitoring (3 years) •Automatically records arrythmias in addition to patient triggered episodes •Subcutaneous approach avoids long term problems associated with surface electrodes •Does not require patient to be compliant.

•Invasive procedure may cause local complications

•Expensive •Not readily available

Pacemakers/Implantable Cardioverter Defibrillators •Dual chamber Devices which are able to detect and store atrial and ventricular Intracardiac Electrograms. •Conventional indications for pacemakers/ICDs •Automatic Arrythmia recording

•Able to discriminate between ventricular and supraventricular arrythmias

•Invasive

•Increased risk of early/long term local/systemic complications

Pacemaker insitu.

Ammerican Heart Association, Approach to Palpitations

[8]

References

  1. ↑ 1.0 1.1 Abbott AV (2005). "Diagnostic approach to palpitations". Am Fam Physician. 71 (4): 743–50. PMID 15742913.
  2. ↑ 2.0 2.1 McLellan AJ, Kalman JM (2019). "Approach to palpitations". Aust J Gen Pract. 48 (4): 204–209. doi:10.31128/AJGP-12-17-4436. PMID 31256490.
  3. ↑ 3.0 3.1 Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L; et al. (2011). "Management of patients with palpitations: a position paper from the European Heart Rhythm Association". Europace. 13 (7): 920–34. doi:10.1093/europace/eur130. PMID 21697315.
  4. ↑ Jamshed N, Dubin J, Eldadah Z (2013). "Emergency management of palpitations in the elderly: epidemiology, diagnostic approaches, and therapeutic options". Clin Geriatr Med. 29 (1): 205–30. doi:10.1016/j.cger.2012.10.003. PMID 23177608.
  5. ↑ "Palpitations: Evaluation in the Primary Care Setting - American Family Physician".
  6. ↑ "StatPearls". 2020. PMID 28613787.
  7. ↑ Wexler RK, Pleister A, Raman S (2011). "Outpatient approach to palpitations". Am Fam Physician. 84 (1): 63–9. PMID 21766757.
  8. ↑ Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ; et al. (2003). "ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias)". Circulation. 108 (15): 1871–909. doi:10.1161/01.CIR.0000091380.04100.84. PMID 14557344.
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