Palpitation history and symptoms: Difference between revisions
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==Overview== | ==Overview== | ||
Many times, the person experiencing palpitations may not be aware of anything apart from the abnormal heart rhythm itself. But palpitations can be associated with other things such as [[chest pain|tightness in the chest]], [[shortness of breath]], [[dizziness]] or [[lightheadedness]]. Depending on the type of rhythm problem, these symptoms may be just momentary or more prolonged. Actual blackouts or near blackouts, associated with palpitations, should be taken seriously because they often indicate the presence of important underlying heart disease. There are certain key questions that need to be asked while taking a patient's history. | Many times, the person experiencing [[palpitations]] may not be aware of anything apart from the abnormal [[heart]] rhythm itself. But [[palpitations]] can be associated with other things such as [[chest pain|tightness in the chest]], [[shortness of breath]], [[dizziness]] or [[lightheadedness]]. Depending on the type of [[rhythm]] problem, these symptoms may be just momentary or more prolonged. Actual [[blackouts]] or near [[blackouts]], associated with [[palpitations]], should be taken seriously because they often indicate the presence of important underlying [[heart]] disease. There are certain key questions that need to be asked while taking a patient's [[history]]. | ||
==History and Symptoms== | ==History and Symptoms== | ||
*Palpitations are transient in nature. | *[[Palpitations]] are [[transient]] in nature.{{cite web |url=https://www.ahajournals.org/doi/full/10.1161/circulationaha.105.566760 |title=Palpitations | Circulation |format= |work= |accessdate=}} | ||
*Therefore, it is important to elicit the answers of specific questions during one’s history taking as patients are often asymptomatic on arrival. | *Therefore, it is important to [[elicit]] the answers of specific questions during one’s [[history]] taking as patients are often [[asymptomatic]] on arrival. | ||
*History taking along with a thorough physical examination and 12 lead ECG form an important trio that would help the physician determine whether the patient requires further investigations, admission or can be sent home with the advice to follow up. | *[[History]] taking along with a thorough [[physical examination]] and 12 lead [[ECG]] form an important trio that would help the [[physician]] determine whether the patient requires further [[investigations]], admission or can be sent home with the advice to [[follow up]]. | ||
*Arrhythmia related cardiac disorders, anxiety and panic disorder are the immediate diagnoses that often come to a physician’s mind.{{cite web |url=https://www.sciencedirect.com/topics/medicine-and-dentistry/palpitations |title=Palpitations - an overview | ScienceDirect Topics |format= |work= |accessdate=}} | *[[Arrhythmia]] related [[cardiac disorders]], [[anxiety]] and [[panic disorder]] are the immediate [[diagnoses]] that often come to a [[physician’s]] mind.<ref>{{cite web |url=https://www.sciencedirect.com/topics/medicine-and-dentistry/palpitations |title=Palpitations - an overview | ScienceDirect Topics |format= |work= |accessdate=}}</ref> | ||
*It is important to keep an open-minded,step-wise approach and suspect cardiac etiologies even in patients with psychiatric symptoms. | *It is important to keep an open-minded,step-wise approach and suspect [[cardiac]] [[etiologies]] even in patients with [[psychiatric]] [[symptoms]]. | ||
*Often physicians employ the use of standardized screening questionnaires to identify panic disorder. | *Often [[physicians]] employ the use of standardized [[screening questionnaires]] to identify [[panic disorder]]. | ||
==Key History taking questions<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="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="pmid28613787">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume= | issue= | pages= | pmid=28613787 | doi= | pmc= | url= }} </ref><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>== | ===Key History taking questions<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="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="pmid28613787">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume= | issue= | pages= | pmid=28613787 | doi= | pmc= | url= }} </ref><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>=== | ||
*''' Age of onset – Young or elderly?''' | *''' Age of [[onset]] – Young or elderly?''' | ||
**Palpitations occurring in childhood suggests a supraventricular tachycardia, atrioventricular re-entry tachycardia and Wolff Parkinson White syndrome | **[[Palpitations]] occurring in childhood suggests a [[supraventricular tachycardia]], [[atrioventricular]] re-entry [[tachycardia]] and [[Wolff Parkinson White syndrome]] | ||
**Palpitations occurring in the elderly would more likely point to a structural heart disease, atrioventricular nodal re-entrant tachycardia (AVNRT), atrial fibrillation and atrial tachycardia. | **[[Palpitations]] occurring in the elderly would more likely point to a [[structural heart disease]], [[atrioventricular nodal re-entrant tachycardia]] (AVNRT), [[atrial fibrillation]] and [[atrial tachycardia]]. | ||
*'''Duration of episode – Momentary or sustained?''' | *'''[[Duration]] of episode – [[Momentary]] or [[sustained]]?''' | ||
**Palpitations lasting less than 5 minutes make cardiac etiology less likely. | **[[Palpitations]] lasting less than 5 minutes make [[cardiac]] [[etiology]] less likely. | ||
*'''Rhythm – Regular or Irregular?''' | *'''[[Rhythm]] – [[Regular]] or [[Irregular]]?''' | ||
**Patients should be encouraged to tap out the rhythm of the palpitations as this provides key diagnostic insight. | **Patients should be encouraged to tap out the [[rhythm]] of the [[palpitations]] as this provides key diagnostic insight. | ||
** Rapid regular rhythm – Paroxysmal supraventricular or ventricular tachycardia | ** Rapid [[regular rhythm]] – [[Paroxysmal supraventricular]] or [[ventricular tachycardia]] | ||
** Rapid irregular rhythm – Atrial fibrillation, atrial flutter, Tachycardia with variable block | ** Rapid [[irregular rhythm]] – [[Atrial fibrillation]], [[atrial flutter]], [[Tachycardia]] with variable block | ||
*'''Sensation in the chest – Flip flop, pounding, fluttering, thud?''' | *'''Sensation in the chest – Flip flop, pounding, fluttering, thud?''' | ||
**A brief flip flopping sensation is likely to be associated with premature supraventricular or ventricular contractions. | **A brief [[flip flopping]] [[sensation]] is likely to be associated with [[premature supraventricular]] or [[ventricular contractions]]. | ||
**A more sustained fluttering is likely to be associated with a long lasting ventricular or supraventricular arrythmia. | **A more sustained [[fluttering]] is likely to be associated with a long lasting [[ventricular]] or [[supraventricular]] [[arrythmia]]. | ||
**Pounding sensations in the chest increased when sitting or lying down suggest premature ventricular contractions. | **[[Pounding sensations]] in the [[chest]] increased when sitting or lying down suggest [[premature ventricular contractions]]. | ||
**Sensation of one’s heartbeat all over the chest may be due to atrial fibrillation. | **[[Sensation]] of one’s heartbeat all over the [[chest]] may be due to [[atrial fibrillation]]. | ||
**A sinking feeling followed by an unknown feeling of apathy may correspond to an | **A [[sinking feeling]] followed by an unknown feeling of [[apathy]] may correspond to an [[extra- systolic compensatory pause]]. | ||
*'''Onset and offset – Sudden or gradual?''' | *'''Onset and offset – Sudden or gradual?''' | ||
**Palpitations with an abrupt onset or offset suggest a paroxysmal supraventricular tachycardia. | **[[Palpitations]] with an abrupt [[onset]] or [[offset]] suggest a [[paroxysmal supraventricular tachycardia]]. | ||
**Sustained palpitations are more likely due to atrial fibrillation. | **Sustained [[palpitations]] are more likely due to [[atrial fibrillation]]. | ||
*'''Activity at the time of onset – Sleep, work, sport squatting or bending?''' | *'''Activity at the time of onset – Sleep, work, sport squatting or bending?''' | ||
**Palpitations that occur at work or during sleep are suggestive of a cardiac cause. | **[[Palpitations]] that occur at work or during sleep are suggestive of a [[cardiac]] cause. | ||
*'''Aggravating factors''' | *'''Aggravating factors''' | ||
**Palpitations aggravated by exertion suggest channelopathies, cardiomyopathies or underlying ischemia. | **[[Palpitations]] [[aggravated]] by [[exertion]] suggest [[channelopathies]], [[cardiomyopathies]] or underlying [[ischemia]]. | ||
*'''Relieving factors- Vagal Maneuvers or rest?''' | *'''Relieving factors- Vagal Maneuvers or rest?''' | ||
**Palpitations terminated by vagal maneuvers are likely due to supraventricular tachycardias. | **[[Palpitations]] terminated by [[vagal maneuvers]] are likely due to [[supraventricular tachycardias]]. | ||
*'''Associated Symptoms- Chest Pain, Syncope, Neck Pulsations, Dizziness, Nausea, | *'''Associated Symptoms- [[Chest Pain]], [[Syncope]], [[Neck Pulsations]], [[Dizziness]], [[Nausea]], [[Vomiting]]?''' | ||
**Palpitations associated with chest pain may be due to myocardial ischemia, exacerbated mitral valve prolapse, cardiomyopathy or dehydration. | **[[Palpitations]] associated with [[chest pain]] may be due to [[myocardial ischemia]], [[exacerbated]] [[mitral valve prolapse]], [[cardiomyopathy]] or [[dehydration]]. | ||
**Palpitations associated with presyncope, syncope, light headedness and dizziness suggest tachyarrhythmias or hypertrophic cardiomyopathy. | **[[Palpitations]] associated with [[presyncope]], [[syncope]], [[light headedness]] and [[dizziness]] suggest [[tachyarrhythmias]] or [[hypertrophic cardiomyopathy]]. | ||
**Palpitations associated with orthostatic intolerance suggest cerebral hypoperfusion and are commonly seen in women of child bearing age. | **[[Palpitations]] associated with [[orthostatic]] intolerance suggest [[cerebral hypoperfusion]] and are commonly seen in women of child bearing age. | ||
**Palpitations associated with elevated jugular venous pressure, pedal edema and breathlessness suggest congestive heart failure. | **[[Palpitations]] associated with elevated [[jugular venous pressure]], [[pedal edema]] and [[breathlessness]] suggest [[congestive heart failure]]. | ||
**Palpitations associated with polyuria may be due to atrial fibrillation that caused the release of atrial natriuretic peptide. | **[[Palpitations]] associated with [[polyuria]] may be due to [[atrial fibrillation]] that caused the release of [[atrial natriuretic peptide]]. | ||
**Visible transmitted pounding neck pulsations and an associated | **Visible transmitted [[pounding neck pulsations]] and an associated ‘[[frog sign]]’ are likely to be the result of [[AV dissociations]] such as AV nodal re-entry [[tachycardia]] that would cause the [[contraction]] of [[atria]] against closed [[AV valves]]. | ||
**Palpitations associated with pupillary dilation, sweating, aberrant behavior and dry mouth such as the use of drugs such as cocaine, MDMA and methamphetamines. | **[[Palpitations]] associated with [[pupillary dilation]], [[sweating]], [[aberrant behavior]] and [[dry mouth]] such as the use of [[drugs]] such as [[cocaine]], [[MDMA]] and [[methamphetamines]]. | ||
*'''Medication History''' | *'''Medication History''' | ||
**Caffeine, alcohol, tobacco, beta agonists, cocaine, amphetamines, methylxanthines, ADHD medication, coenzyme Q inhibitors, carnitine and omega 3 polyunsaturated fatty acids can cause palpitations. | **[[Caffeine]], [[alcohol]], [[tobacco]], [[beta agonists]], [[cocaine]], [[amphetamines]], [[methylxanthines]], [[ADHD]] medication, [[coenzyme Q inhibitors]], [[carnitine]] and [[omega 3 polyunsaturated fatty acids]] can cause [[palpitations]]. | ||
*'''Family History – Sudden death, cardiac disease, Psychiatric condition?''' | *'''Family History – [[Sudden death]], [[cardiac]] disease, [[Psychiatric]] condition?''' | ||
**Inherited conditions such as Arrhythmogenic right ventricular cardiomyopathy, Brugada syndrome | **[[Inherited]] conditions such as [[Arrhythmogenic right ventricular cardiomyopathy]], [[Brugada syndrome]] | ||
*'''Past History''' | *'''Past History''' | ||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Psychiatry]] | [[Category:Psychiatry]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
Latest revision as of 17:16, 31 January 2021
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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]Cafer Zorkun, M.D., Ph.D. [3]
Overview
Many times, the person experiencing palpitations may not be aware of anything apart from the abnormal heart rhythm itself. But palpitations can be associated with other things such as tightness in the chest, shortness of breath, dizziness or lightheadedness. Depending on the type of rhythm problem, these symptoms may be just momentary or more prolonged. Actual blackouts or near blackouts, associated with palpitations, should be taken seriously because they often indicate the presence of important underlying heart disease. There are certain key questions that need to be asked while taking a patient's history.
History and Symptoms
- Palpitations are transient in nature."Palpitations | Circulation".
- Therefore, it is important to elicit the answers of specific questions during one’s history taking as patients are often asymptomatic on arrival.
- History taking along with a thorough physical examination and 12 lead ECG form an important trio that would help the physician determine whether the patient requires further investigations, admission or can be sent home with the advice to follow up.
- Arrhythmia related cardiac disorders, anxiety and panic disorder are the immediate diagnoses that often come to a physician’s mind.[1]
- It is important to keep an open-minded,step-wise approach and suspect cardiac etiologies even in patients with psychiatric symptoms.
- Often physicians employ the use of standardized screening questionnaires to identify panic disorder.
Key History taking questions[2][3][4][5]
- Age of onset – Young or elderly?
- Palpitations occurring in childhood suggests a supraventricular tachycardia, atrioventricular re-entry tachycardia and Wolff Parkinson White syndrome
- Palpitations occurring in the elderly would more likely point to a structural heart disease, atrioventricular nodal re-entrant tachycardia (AVNRT), atrial fibrillation and atrial tachycardia.
- Duration of episode – Momentary or sustained?
- Palpitations lasting less than 5 minutes make cardiac etiology less likely.
- Rhythm – Regular or Irregular?
- Patients should be encouraged to tap out the rhythm of the palpitations as this provides key diagnostic insight.
- Rapid regular rhythm – Paroxysmal supraventricular or ventricular tachycardia
- Rapid irregular rhythm – Atrial fibrillation, atrial flutter, Tachycardia with variable block
- Sensation in the chest – Flip flop, pounding, fluttering, thud?
- A brief flip flopping sensation is likely to be associated with premature supraventricular or ventricular contractions.
- A more sustained fluttering is likely to be associated with a long lasting ventricular or supraventricular arrythmia.
- Pounding sensations in the chest increased when sitting or lying down suggest premature ventricular contractions.
- Sensation of one’s heartbeat all over the chest may be due to atrial fibrillation.
- A sinking feeling followed by an unknown feeling of apathy may correspond to an extra- systolic compensatory pause.
- Onset and offset – Sudden or gradual?
- Palpitations with an abrupt onset or offset suggest a paroxysmal supraventricular tachycardia.
- Sustained palpitations are more likely due to atrial fibrillation.
- Activity at the time of onset – Sleep, work, sport squatting or bending?
- Palpitations that occur at work or during sleep are suggestive of a cardiac cause.
- Aggravating factors
- Palpitations aggravated by exertion suggest channelopathies, cardiomyopathies or underlying ischemia.
- Relieving factors- Vagal Maneuvers or rest?
- Palpitations terminated by vagal maneuvers are likely due to supraventricular tachycardias.
- Associated Symptoms- Chest Pain, Syncope, Neck Pulsations, Dizziness, Nausea, Vomiting?
- Palpitations associated with chest pain may be due to myocardial ischemia, exacerbated mitral valve prolapse, cardiomyopathy or dehydration.
- Palpitations associated with presyncope, syncope, light headedness and dizziness suggest tachyarrhythmias or hypertrophic cardiomyopathy.
- Palpitations associated with orthostatic intolerance suggest cerebral hypoperfusion and are commonly seen in women of child bearing age.
- Palpitations associated with elevated jugular venous pressure, pedal edema and breathlessness suggest congestive heart failure.
- Palpitations associated with polyuria may be due to atrial fibrillation that caused the release of atrial natriuretic peptide.
- Visible transmitted pounding neck pulsations and an associated ‘frog sign’ are likely to be the result of AV dissociations such as AV nodal re-entry tachycardia that would cause the contraction of atria against closed AV valves.
- Palpitations associated with pupillary dilation, sweating, aberrant behavior and dry mouth such as the use of drugs such as cocaine, MDMA and methamphetamines.
- Medication History
- Caffeine, alcohol, tobacco, beta agonists, cocaine, amphetamines, methylxanthines, ADHD medication, coenzyme Q inhibitors, carnitine and omega 3 polyunsaturated fatty acids can cause palpitations.
- Family History – Sudden death, cardiac disease, Psychiatric condition?
- Inherited conditions such as Arrhythmogenic right ventricular cardiomyopathy, Brugada syndrome
- Past History
References
- ↑ "Palpitations - an overview | ScienceDirect Topics".
- ↑ 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.
- ↑ 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.
- ↑ "StatPearls". 2020. PMID 28613787.
- ↑ Abbott AV (2005). "Diagnostic approach to palpitations". Am Fam Physician. 71 (4): 743–50. PMID 15742913.