Palpitations resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D.

Palpitations Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Gallery

Overview

Causes

Life-Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Ventricular arrhythmia
• Cardiac tamponade
• Acute coronary syndrome
• Third degree AV block

Common causes

• Cardiac causes

• Arrhythmic

• Premature ventricular contractions
• Narrow complex tachycardia
• Wide complex tachycardia

• Non-arrhythmic

• Valvular disease
• Pericarditis
• Structural heart disease
• Malfunctioning pacemaker

• Psychiatric causes

• Anxiety
• Panic attack

• Substance - drug causes

• Cardiac Glycosides
• Antiarrhythmics
• Sympathomimetics
• Insulin
• Thyroxine
• Alcohol
• Caffeine
• Beta-blocker withdrawal
• Amphetamines
• Cannabis
• Cocaine

• Systemic causes

• Anemia
• Fever
• Hyperthyroidism
• Hypoglycemia
• Hypoxia
• Hypercapnia

Click here for a complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
Boxes in the red signify that an urgent management is needed.

Abbreviations: EKG: Electrocardiogram; IV: Intravenous; NSTEMI: Non ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction; TTE: Transthoracic echocardiography; VT: Ventricular tachycardia; WPW: Wolff-Parkinson-White syndrome

Does the patient have any of the following findings that require urgent management? ❑ Syncope (suggestive of VT, complete AV block) ❑ Hypotension or shock (suggestive of VT) ❑ Chest pain (suggestive of ischemia, complete AV block) ❑ Shortness of breath (suggestive of PE, cardiac tamponade, complete AV block)

Yes

No

Continue with the complete diagnostic approach below

Stabilize the patient ❑ Consider intubation if the patient's airway is compromised, has a Glasgow coma scale (GCS < 8) or profound hemodynamic instability ❑ Administer oxygen and maintain a saturation >90% ❑ Secure 2 large-bore intravenous lines (IVs) and initiate fluid resuscitation ❑ Consider vasopressors only if patient remains hypotensive despite fluids Obtain the following ❑ 12 lead ECG ❑ Blood for CBC, electrolytes, troponin I, CK-MB, free T3/T4, toxicology screen ❑ Consider CTA if patient has a Wells score >4

Does the patient have any characteristic signs and symptoms or any ECG / lab abnormalities?

Yes

No

❑ Continue supportive care ❑ Place patient on cardiac monitor ❑ Re-evaluate if status worsens

Tachyarrhythmia ❑ Abnormal rhythm w/ a ventricular rate of ≥100/min

Ischemia ❑ ST-segment deviation ❑ Elevated cardiac biomarkers

Cardiac Tamponade ❑ Elevated JVP ❑ Pulsus paradoxus ❑ Low-voltage QRS complexes ❑ Electrical alternans ❑ PR segment depression

Thyroid Storm ❑ Suppressed TSH ❑ Elevated free T3/T4

Pulmonary Embolism ❑ Tachypnea ❑ Wells Score >4 ❑ Positive chest CTA

Supraventricular / Narrow-Complex Tachyarrhythmia Treatment Algorithm Ventricular / Wide-Complex Tachyarrhythmia Treatment Algorithm

UA / NSTEMI Treatment Algorithm STEMI Treatment Algorithm

Cardiac Tamponade Treatment Algorithm

Thyroid Storm Treatment Algorithm

Pulmonary Embolism Treatment Algorithm

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

Abbreviations: AF: Atrial fibrillation; AVRT: AV reentry tachycardia; AVNRT: AV nodal reentry tachycardia; BP: Blood pressure; CBC: Complete blood count; EKG: Electrocardiogram; EPS: Electrophysiological study SVT: Supraventricular tachycardia TSH: Thyroid stimulating hormone; TTE: Transthoracic echocardiography; VT: Ventricular tachycardia; WPW: Wolff-Parkinson-White syndrome

Characterize the symptoms: ❑ Character of palpitations ❑ Flip-flopping of the chest ❑ Rapid fluttering of the chest ❑ Pounding in the neck ❑ Pulsation palpitations ❑ Anxiety-related palpitations ❑ Onset ❑ Sudden ❑ Gradual ❑ Duration ❑ Brief ❑ Persistent ❑ Frequency ❑ Daily ❑ Weekly ❑ Monthly ❑ Termination ❑ Successful with vagal maneuvers (suggestive of SVT) ❑ Associated with ❑ Sudden changes of posture (suggestive of intolerance to orthostasis or AVNRT) ❑ Syncope ❑ Angina, dyspnea, fatigue, vertigo, dizziness ❑ Polyuria (suggestive of AF) ❑ Rapid regular pulse in the neck

Inquire about drugs that can cause palpitations: ❑ Sympathomimetic agents ❑ Inhaled beta-agonists ❑ Vasodilators ❑ Anticholinergic agents ❑ Beta-blocker withdrawal ❑ Recreational drugs ❑ Alcohol ❑ Cocaine ❑ Heroin ❑ Amphetamines ❑ Caffeine ❑ Nicotine ❑ Cannabis ❑ Synthetic drugs ❑ Weight reduction drugs

Obtain a detailed past medical history: ❑ Previous episodes of palpitations ❑ First episode ❑ Number of episodes ❑ Time since last episode ❑ Circumstances of past episodes ❑ Cardiac arrhythmia ❑ Structural heart disease ❑ Hypertrophic cardiomyopathy ❑ Valvular disease ❑ Congenital heart disease ❑ Cardiomegaly ❑ Systemic diseases ❑ Hyperthyroidism ❑ Pheochromocytoma ❑ History of panic attacks ❑ History of depression ❑ Family history of arrhythmias and structural heart disease

Examine the patient: Vitals ❑ Pulse ❑ Rhythm ❑ Regular (suggestive of SVT or VT) ❑ Irregular (suggestive of premature ventricular beats) ❑ Irregularly irregular (suggestive of AF) ❑ Rate ❑ Tachycardia ❑ Bradycardia (suggestive of sinus bradycardia, AV block) ❑ Pulse deficit (suggestive of AF or premature ventricular beats) ❑ Blood pressure ❑ Hypotension ❑ Orthostatic hypotension ❑ Hypertension ❑ Temperature ❑ Fever (suggestive of infection) ❑ Tachypnea (non-specific) Eyes ❑ Exophthalmos (suggestive of Graves disease) Neck ❑ Goiter (suggestive of hyperthyroidism) ❑ Jugular venous pulse: cannon A wave (suggestive of AV dissociation) Skin ❑ Hot and sweaty (suggestive of hyperthyroidism or fever) Hair ❑ Thin (suggestive of hyperthyroidism) Respiratory ❑ Rales (suggestive of heart failure) ❑ Wheezing (non-specific) Cardiovascular ❑ Muffled heart sounds ❑ Pericardial friction rub (suggestive of pericarditis) ❑ Murmurs (suggestive of valve disease) ❑ Displaced apex beat (suggestive of cardiomegaly ❑ S3 (suggestive of heart failure) ❑ S4 Neurologic ❑ Tremors (suggestive of panic attacks or hyperthyroidism)

Order labs and tests: ❑ EKG ❑ Determine if the rhythm is regular or irregular ❑ Assess the p wave and QRS morphology ❑ Rate over 100 bpm, QRS < 120 ms (suggestive of narrow complex tachycardia) ❑ Search for short PR intervals and delta waves (suggestive of WPW) ❑ Irregular rhythm, change in p wave morphology (suggestive of AF) ❑ Regular rhythm, saw-tooth appearance (suggestive of atrial flutter) ❑ Rate over 100 bpm, QRS > 120 ms (suggestive of wide complex tachycardia) ❑ Search for deep septal Q waves in I, V4 to V6 and signs of left ventricular hypertrophy (suggestive of hypertrophic obstructive cardiomyopathy) ❑ Normal EKG (suggestive of anxiety or panic attack) ❑ CBC (to rule out anemia or infection) ❑ Electrolytes (to rule out potassium and magnesium imbalances) ❑ TSH (to rule out hyperthyroidism) ❑ Glucose level (to rule out hypoglycemia) ❑ Cardiac enzymes (to rule out MI) Order imaging studies ❑ TTE (to rule out structural heart disease)

Consider hospitalization ❑ Recurrent episodes when no ambulatory EKG devices are available ❑ Severe structural heart disease, family history of sudden cardiac death and/or heart conduction abnormalities

Does the patient have clinical or EKG findings suggestive of a cardiac cause of the palpitations?

Yes

No

Arrhythmia ❑ Premature ventricular beat ❑ Narrow complex tachycardia ❑ Wide complex tachycardia ❑ Bradyarrhythmias ❑ Wolff-Parkinson-White syndrome

Myocardial ischemia ❑ Acute coronary syndrome ❑ STEMI ❑ NSTEMI ❑ Unstable angina

Other EKG findings

Does the patient have a history of psychiatric disorders?

EKG findings suggestive of pericarditis Pericarditis ❑ ST segment elevation in leads I, II, aVL, aVF, and V3-V6 ❑ PR segment depression ❑ Low QRS voltage (in large Pericardial effusion and Constrictive pericarditis)

Non-specific EKG findings

Yes

No

Order a TTE

Consider the following if all diagnostic tests are normal: ❑ Anxiety ❑ Panic attack ❑ Depression ❑ Somatization

Is the patient taking any substances/drugs that can cause palpitations?

❑ Congenital heart disease ❑ Cardiomyopathy ❑ Congestive heart failure ❑ Pericarditis ❑ Valvular disease ❑ Aortic stenosis ❑ Mitral valve prolapse

Yes

No

Click in each link for the specific diagnostic approach and management ❑ Alcohol ❑ Caffeine ❑ Medications ❑ Sympathomimetic agents ❑ Vasodilators ❑ Anticholinergic agents ❑ Beta-blocker withdrawal ❑ Beta-agonists ❑ Digitalis ❑ Recreational drugs ❑ Cocaine ❑ Heroin ❑ Cannabis ❑ Amphetamines ❑ Nicotine

Click in each link for the specific diagnostic approach and management ❑ Anemia ❑ Electrolyte disturbances ❑ Fever ❑ Hyperthyroidism ❑ Hypoglycemia ❑ Hypovolemia ❑ Pheochromocytoma ❑ Vasovagal reflex

Treatment

The management of palpitations should be directed towards the underlying cause. If the etiology can be determined and low risk, potentially curative treatments are available these should be the first choice of management. For benign arrhythmias, such as extrasystole, lifestyle changes may be sufficient to prevent future episodes. For patients in whom no clear disease has been established, patients should be advised to avoid possible triggers of palpitations such as caffeine, alcohol, nicotine, recreational drugs.
Abbreviations: NSTEMI: Non ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction

Determine the cause of the palpitations

Cardiac cause

Non-cardiac cause

Arrhythmia Premature ventricular contraction Narrow complex tachycardia Wide complex tachycardia Bradyarrhythmias Wolff-Parkinson-White syndrome

Nonarrhythmic cardiac cause Acute coronary syndrome Unstable angina NSTEMI STEMI Congenital heart disease Cardiomyopathy Congestive heart failure Acute heart failure Chronic heart feilure Mitral valve prolapse Pericarditis Valvular disease Aortic stenosis Aortic regurgitation

Psychiatric disorder Anxiety Panic attack Depression Somatization

Substance/drug intake ❑ Alcohol ❑ Caffeine ❑ Medications ❑ Sympathomimetic agents ❑ Vasodilators ❑ Anticholinergic agents ❑ Beta-blocker withdrawal ❑ Beta-agonists ❑ Digitalis ❑ Recreational drugs ❑ Cocaine ❑ Heroin ❑ Cannabis ❑ Amphetamines ❑ Nicotine

Systemic disease Anemia Electrolyte disturbances Fever Hyperthyroidism Hypoglycemia Hypovolemia Pheochromocytoma Vasovagal syndrome

Consider hospitalization ❑ Implantations or replacement of pacemakers for bradyarrhythmias ❑ VT and SVT which require urgent electrical cardioversion or catheter ablation therapy ❑ Symptoms of hemodynamic instability or heart failure ❑ Patients with structural heart disease who requires surgical or transcatheter intervention ❑ Severe psychiatric conditions ❑ Severe systemic disease

Do's

• If possible, perform a physical exam and an ECG when the patient is symptomatic.
• If a patient is asymptomatic, search for signs of structural heart disease such as murmurs, displaced apex beat or S3.
• Perform an ambulatory ECG in patients with recurrent episodes of palpitations of undetermined etiology.
• Perform an electrophysiologic study (EPS) for patients with inconclusive ambulatory ECG.
• Perform an EPS, with ablation therapy if necessary, in patients with severe heart disease, particularly when palpitations preceded syncope and when the patient required cardio-respiratory resuscitation maneuvers.
• Advise life-style changes that may lower the possibility of future episodes, such as exercise, lower alcohol and caffeine intake, and smoking cessation.
• Perform an exercise stress test in patients with exercise induced palpitations.
  

EKG gallery

Narrow complex tachycardia

Type of Arrhythmia	EKG (lead II)	Clues
Sinus tachycardia		Onset and termination: gradual Rhythm: regular Rate: >220 minus the age of the patient Response to adenosine: transient decrease of the rate
Atrial fibrillation		Onset and termination: abrupt Rhythm: irregular Rate:100-180 bpm Response to adenosine: transient decrease of the ventricular rate
Atrial flutter		Onset and termination: abrupt Rhythm: regular Rate: >150 bpm Response to adenosine: transient decrease of the rate Presence of saw-tooth appearance
AVNRT		Onset and termination: abrupt Rhythm: regular Rate: 150-250 bpm Response to adenosine: termination of the arrhythmia
AVRT		Onset and termination: abrupt Rhythm: regular Rate: 150-250 bpm Response to adenosine: termination of the arrhythmia
Focal atrial tachycardia		Onset and termination: abrupt Rhythm: regular Rate: 150-250 bpm
Nonparoxysmal junctional tachycardia		Rhythm: regular Retrograde P wave Most commonly due to ischemia or digitalis toxicity
Multifocal atrial tachycardia		Onset and termination: gradual Rhythm: irregular Rate: 100-150 bpm Response to adenosine: no effect 3 different P wave morphologies

Wide complex tachycardia

	Example	Regularity	Atrial frequency	Ventricular frequency	Origin (SVT/VT)	p-wave	Effect of adenosine
Wide complex (QRS > 0.12)
Ventricular Tachycardia		regular (mostly)	60-100 bpm	110-250 bpm	ventricle (VT)	AV-dissociation	no rate reduction (sometimes accelerates)
Ventricular Fibrillation		irregular	60-100 bpm	400-600 bpm	ventricle (VT)	AV-dissociation	none
Ventricular Flutter		regular	60-100 bpm	150-300 bpm	ventricle (VT)	AV-dissociation	none
Accelerated Idioventricular Rhythm		regular (mostly)	60-100 bpm	50-110 bpm	ventricle (VT)	AV-dissociation	no rate reduction (sometimes accelerates)
Torsade de Pointes		regular		150-300 bpm	ventricle (VT)	AV-dissociation	no rate reduction (sometimes accelerates)
Bundle-branch re-entrant Tachycardia*		regular	60-100 bpm	150-300 bpm	ventricles (VT)	AV-dissociation	no rate reduction
* Bundle-branch re-entrant tachycardia is extremely rare

STEMI

Shown below is an EKG demonstrating the evolution of an infarct on the EKG. ST elevation, Q wave formation, T wave inversion, normalization with a persistent Q wave suggest STEMI.

NSTEMI

Shown below is an EKG showing an ST depression in V2, V3, V4 and V6.

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Shown below is an EKG showing an inversion in the T wave at leads V4, V5 and V6.

Pericarditis

Shown below is an EKG with ST elevation in lead I, II, V2, V3, V4, V5 and V6.

ST elevation in leads I, II, V2, V3, V4, V5, and V6 depicting acute pericarditis

References

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