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Palpitations are one of the most common complains of patients when visiting a physician. The causes of palpitations can range from benign (most common) to life-threatening conditions if not managed properly. Palpitations are described differently by each patient, usually as an uncomfortable awareness of rapid, pounding heart beats, but also described as flip-flopping of the chest, rapid fluttering in the chest or pounding in the neck. The diagnosis is made by a detailed history, physical examination and a surface 12-lead EKG. The management of palpitations consists in treating the underlying cause.

Causes

Life-Threatening Causes

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

• Acute coronary syndrome
• Malignant hypertension
• Myocardial infarction
• Third degree AV block
• Ventricular arrhythmia

Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

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.

Characterize the symptoms: ❑ Type of palpitations ❑ Flip-flopping of the chest: (suggestive of extrasystole) ❑ Rapid fluttering of the chest: (suggestive of Tachycardia) ❑ Pounding in the neck: (suggestive of AVRT and AVNRT) ❑ Pulsation palpitations (suggestive of structural heart disease) ❑ Anxiety-related palpitations ❑ Chest pain ❑ Dizziness ❑ Syncope

Search for associated symptoms and circumstances ❑ Sudden changes of posture (suggestive of intolerance to orthostasis or AVNRT) ❑ Syncope (suggestive of SVT or stuctural heart disease) ❑ Angina, dyspnea, fatige (suggestive of stuctural heart disease) ❑ Polyuria (suggestive of AF) ❑ Rapid regular pulse in the neck (suggestive of AVNRT)

Inquire about drug that can cause palpitations: ❑ Sympathicomimetic agent pump inhalers (asthmatic patients) ❑ Vasodilators ❑ Anticholinergics ❑ Hydralazine ❑ Whithdrawl of beta-blockers ❑ Alcohol ❑ Cocaine ❑ Heroin ❑ Amphetamines ❑ Caffeine ❑ Nicotine ❑ Cannabis ❑ Synthetic drugs ❑ Weight reaction drugs

Obtain a detailed past medical hystory: ❑ Prevous episodes of palpitations ❑ Number of episodes ❑ Time since last episode ❑ Circumstances of past episodes ❑ Cardiac arrhythmya ❑ Structural heart disease ❑ Hypertrophic cardiomyopathy ❑ Valvular disease ❑ Congenital heart disease ❑ Cardiomegaly ❑ Sistemic diseases ❑ Hyperthyrodism ❑ Pheochromocytoma ❑ History of panic attacks ❑ History of depression

Examine the patient: Vitals ❑ Pulse ❑ Rythm ❑ Regular ❑ Irregular ❑ Rate ❑ Blood pressure ❑ Orthostatic hypotension (Fall in systolic BP ≥ 20 mmHg and/or in diastolic BP of at least ≥ 10 mmHg between the supine and sitting BP reading) ❑ Respiratory rate Face ❑ Exoftalmos (sugestive of hyperthyroidism) Neck ❑ Goirter (suggestive of hypherthyroidism) ❑ Jugular venous pulse: cannon A wave (suggestive of AV dissociation) Respiratory ❑ Cardiovascular ❑ ❑ ❑ Neurologic ❑ ❑

Order labs and tests: ❑ ECG ❑ Electrolytes ❑ TSH ❑ Cardiac enzymes

Order imagin studies ❑ Chest x-ray

References

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