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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.

Abbreviations: AF: Atrial fibrillation; AVRT: AV reentry tachycardia; AVNRT: AV nodal reentry tachycardia; BP: Blood pressure; CBC: Complete blood count; ECG: Electrocardiogram; TSH: Thyroid stimulationg hormone; TTE: Transthorasic echocardiography; VT: Ventricular tachycardia; WPW: Wolff-Parkinson-White syndrome

Characterize the symptoms: ❑ Duration ❑ Short lasting: spontaneous termination ❑ Long lasting: need appropriate tratment for controlling the symptoms ❑ Frequency ❑ Daily ❑ Weekly ❑ Monthly ❑ Yearly ❑ Onset ❑ Sudden (suggestive of SVT of VT) ❑ Gradual (suggestive of axiety of excerise induced sinus tachycardia) ❑ 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 ❑ Prodrome ❑ Chest pain ❑ Dizziness ❑ Syncope ❑ Dyspnea ❑ Vertigo ❑ Fatige ❑ Position ❑ After standing up straight (suggestive of orthostatic hypotension or AVNRT) ❑ Pounding sensation while lying in bed (suggestive of AVNRT)

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 or ischemic 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 ❑ First episode: young age (suggestive of AVRT) ❑ 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 arhythmias and structural heart disease

Examine the patient: Vitals ❑ Pulse ❑ Rhythm ❑ Regular (suggestive of AVRT, AVNRT, atrial flutter or VT) ❑ Irregular (suggestive of extrasystole, AF or atrial flutter) ❑ Rate ❑ Tachycardia ❑ Over the estimated maximum for the patient's age (suggestive of SVT or VT) ❑ Under the estimated maximum for the patient's age (suggestive of anxiety or panic attack) ❑ Bradycardia (suggestive of sinus bradycardia, second degree AV block and third degree AV block) ❑ Pulse deficit (suggestive of AF) ❑ 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) ❑ Hypertension ❑ Temperature ❑ Fever (suggestive of infection) ❑ Respiratory rate Face ❑ Exophthalmos (sugestive of hyperthyroidism) Neck ❑ Goirter (suggestive of hypherthyroidism) ❑ Jugular venous pulse: cannon A wave (suggestive of AV dissociation) Skin ❑ Hot and sweaty (suggestive of hyperthyroidism) Hair ❑ Thin (suggestive of hyperthyroidism) Respiratory ❑ Rales (suggestive of heart failure) Cardiovascular ❑ Murmurs (suggestive of valve disease) ❑ Associated with midsystolic click (suggestive of mitral valve prolapse) ❑ Holosystolic murmur in the left sternal border that increases with valsalva (suggestive of hypertrophic obstructive cardiomyopathy) ❑ Displaced apex beat (suggestive of cardiomegaly ❑ S3 (suggestive of cardiac heart failure) Neurologic ❑ Tremors (suggestive of panic attacks or Hyperthyroidism)

Order labs and tests: ❑ ECG ❑ Determine if the rythm is regular or irregular ❑ Assess the p wave and QRS morphology ❑ Search for short PR intervals and delta waves (suggstive of WPW) ❑ Search for deep septal Q waves in I, V4 to V6 and signs of left ventricular hypertrophy (suggestive of hypertrophic obstructive cardiomyopathy) ❑ Presence of more negative than 0.04 ms p wave in V1 (suggestive of AF) ❑ Presence of prior myocardial infaction Q waves (suggestive of VT) ❑ Presence of aberrant T wave with prolonged QT segment (suggestive of Long-QT syndrome) ❑ Normal ECG (suggestive of anxiety or panic attack) ❑ CBC (to rule out anemia or infection) ❑ Electrolytes (to rule out hypokalemia and hypomagnesemia) ❑ TSH (to rule out hyperthyroidism) ❑ Glucose level ❑ Cardiac enzymes (to rule out MI) Order imaging studies ❑ TTE (to rule out structural heart disease)

Does the patient has EKG findings or TTE findings suggestive of a cardiac cause for the palpitations?

Yes

No

Does the patient has EKG findings of an arrhythmia?

Does the patient has history signs of a psychiatric disorder?

Yes

No

Yes

No

Arrhythmia ❑ Extrasystole ❑ Narrow complex tachycardia ❑ Wide complex tachycardia ❑ Bradyarrhythmias ❑ Wolff-Parkinson-White syndrome

Nonarrhythmic cardiac cause ❑ Atrial septal defect ❑ Ventricular septal defect ❑ Cardiomyopathy ❑ Congestive heart failure ❑ Congenital heart disease ❑ Mitral valve prolapse ❑ Paricarditis ❑ Valvular disease ❑ Aortic stenosis ❑ Aortic regurgitation

Psychiatric cause ❑ Anxiety ❑ Panic attack ❑ Depression ❑ Somatization

Does the patient has history of taking drugs or madications that can cause palpitations?

Yes

No

Drugs or medication intake ❑ Alcohol ❑ Caffeine ❑ Medications ❑ Sympathicomimetic agents ❑ Vasodialators ❑ Anticholinergics agents ❑ Hydralazine ❑ Withdrawal of beta-blockers ❑ Beta-agonists ❑ Digitalis ❑ Recreational drugs ❑ Cocaine ❑ Heroine ❑ Cannabis ❑ Nicotine

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

Treatment

The management of palpitations will be directed to the specific undelying cuase. If the etiology can be determined and low risk, portentialy curative treatments are availabe, that should be the first choise of management. For benign arrhythmias, such as extrasystole, lifestyle changes may be sufficient to prevent future episodes. For patiens in whom no clear disease has been established, advise should be made for them to avoid possible triggers for palpitations as caffeine, alcohol, nicotine, recreational drugs.

Determine the cause of the palpitations

Cardiac cause

Extracardiac cause

Arrhythmia Extrasystole Narrow complex tachycardia Wide complex tachycardia Bradyarrhythmias Wolff-Parkinson-White syndrome ❑ Unstable: Electrical cardioversion ❑ Orthodromic AVRT: vagal maneuvers or adenosine ❑ Antidromic AVRT: procainamide (avoid AV node blockers) Click here for a complete management

Nonarrhythmic cardiac cause Atrial septal defect ❑ Surgical closure Click here for a complete management Ventricular septal defect ❑ Srgical closure: depends on the age of the patient and size of the defect Click here for a complete management Cardiomyopathy ❑ Depends on the type of cardiomyopathy, directed towards symptom relief ❑ Includes: BP control, heart rate control, implanted devices, ablation therapy Click here for a complete management Congestive heart failure Acute heart feilure ❑ Hypertensive with no volume overload: ACE inhibitos + Beta-blockers ❑ Hypertensive with volume overload: diuretics ❑ Hypotensive with volume overload: IV inotrope + diuretics (monitor BP) ❑ Hypotensive with no volume overload: IV inotrope Click here for a complete management Chronic heart feilure ❑ Fluid retention: diuretics ❑ No fluid retension: ACE inhibitors + Beta-blockers Click here for a complete management Congenital heart disease ❑ Mild defects don't require treatment ❑ Severe defects require surgical repair Click here for a complete management Mitral valve prolapse ❑ Only palpitations or chest pain: beta-blockers Click here for a complete management Pericarditis ❑ Unstable: resuscitation maneuvers, immidiate treatment of cardiac tamponade if needed ❑ Previous MI: high dose aspirin ❑ No previous M: NSAID Click here for a complete management Valvular disease Aortic stenosis ❑ Classify the stege of AS and treat accordingly Click here for a complete management Aortic regurgitation Acute AR: ❑ IE: antibiotics (mild), surgery (severe) ❑ AD: surgery Chronic AR: ❑ Classify the stege of AS and treat accordingly Click here for a complete management

Psychiatric cause Anxiety ❑ Psycological therapy ❑ Pharmacological treatment acording to the specific disorder Click here for a complete management Panic attack ❑ Paper bag breathing ❑ Benzodiazepines Click here for a complete management Depression Somatization

Drugs or medication intake ❑ Alcohol ❑ Caffeine ❑ Medications ❑ Sympathicomimetic agents ❑ Vasodialators ❑ Anticholinergics agents ❑ Hydralazine ❑ Withdrawal of beta-blockers ❑ Beta-agonists ❑ Digitalis ❑ Recreational drugs ❑ Cocaine ❑ Heroine ❑ Cannabis ❑ Nicotine

Systemic disease Anemia ❑ Unstable: resuscitation maneuvers ❑ <8mg/dl blood transfusions ❑ Treat the underlying cause of the anemia Click here for a complete management Electrolyte disturbances ❑ Treat the particular electrolyte disturbance Click here for a complete management Fever ❑ Treat the underlying cause of the fever Click here for a complete management Hyperthyroidism ❑ Beta-blockers ❑ Supresive thyrostatics (initial therapy) ❑ Surgical or radioisotope therapy (permanent treatment) Click here for a complete management Hypoglycemia ❑ Consious patient: oral ingestion of carbohydrates ❑ Unconsious patient: IV infusion of glucose Click here for a complete management Hypovolemia ❑ Fluid reposition Click here for a complete management Pheochromocytoma ❑ Treatment of choice: surgical removal of the tumor Click here for a complete management Pulmonary disease Vasovagal syndrome

References

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