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<span style="font-size:85%">Click in each link for the specific diagnostic approach and management</span><br>
<span style="font-size:85%">Click in each link for the specific diagnostic approach and management</span><br>


❑ [[Acute coronary syndrome]]<br>
❑ [[Congenital heart disease]]<br>
❑ [[Congenital heart disease]]<br>
❑ [[Cardiomyopathy]]<br>
❑ [[Cardiomyopathy]]<br>

Revision as of 15:39, 29 April 2014

Overveiw

Palpitations are one of the most common complains of patients when visiting a physician.[1][2] The causes of palpitations can range from benign (most common) to life-threatening conditions if not managed properly.[2] 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.[1][2] 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.

Common Causes

Focused Initial Rapid Evaluation

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

 
 
 
 
 
 
 
 
 
 
Identify cardinal signs and symptoms that increase the pre-test probability of palpitations
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the followign findings that require urgent management?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue with the complete duagnostic apporoach shown below
 
 
 
 
 
 
 
 
 
 
Stabilize the patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Orger and EKG immedietly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EKG findings
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
{{{ E01 }}}
 
{{{ E02 }}}
 
{{{ E03 }}}
 
{{{ E04 }}}
 
 

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.[1][2][3][4][5][6]

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
Anticholinergic agents
❑ 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 SVT or VT)
❑ Irregular (suggestive of extrasystole or AF)
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, 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
Goiter (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
❑ Rate over 100 bpm, QRS <120 ms (suggestive of narrow complex tachycardia)
❑ Search for short PR intervals and delta waves (suggstive of WPW)
❑ Irragular 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)
❑ Presence of prior myocardial infaction Q waves (suggestive of VT)
❑ Search for deep septal Q waves in I, V4 to V6 and signs of left ventricular hypertrophy (suggestive of hypertrophic obstructive cardiomyopathy)
❑ 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 (to rule out hypoglycemia)
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

Click in each link for the specific diagnostic approach and management

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

 
 
 
Nonarrhythmic cardiac cause

Click in each link for the specific diagnostic approach and management

Acute coronary syndrome
Congenital heart disease
Cardiomyopathy
Congestive heart failure
Mitral valve prolapse
Paricarditis
Valvular disease

Aortic stenosis
Aortic regurgitation
 
Psychiatric cause

Click in each link for the specific diagnostic approach and management

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

Click in each link for the specific diagnostic approach and management

Alcohol
Caffeine
❑ Medications

Sympathicomimetic agents
Vasodilators
Anticholinergics agents
❑ Withdrawal of beta-blockers
Beta-agonists
Digitalis

❑ Recreational drugs

Cocaine
Heroin
Cannabis

Nicotine

 
 
Systemic disease

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 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.[1][2][3][4][6]


 
 
 
 
 
 
 
Determine the cause of the palpitations
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardiac cause
 
 
 
 
 
 
 
Extracardiac cause
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Drugs or medication intake

Alcohol
Caffeine
❑ Medications

Sympathicomimetic agents
Vasodialators
Anticholinergics agents
❑ Withdrawal of beta-blockers
Beta-agonists
Digitalis

❑ Recreational drugs

Cocaine
Heroine
Cannabis

Nicotine

 
 
 
 

References

  1. 1.0 1.1 1.2 1.3 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.
  2. 2.0 2.1 2.2 2.3 2.4 Zimetbaum, P.; Josephson, ME. (1998). "Evaluation of patients with palpitations". N Engl J Med. 338 (19): 1369–73. doi:10.1056/NEJM199805073381907. PMID 9571258. Unknown parameter |month= ignored (help)
  3. 3.0 3.1 "http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf" (PDF). Retrieved 16 April 2014. External link in |title= (help)
  4. 4.0 4.1 Abbott, AV. (2005). "Diagnostic approach to palpitations". Am Fam Physician. 71 (4): 743–50. PMID 15742913. Unknown parameter |month= ignored (help)
  5. Thavendiranathan, P.; Bagai, A.; Khoo, C.; Dorian, P.; Choudhry, NK. (2009). "Does this patient with palpitations have a cardiac arrhythmia?". JAMA. 302 (19): 2135–43. doi:10.1001/jama.2009.1673. PMID 19920238. Unknown parameter |month= ignored (help)
  6. 6.0 6.1 "http://www.turner-white.com/pdf/hp_jan03_methods.pdf" (PDF). Retrieved 25 April 2014. External link in |title= (help)


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