Palpitations resident survival guide

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

Overview

Palpitations are one of the most common complains of patients when visiting outpatient clinics and emergency rooms. 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
• Aortic valve disease
• Cardiac tamponade
• Hypovolemia
• Third degree AV block
• Ventricular arrhythmia

Common causes

• Cardiac causes

• Arrhythmia

• Premature ventricular contraction
• Narrow complex tachycardia
• Wide complex tachycardia

• Non-arrhythmic cardiac causes

• Diseases of the valvular structures
• Pericarditis
• Structural heart disease

• Malfunctioning or wrong programing of pacemakers

• Psychiatric causes

• Anxiety
• Panic attack

• Drug and medications

• Alcohol
• Caffeine
• Recent withdrawal of beta-blockers
• Recreational drugs

• Amphetamines
• Cannabis
• Cocaine
• Heroin

• Systemic causes

• Anemia
• Fever
• Hyperthyroidism
• Hypoglycemia

Click here for a complte list of causes for palpitations.

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: AS: Aortic stenosis; AR: Aortic regurgitation; EKG: Electrocardiogram; IV: Intravenous; NSTEMI: Non ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction; TTE: Trasthorasic echocardiography WPW: Wolff-Parkinson-White syndrome

Identify cardinal symptoms and signs that increase the pre-test probability of palpitations Symptoms: ❑ Flip-flopping of the chest ❑ Rapid fluttering of the chest ❑ Pounding in the neck ❑ Pulsation palpitations Signs: ❑ Increased heart rate with regular or irregular rhythm ❑ Cardiological findings suggestive of a cardiological disease ❑ Murmurs ❑ S3 sound ❑ Muffled heart sounds ❑ Displaced apex beat

Does the patient have any of the followign findings that require urgent management? ❑ Palpitations asociated with syncope (suggestive of VT of structural heart disease) ❑ Chest discomfort suggestive of ischemia ❑ Decompensated heart failure ❑ Consider electrical cardioversion

Yes

No

Continue with the complete duagnostic apporoach shown below

Does the patient have any of the following findings suggesting of hemodynamic instability? ❑ Hemodynamic instability ❑ Hypotension ❑ Cold extremities ❑ Peripheral cyanosis ❑ Mottling ❑ Altered mental status

Yes

No

Stabilize the patient ❑ Assess circulation, secure airway and breathing ❑ Secure IV line ❑ Offer oxygen ❑ Cardiac monitor to identify rhythm ❑ Monitor blood pressure and oximetry

Order an EKG immediately Does the patient has any EKG findings suggestive of an arrhythmia?

Yes

No

Narrow complex tachycardia Wide complex tachycardia Bradycardia WPW

Does the patient have any EKG findings suggestive of myocardial ischemia or pericarditis? STEMI ❑ ST elevation in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads ❑ ST depression in at least two precordial leads V1-V4 (suggestive of posterior MI) ❑ ST depression in several leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery) ❑ New LBBB NSTEMI: ❑ Non specific ST / T wave changes ❑ Flipped or inverted T waves ❑ ST Depression 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) ❑ Cardiac tamponade: electrical alternans

Yes

No

STEMI NSTEMI

Pericarditis

Order a TTE

Does the patient have any structural heart disease?

Yes

No

Acute heart failure AS Acute AR

Does the patient have history of consuming any toxic substance that can explain the palpitations and hemodynamic instability?

Yes

No

Alcohol Cocaine Heroin Amphetamines

Look for systemic diseases than can cause palpitations and hemodynamic instability

Electrolyte disturbances Hyperthyroidism Hypoglycemia Hypovolemia

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: Transthorasic echocardiography; VT: Ventricular tachycardia; WPW: Wolff-Parkinson-White syndrome

Characterize the symptoms: ❑ Duration ❑ Breif: spontaneous termination ❑ Persistent: need appropriate tratment for controlling the symptoms ❑ Frequency: (daily, weekly, monthly) ❑ Onset ❑ Sudden (suggestive of SVT or VT) ❑ Gradual (suggestive of anxiety or excerise induced sinus tachycardia) ❑ Termination: with vagal maneuvers (suggestive of SVT) ❑ 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 ❑ Fatigue ❑ Position ❑ After standing up (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 structural heart disease) ❑ Angina, dyspnea, fatigue (suggestive of structural heart disease or ischemic heart disease) ❑ Polyuria (suggestive of AF) ❑ Rapid regular pulse in the neck (suggestive of AVNRT)

Inquire about drugs that can cause palpitations: ❑ Sympathomimetic agent pump inhalers (asthmatic patients) ❑ Vasodilators ❑ Anticholinergic agents ❑ Withdrawal of beta-blockers ❑ Alcohol ❑ Cocaine ❑ Heroin ❑ Amphetamines ❑ Caffeine ❑ Nicotine ❑ Cannabis ❑ Synthetic drugs ❑ Weight reduction drugs

Obtain a detailed past medical history: ❑ Previous episodes of palpitations ❑ First episode ❑ Childhood (suggestive of AVRT or AVNRT) ❑ Adult patients (suggestive of AF or VT) ❑ 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 extrasystole) ❑ Irregularly irregular (suggestive of AF) ❑ Rate ❑ Tachycardia ❑ Over 220 minus the patient's age (suggestive of SVT or VT) ❑ Under 220 minus the patient's age (suggestive of anxiety or panic attack) ❑ Bradycardia (suggestive of sinus bradycardia, AV block) ❑ Pulse deficit (suggestive of AF or premature ventricular beats) ❑ Blood pressure ❑ Hypotension (suggestive of hypovolemia) ❑ 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 (non-specific) Face ❑ 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) Hair ❑ Thin (suggestive of hyperthyroidism) Respiratory ❑ Rales (suggestive of heart failure) ❑ Wheezing (non-specific) Cardiovascular ❑ Muffled heart sounds (suggestive of pericarditis) ❑ Pericardial friction rub (suggestive of pericarditis) ❑ 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 menuver (suggestive of hypertrophic obstructive cardiomyopathy) ❑ Displaced apex beat (suggestive of cardiomegaly ❑ S3 (suggestive of heart failure) 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) ❑ Presence of prior myocardial infarction 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 EKG (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)

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

Yes

No

Does the patient have EKG findings of an arrhythmia?

Does the patient have 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

Non-arrhythmic 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 ❑ Pericarditis ❑ 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 have history of taking drugs or medications that can cause palpitations?

Yes

No

Drugs or medication intake Click in each link for the specific diagnostic approach and management ❑ Alcohol ❑ Caffeine ❑ Medications ❑ Sympathomimetic agents ❑ Vasodilators ❑ Anticholinergic agents ❑ Withdrawal of beta-blockers ❑ Beta-agonists ❑ Digitalis ❑ Recreational drugs ❑ Cocaine ❑ Heroin ❑ Cannabis ❑ Amphetamines ❑ 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 underlying cuase. If the etiology can be determined and low risk, potentialy curative treatments are available that 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, advise should be made for them to avoid possible triggers for palpitations 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

Extracardiac 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 cause Anxiety Panic attack Depression Somatization

Drugs or medication intake ❑ Alcohol ❑ Caffeine ❑ Medications ❑ Sympathomimetic agents ❑ Vasodilators ❑ Anticholinergic agents ❑ Withdrawal of beta-blockers ❑ 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 physical exam and EKG when the patient is symptomatic.
• While asymptomatic, search for signs of structural heart disease such as murmurs, displaced apex beat or S3.
• Perform an ambulatory EKG in patients with recurrent episodes of palpitations in which the cause couldn't be determined.
• Perform an EPS in patients in whom the ambulatory EKG is inconclusive.
• Perform an EPS, with ablation therapy if necessary, in patients severe heart disease, when palpitations preceded syncope and when the patient need cardiorespiratory resuscitation maneuvers.
• Estimulate life-style changes that may lower the posibility of future episodes, such as exercise, lower alcohol and caffeine intake, smoke cesation.
• Perform an exercise stress test in patients with exercise induced palpitations.
  

Don'ts

• Do not recomend high intesity sports as it may induce atrial fibrillation.

EKG examples

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

† ECG strips are courtesy of ECGpedia.

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.

Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:AMI_evolutie.png

NSTEMI

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

Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page

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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