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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
• 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.

Identify cardinal symptoms and signs that increase the pre-test probability of palpitations Symprtoms: ❑ 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? ❑ Hemodynamic instability ❑ Hypotension ❑ Cold extremities ❑ Peripheral cyanosis ❑ Mottling ❑ Altered mental status ❑ Chest discomfort suggestive of ischemia ❑ Decompensated heart failure

Yes

No

Continue with the complete duagnostic apporoach shown below

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

Orger and EKG immedietly Does the patient has any EKG findings suggestive of an arrhythmia?

Yes

No

Narrow complex tachycardia Wide complex tachycardia Bradycardia WPW

Does the patient has any EKG findings suggestive of myocardial isquemia?

Yes

No

STEMI NSTEMI

Order a TTE

Does the patient has a structural heart disease?

Yes

No

Acute heart failure AS Acute AR

Does the patient has history of cosuming 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 Fever 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; 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 ❑ Muffled heart sounds ❑ Pericardial friction rub ❑ 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 ❑ 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 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 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 ❑ Sympathicomimetic agents ❑ Vasodialators ❑ Anticholinergics agents ❑ Withdrawal of beta-blockers ❑ Beta-agonists ❑ Digitalis ❑ Recreational drugs ❑ Cocaine ❑ Heroine ❑ Cannabis ❑ Amphetamines ❑ Nicotine

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

References

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