Palpitations resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D.
Wolff-Parkinson-White Syndrome Resident Survival Guide Microchapters |
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Overview |
Causes |
FIRE |
Diagnosis |
Treatment |
Do's |
Don'ts |
EKGs |
Overview
Palpitations are one of the most common complains of patients when visiting outpatient clinics and emergency rooms.[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.
- Acute coronary syndrome
- Aortic valve disease
- Cardiac tamponade
- Hypovolemia
- Third degree AV block
- Ventricular arrhythmia
Common causes
- Cardiac causes
-
- Non-arrhythmic cardiac causes
- Malfunctioning or wrong programing of pacemakers
- Psychiatric causes
- Drug and medications
- Alcohol
- Caffeine
- Recent withdrawal of beta-blockers
- Recreational drugs
- Systemic causes
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.[1][2][3][4][5][6][7]
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:
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Does the patient have any of the followign findings that require urgent management? ❑ Palpitations asociated with syncope (suggestive of VT of structural heart disease) ❑ 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 | |||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||
Stabilize the patient ❑ Assess circulation, secure airway and breathing | |||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||
Does the patient have any EKG findings suggestive of myocardial ischemia or pericarditis? STEMI NSTEMI: Pericarditis | |||||||||||||||||||||||||||||||||||||||||||||
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 | ||||||||||||||||||||||||||||||||||||||||||||
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.[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; 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
❑ Frequency: (daily, weekly, monthly)
❑ Termination: with vagal maneuvers (suggestive of SVT)
❑ Prodrome ❑ Position
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Search for associated symptoms and circumstances ❑ Sudden changes of posture (suggestive of intolerance to orthostasis or AVNRT) | |||||||||||||||||||||||||||||||||||||||||||
Inquire about drugs that can cause palpitations: ❑ Sympathomimetic agent pump inhalers (asthmatic patients) | |||||||||||||||||||||||||||||||||||||||||||
Obtain a detailed past medical history: ❑ Previous episodes of palpitations
❑ Cardiac arrhythmia ❑ History of panic attacks | |||||||||||||||||||||||||||||||||||||||||||
Examine the patient: Vitals
❑ Respiratory rate (non-specific)
❑ Displaced apex beat (suggestive of cardiomegaly | |||||||||||||||||||||||||||||||||||||||||||
Order labs and tests: ❑ EKG
❑ CBC (to rule out anemia or infection) Order imaging studies | |||||||||||||||||||||||||||||||||||||||||||
Consider hospitalization ❑ Recurrent episodes when no ambulatory EKG devices are available | |||||||||||||||||||||||||||||||||||||||||||
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 | Non-arrhythmic cardiac cause Click in each link for the specific diagnostic approach and management ❑ Acute coronary syndrome | Psychiatric cause Click in each link for the specific diagnostic approach and management ❑ Anxiety | |||||||||||||||||||||||||||||||||||||||||
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
❑ Recreational drugs
❑ Nicotine | Systemic disease Click in each link for the specific diagnostic approach and management ❑ Anemia | ||||||||||||||||||||||||||||||||||||||||||
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.[1][2][3][4][6]
Abbreviations: NSTEMI: Non ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction
Determine the cause of the palpitations | |||||||||||||||||||||||||||||||||||||||||||
Cardiac cause | Extracardiac cause | ||||||||||||||||||||||||||||||||||||||||||
Psychiatric cause | Drugs or medication intake ❑ Alcohol
❑ Recreational drugs
❑ Nicotine | ||||||||||||||||||||||||||||||||||||||||||
Consider hospitalization ❑ Implantations or replacement of pacemakers for bradyarrhythmias | |||||||||||||||||||||||||||||||||||||||||||
Do's
- If possible, perform physical exam and EKG when the patient is symptomatic.[1]
- While asymptomatic, search for signs of structural heart disease such as murmurs, displaced apex beat or S3.[1]
- Perform an ambulatory EKG in patients with recurrent episodes of palpitations in which the cause couldn't be determined.[1]
- Perform an EPS in patients in whom the ambulatory EKG is inconclusive.[1]
- 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.[1][5]
- Estimulate life-style changes that may lower the posibility of future episodes, such as exercise, lower alcohol and caffeine intake, smoke cesation.[1]
- Perform an exercise stress test in patients with exercise induced palpitations.[6]
Don'ts
- Do not recomend high intesity sports as it may induce atrial fibrillation.[1]
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.
![](/images/9/93/STEMI_evolution.png)
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.
![](/images/b/b6/Unstable-angina.jpg)
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.
![](/images/8/89/Acute-pericarditis.jpg)
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 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.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 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) - ↑ 3.0 3.1 3.2 "http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf" (PDF). Retrieved 16 April 2014. External link in
|title=
(help) - ↑ 4.0 4.1 4.2 Abbott, AV. (2005). "Diagnostic approach to palpitations". Am Fam Physician. 71 (4): 743–50. PMID 15742913. Unknown parameter
|month=
ignored (help) - ↑ 5.0 5.1 5.2 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) - ↑ 6.0 6.1 6.2 6.3 "http://www.turner-white.com/pdf/hp_jan03_methods.pdf" (PDF). Retrieved 25 April 2014. External link in
|title=
(help) - ↑ "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 3 April 2014.