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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

Arrhythmias ❑ Extrasystole ❑ SVT ❑ Sinus tachycardia ❑ Atrial fibrillation ❑ Atrial flutter ❑ AVNRT ❑ AVRT ❑ Focal atrial tachycardia ❑ Nonparocymal juntional tachycardia ❑ Multifocal atrial tachycardia ❑ VT ❑ Long-QT syndorme ❑ Torsades de pointes ❑ Bradyarrhythmias ❑ Sick sinus syndrome ❑ Wolff-Parkinson-White syndrome

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

Psychiatric disorders ❑ Anxiety ❑ Panic attack ❑ Depression ❑ Somatization

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

Yes

No

Drugs and Medications ❑ Alcohol ❑ Caffeine ❑ Medications ❑ Sympathicomimetic agents ❑ Vasodialators ❑ Anticolinergics 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

References

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