Palpitation

A CLINICAL APPRAISAL @ 2 0 1 2

@ dr navojit chowdhury

National institute of cardiovascular diseases .Dhaka

Patients may use a variety of terms to describe their awareness of the heart beat (palpitations).

palpitation may be due , (1) rhythm disturbance ,or (2) subjective awareness of normal sinus rhythm

This can be described as skipped beats, a sudden thump, hard beating, fluttering in the chest, a jittery sensation, a rapid pulse, or a vague feeling of irregular heart rate.

A premature atrial or ventricular complex is not felt by the patient, it is the strong heartbeat that follows the pause.

Palpitations may be more prominent at night, especially when patients lie on their left side.

Diagnosis

History A rapid regular rhythm that occurs a few times, per year for many years is likely a form of PSVT. Tapping by the patient, may be helpful, to distinguish between atrial fibrillation (AF) and PSVT. Alcohol and caffeine play a minor role in patients who have arrhythmias particularly AF but not VT and PSVT.

Distinguishing points in history

Ectopic beats give sensation of jumping of the Heart, missed beats or extra beats. Parosysmal tachycardia ,sudden onset and sudden termination. Patients with atrial fibrillation may be able to describe the chaotic irregularity @dr navojit,nicvd,dhaka,2012

OTHER IMPORTANT POINTS

Mode of termination of palpitation

1)It is particularly important to ask about termination of palpitation 2) By definition ,all palpitation starts abruptly

3) Sudden termination means sudden reversal of paroxysmal arrhythmia.

4)Where as, the palpitation that subsides gradually is usually sinus tachycardia that subsided gradually

additional things in history

Dizziness,Syncope Dysponea Chest discomfort ,Angina primary or precipitated by tachycardia these may be features of a rapid heamo dynamic compromise by arrhythmia & Family history

Family history

sudden cardiac death

Cardiomyopathy

long QT-syndrome

CAUSES OF PALPITITION

Cardiac 43%
Arrhythmia (40%)
Paroxysmal AF, SVT, supraventricular contractions , Multifocal atrial tachycardia ,WPW syn, Sick Sinus Syndrome ,Sinus tachycardia ,PVC VT

Nonarrhythmic cardiac causes (3%)

MVP, Valvular heart disease(AS, AI) . Atrial myxoma , Pacemaker-mediated tachycardia , CHF ,Congenital heart disease : Atrial septal defect, Patent ductus arteriosus , Ventricular septal defect , Pericarditis , Cardimyopathy,Aortic aneurysm . @dr navojit,nicvd,dhaka,2012

Psychiatric 43%

Generalized anxiety Panic disorder Hypochondriasis Major depression Somatization

Drugs or medication 6%

Alcohol Amphetamines Anticolinergic B-blockers Caffeine Cocaine Epinephrine Digitalis Theophylline Vasodilators (Nitrates)

Other disorders causing palpitations

Metabolic disorder
Hyperthyroidism Hypoglycemia Hypo/hypercalcemia Hypo/hyperkalemia Hypo/hypermagnesemia Pheochromocytoma

High cardiac output

Anemia Arteriovenous fistula BeriberiFever Pagets disease Pregnancy Mastocytosis

Lab investigations
To rule out , anemia and infection (complete blood count), electrolyte imbalance thyroid dysfunction (TSH) toxicology screening as guided by clinical suspicion

Cardiologic Investigations notes

a previous rhythm strip or 12 lead ecg (WPW syn ) or episodal ecg electrophysiologic study is typically required for diagnostic and/or therapeutic reasons . Noninvasive monitoring for infrequent arrhythmias is usually futile, and an electrophysiologic study is preferred. In contrast, for patients with more frequent symptoms, noninvasive event recorder monitoring is often investigation of choice.

Investigations
Electrocardiogram can diagnose:

Prior Myocardial Infarction Left Ventricular Hypertrophy Right Ventricular Hypertrophy Atrial Fibrillation Atrial enlargement AV nodal block Prolonged QT Interval (QTc >460 in men, QTc >440 in men) Delta Waves Wolff-Parkinson-White Syndrome Short PR interval AV Nodal reentry rhythm

Advanced Diagnostics: Ambulatory EKG monitoring

Continuous EKG Monitor (Holter Monitor for 24-48 hours) Event Monitor (Implantable loop recorder, ILR, for intermittent episodes over 1 month). The ILR is a subcutaneous monitoring device implanted on the left anterior chest wall that stores events when the device is activated automatically by programmed criteria or manually by magnet application. An ILR may be used in selected patients with infrequent, symptomatic palpitations or those with unexplained syncope. @dr navojit,nicvd,dhaka,2012

Consider additional testing when indicated Exercise Stress Test

Echocardiogram ,Suspected structural heart disease

Electrophysiologic Study
Syncope, Life threatening arrhythmia suspected WPWsyn

future directions MCOT. unique new technology using wireless outpatient continuous monitoring can identify asymptomatic arrhythmic episodes and transmit ECG data .

Real-time data analysis and surveillance of the transmitted information by a technician. Mobile cardiac outpatient telemetry , (MCOT, CardioNet div. Sun Diego.CA, 2009). These devices are used to record suspected asymptomatic arrhythmias, studies suggest that mobile cardiac outpatient telemetry (MCOT) provides more effective detection of infrequent cardiac arrhythmias than external loop monitor.
https://www.oxhp.com/secure/policy/real_time_cardiac_surveillance_1211.html

@dr navojit,nicvd,dhaka,2012

End note

Even if sinus rhythm is identified as the cause of palpitations, the results are very valuable to the patient.

@dr navojit,nicvd,dhaka,2012