Modified by Dr.

Salah H Sinjary
College of medicine HMU
Department of Medicine
Salahsinjary@gmail.com
07504454134
To be discussed…..
Definition
Introduction
Pathophysiololgy
Aetiology
Diagnostic pathway
 History
 Examination
 Resting ECG
 ECG with symptoms
 Additional investigations

Management
Definition

These represent an increased awareness of the normal

heartbeat or the sensation of slow, rapid or irregular
heart rhythms.
Introduction

Palpitation does not means heart disease.


The degree of palpitation is not equal to the severity
of heart disease.


Patients with anxiety states often exhibit a lowered
threshold at which disorders of rate and rhythm
result in palpitation.
Introduction contd.

Persistent tachycardia and/or atrial fibrillation
may not be accompanied by continual palpitation.


A sudden, brief alteration in cardiac rate or rhythm
which often causes considerable subjective
discomfort.
Pathophysiology

Augmentation of heart contractility


Arrhythmia


Cardiac neurosis
Augmentation of heart contractility


Physiological augmentation


Pathological augmentation
Physiological augmentation

Exercising strongly and over nervous


After drinking coffee, tea, alcohol


Taking medicine such as ephedrine,
aminophylline, atropine etc.
Pathological augmentation
Ventricular hypertrophy: such as hypertensive
heart disease, valvular insufficiency, PDA, VSD
etc.

Preload or afterload increase → hypertrophy →

augmentation of contractility → palpitation
 Pathological augmentation contd.
Other diseases which increase cardiac output:

Thyrotoxicosis: basic metabolism amplify & sympathetic

nerve excite →heart rates ↑

 Anemia: hypoxaemia → heart rates ↑

 Mild, chronic anemia may cause palpitation during

exertion. severe, acute anemia may cause palpitation at
rest.
Pathological augmentation contd.
Fever: basic metabolism amplify

Hypoglycemia: Palpitation is often a prominent

feature of the condition and appears to be release of
catecholamine.
Arrhythmia

Tachycardia: sinus, supraventricular, ventricular

Bradycardia: SSS, AVB, sinus bradycardia
Diastolic period prolong → EDV ↑ → augmentation of
heart contractility
Arrhythmia: premature beat, atrial fibrillation
Irregular beat
 Cardiac neurosis

Turbulence of sympathetic nerve & pneumogastric

nerve

Various symptom: palpitation, chest pain, tire,

insomnia, headache, dizziness etc

 Usually seen in female

 Inducement: anxiety, excitement

Etiology
 Extracardiac causes

 Cardiac causes
–
Arrhythmias
– Nonarrhythmic cardiac cause

 Psychiatric causes

 Drugs & Diets

Extracardiac causes

 Anemia
 Electrolyte imbalance
 Fever
 Hyperthyroidism
 Hypoglycemia
 Hypovolemia
 Pheochromocytoma
 Vasovagal syndrome
Cardiac cause: Arrhythmias
 Atrial fibrillation/flutter
 Bradycardia caused by advanced AV block or
sinus node dysfunction
 Bradycardia-tachycardia syndrome (SSS)
 Multifocal atrial tachycardia
 Premature supraventricular or ventricular
contractions
 Sinus tachycardia
 Supraventricular tachycardia
 Ventricular tachycardia
 Wolff-Parkinson-White syndrome
 CARDIAC Cause:
ARRHYTHMIA
 S tachycardia and supraventricular tachycardia may
Episodes of ventricular
cause palpitations but also can be asymptomatic or lead to syncope.

 Palpitations associated with dizziness, near-syncope, or syncope

suggest tachyarrhythmia and are potentially more serious.

 Orthostatic intolerance or inadequate cerebral perfusion on upright posture

may result in palpitations, tachycardia, headache, nausea, pre- syncope, and,
occasionally, syncope.

 Orthostatic intolerance in women of childbearing age

 Nonarrhythmic cardiac causes

 Atrial or ventricular septal defect

 Cardiomyopathy
 Congenital heart disease
 Congestive heart failure
 Mitral valve prolapse
 Pacemaker-mediated tachycardia
 Pericarditis
 Valvular disease (aortic insufficiency, stenosis)
Psychiatric Cause

 Anxiety disorder

 Panic attacks
 ANXIETY OR PANIC DISORDER

 Prevalence of panic disorder in patients with palpitations is 15 to

31 percent

 Screening question: Have you experienced brief periods, for

seconds or minutes, of an overwhelming panic or terror that was
accompanied by racing heartbeats, shortness of breath, or
dizziness?

 Panic disorder and significant arrhythmias are not mutually

exclusive, and that cardiac evaluation still may be necessary in
patients with suspected panic disorder
 Drugs and Diets

 Beta agonists, phenothiazine, theophylline,

isotretinoin, d igoxin
 Tobacco, Alcohol
 Caffeine, Chocolate
 Cocaine
Diagnostic pathway
 History

 Examination

 Resting ECG

 ECG with symptoms

 Additional investigations
History
 Is the palpitation continuous or intermittent?
 Is the heart beat regular or irregular?
 What is the approximate heart rate?
 Do symptoms occur in discrete attacks?
 Is the onset abrupt?
 How do attacks terminate?
 Are there any associated symptoms?
e.g. Chest pain
 Lightheadedness
 Polyuria (a feature of supraventricular tachycardia)
 Are there any precipitating factors, e.g. exercise, alcohol?
 Is there a history of structural heart disease, e.g. coronary
artery disease, valvular heart disease?
Accompanying symptoms

 Palpitation with chest pain: It is often present in

coronary heart disease (angina, myocardial
infarction), myocarditis, pericarditis. It is also
present in cardiac neurosis.
Accompanying symptoms

 Palpitation with fever: It is observed in acute

infection, rheumatic fever, myocarditis,
pericarditis, infective endocarditis.
Accompanying symptoms

 Palpitation with syncope or twitch: It is present in

high-degree AVB, ventricular fibrillation,
paroxysmal ventricular tachycardia, SSS.
Accompanying symptoms

 Palpitation with anemia: It happens after

acute hemorrhage, which accompanys with
sweat, hypotension, shock.

 Palpitation with weight loss and sweating: It

suggests thyrotoxicosis.
Clinical findings & Diagnosis
Examination
 Cardiovascular
Pulse
Blood Pressure
Heart murmurs
Signs of left / right ventricular dysfunction

 Features of endocrine abnormality

 ECG
EVALUATION
 All patients who complain of palpitations

 ECG findings warrant further cardiac

investigation ; evidence of previous myocardial
infarction, left or right ventricular hypertrophy,
atrial enlargement, AV block, short PR interval and
delta waves (Wolff-Parkinson-White syndrome),
prolonged QT interval
 ETT

 ECG exercise testing is appropriate in

patients who have palpitations with
physical exertion and patients with
suspected coronary artery disease or
myocardial ischemia.
 PR interval

Normal 3 to 5 small squares

(0.12 to 0.2s)

QRS interval Normal

up to 3 small squares

(0.12s)
 QT interval
Normal up to 12 small
squares
(dependent rate)

(0.450s)

QT
interval
Sinus tachycardia
Sinus bradycardia with premature atrial
contractions
Atrial Fibrillation
Atrial fibrillation with premature
ventricular contractions
Wolff-Parkinson-White Syndrome
 Further Diagnostic Testing

 CONTINUOUS ECG MONITOR (Holter monitor)

- continuously to record data for 24 or 48 hours
- diary of any symptoms that occur during the monitoring
- most expensive
- maintained and operated by hospitals or larger outpatient
clinics
Holter monitoring

Most of use if symptomatic during study

May detect asymptomatic abnormalities
Additional Investigations

Echocardiogram

Cardiac MRI

Heart Catheterisation / angiography

Echocardiographic risk stratification

Septal
thickness
<30mm

Aortic
Gradient
<30mmh
g
 Management

 If the evaluation of the heart is otherwise

normal, ventricular premature contractions or
brief episodes of ventricular tachycardia are not
associated with increased mortality

 Appropriate patient education

Management
 Sustained arrhythmias; pharmacologic or invasive
electrophysiologic study

 Treat underlying for the noncardiac, psychiatric,

or nonarrhythmia cardiac etiology
 Management

 If fail to reveal any abnormality or etiology for

palpitations
- advised to abstain from caffeine and alcohol,
as well as foods or stressful situations that
appear to trigger palpitations
Management

the majority of patients with palpitations have

benign diagnoses and can be treated with
reassurance