Approach to palpitations

1. APPROACH TO PALPITATION

2. PALPITATION
• Unpleasant awareness of heartbeat or undue
awareness of heart action.
• Patient may describe it as pounding , thumping or
fluttering sensation in the chest.
• They are often noted when the patient is quietly
resting, during which time other stimuli are minimal.

3. PHYSIOLOGY OF PALPITATION
Palpitation is due to
• Alteration in heart rate
Eg: Sinus tachycardia & bradycardia
• Alteration in heart rhythm
Eg: Atrial fibrillation
• Augmentation of myocardial contraction
Eg: Anxiety & drugs

4. CAUSES OF PALPITATIONS
• Cardiovascular causes
• Non-arrhythmic cardiac causes
• Psychiatric causes
• Miscellaneous causes

5. CARDIOVASCULAR CAUSES
• Arrhythmias
1. Premature atrial and ventricular contraction
2. Supraventricular and ventricular arrhythmias
3. Atrial fibrillation
4. Atrial flutter with varying block
5. Brady-arrhythmias : complete heart block

6. Non-arrhythmic cardiac causes
• Mitral valve prolapse(with or without associated arrhythmias)
• Aortic insufficiency
• Atrial myxoma
• Pulmonary embolism
• Congenital heart disease
• Systemic hypertension
• Pericarditis

7. PSYCHIATRIC CAUSES
• Panic attacks
• Anxiety
• Somatization
Patients with psychiatric causes for palpitations more commonly
report a longer duration of sensation >15min and multiplicity of
symptoms than do patients with other causes.

8. MISCELLANEOUS CAUSES
• Hyperkinetic circulatory states
anemia, fever, thyrotoxicosis, hypoglycemia,
pheochromocytoma
• Drugs
aminophylline, atropine, vasodilators, digitalis
• Others
caffeine, cocaine, tobacco, ethanol

9. Approach to the Patient
“Principal goal in assessing patients with palpitations is to
determine if the symptom is caused by a life threatening
arrhythmia”
“All palpitations are not arrhythmias and many arrhythmias
do not palpitate”

10. HISTORY
“Patients with CAD or risk factors for CAD are at greater risk
for ventricular arrhythmias as a cause for palpitations”
The association of palpitations with other symptoms
suggesting haemodynamic compromise including syncope
or light-headedness supports this diagnosis.

11. EVALUATION OF PALPITATION
Is palpitation continuous or intermittent?
Intermittent palpitations are commonly caused by
premature atrial and ventricular contraction.

12. Is heartbeat regular or irregular?
Regular, sustained palpitations can be caused by
Supraventricular tachycardia and Ventricular
tachycardia.
Irregular, sustained palpitations can be caused by
atrial fibrillation.

13. What is the heart rate?
Does palpitations occur in discrete attacks?
Is onset abrupt?
How do attacks terminate?
. Ventricular arrhythmias are sudden onset
. Holding breath or vagal maneuver decrease
palpitations in Supraventricular tachycardia (SVT)

14. • Are there associated symptoms?
1. Chest pain : arrhythmogenic MI
2. Dyspnea : heart failure due to arrhythmias
3. Syncope: low cardiac output during arrhythmias
4. Polyuria: SVT
5. Sweating: anxiety
6. Diarrhea: thyrotoxicosis

15. • Are there any precipitating factors?
Exercise ,stress(Hyper dynamic cardiovascular States caused by
catecholamine administration)
alcohol intake ,drugs
• Is there history of structural heart disease?
Coronary artery disease
Valvular heart disease

16. Physical Examination
To confirm the presence of arrhythmia as a cause of
palpitations
• Measurement of vital signs
• Assessment of jugular venous pressure and pulse
• Auscultation of chest and precordium

17. INVESTIGATIONS
• A resting ECG
• If exertion is known to induce arrhythmia and
accompanying palpitations, exercise ECG is useful
• If arrhythmia is sufficiently infrequent, methods used are
Continuous ECG (Holter) monitor
Loop recordings (external or implantable)

19. NATURE OF PALPITATIONS

20. MANAGEMENT
• Occasional benign atrial or ventricular premature
contractions can be managed with beta blocker therapy.
• Palpitations incited by alcohol, tobacco, illicit drugs need
to be managed by abstention.
• Those caused by pharmacological agents should be
managed by considering alternate therapies if possible.

21. • Psychiatric causes of palpitations may benefit from
cognitive or pharmacotherapies.
• Once serious causes for the symptom have been
excluded, patient should be reassured that
palpitations will not adversely affect prognosis.

22. Thank You