Approach to a patient with palpitation

1. Palpitations
DR SEEBAT MASRUR
D-CARD RESIDENT
CARDIOLOGY DEPARTMENT
SZMCH

2. Introduction
Palpitation is defined as unpleasant awareness of forceful
or rapid beating of once own heart beat.
It’s a subjective sensation that one`s heart is beating
-Faster than normal
-Stronger than normal
-Irregularly
Patients may describe the sensation as a rapid fluttering in
the chest, flip-flopping in the chest, or pounding sensation
in the chest or neck.

3. Pathophysiology
Alteration in heart rate Sinus Tachycardia
Alteration in Rhythm Atrial Fibrillation
Alteration in contraction Exercise

4. Etiology
Sinus Tachycardia Tachyarrhythmias Bradyarrhythmias Premature Beats
Stimulants
Intoxication
Alcohol
Benzodiazepine
Betablockers
withdrawal
Hypoglycemia
Hyperthyroidism
Anxiety
Autonomic
Dysregulation(POTS,IS
T)
Atrial Fibrillation
Atrial Flutter
Supraventricular
Tachycardia
Ventricular
Tachycardia
Slow Atrial Fibrillation
Complete Heart Block
PACs
PVCs

5. Not All Palpitations are due to
Arrhythmias
Non-Arrhythmic cardiac causes
•Mitral Valve Prolapse
•Aortic insufficiency
•Atrial Myxoma
•Congenital heart Disease
•Pericarditis

6. Non-Cardiac Causes:
Anxiety and Stress
Caffeine, Nicotine, Alcohol, Illicit drug use
Thyroid Dysfunction
Anemia
Electrolyte Imbalance
Fever & Dehydration
Pheochromocytoma
GERD
Autonomic Dysfunction

7. Ref:https://www.aafp.org/pubs/afp/issues/2017/1215/p784.html
Cardiac 43% Psychiatric 31%
Miscellaneous 10% Unknown 16%

8. Predictors of
Cardiac Etiology
Male Sex
Known Cardiac Disease
Syncope
Irregular Beats
During Sleep
Neck Pulsations
Lasting > 5 mis

9. Predictors of Psychosomatic Cause
Young Age <30 yrs.
Female
Other symptoms insomnia, headache, chest pain
Palpitations lasting < 5 mins

11. Focused History
Onset, Duration and timing of palpitations
Specific trigger and mode of termination
Quality of palpitations-Fast , Strong , Irregular
Presence of dyspnea, lightheadedness, syncope,
chest pain or anxiety
History of cardiac diseases or CV risk factors
Alcohol & Drug history
Postural Changes
Family history of early sudden cardiac death

12. Specific Clues
PACs, PVCs Random and episodic
Sinus Tachycardia  Gradual onset and gradual resolution
Abrupt onset/Abrupt resolution SVT, VT

13. https://my.clevelandclinic.org/health/treatments/23209-valsalva-maneuver
Patient Self Terminating AVRT,AVNRT
•Modified Valsalva maneuver, your provider
raises your legs right after you stop straining.
This version may work better than the
standard Valsalva maneuver. One study found
the standard method worked for 16% of
people, while the modified version worked for
for 46% of people. It may work better because
because having your legs up helps more blood
blood come back to your heart.
•In the reverse Valsalva maneuver, you sit and
inhale for 10 seconds with your nose and
mouth closed.

14. Postural
Changes

15. Exercise
Sympathetic stimulation/Catecholamine excess
can provoke SVTs/VTs
Non-sustained arrhythmias are more common
than sustained arrhythmias
Idiopathic VT(RVOT VT) may occur during
exercise in young patients with a structurally
normal heart
SVTs including afib can be induced during or at
the termination of the exercise

16. Emotional
Distress
EMOTIONALLY STARTLING EXPERIENCE CAN
PRECIPITATE POLYMORPHIC VT IN LQTS.
PALPITATION ASSOCIATED WITH ANXIETY
PANIC ATTACKS

17. Other Clues
Palpitation + Breathlessness Atrial fibrillation
Palpitation +Polyuria SVT
Palpitation+ Syncope Strokes-Adam Attacks, Severe Bradycardia, VT,
Hypoglycemia, Pheochromocytoma
Palpitation + Chest Pain Myocardial ischemia
Palpitation +Frog Sign  AVNRT
Persistent Palpitation Thyrotoxicosis, Carditis, permanent AF

18. Focused Physical Examinations
Focused physical examination will help determine the presence of arrhythmia
as well as causes of arrhythmias
Measurement of vital signs(Temperature)
Assessment of JVP
Auscultation of chest and precordium
Orthostatic vital signs
Thyroid exam

19. Investigation
CBC Anemia
12 lead ECG
Holter monitoring
Loop Recorder(External and Implantable)
Echo
Thyroid Function Test
Serum Glucose, Electrolyte
Tilt Table Test
EPS-Gold Standard

20. Risk Stratification
Low Risk Intermediate Risk High Risk
Skipped Beats
Thumping Beats
Slow Ponding Beats
Short Fluttering
No FHx
No structural Heart
Disease
Normal ECG
Recurrent Tachycardias
Abnormal ECGs and/or
Structural heart Disease
Palpitation during
exercise
Palpitation with syncope
High risk structural
disease
FHx of SCD
High degree AV block

21. Treatment
Tailored Approach: Individualized approach based on
underlying cause.
Lifestyle Modifications: Stress reduction, Dietary changes,
Hydration.
Medications: Antiarrhythmics, BB, Thyroid.
Cardioversion: Some patients require electrical
cardioversion.
Ablation
Surgical Intervention: For Structural heart disease.
Psychological Support: Anxiety & stress reduction.
Patient Education: educate about their condition, triggers &
Self care strategies.
Long Term management: Regular follow up.

23. When to Refer
Persistent Palpitation
Sustained rapid palpitations
Significant associated symptoms-Presyncope, Breathlessness, Chest pain
Family history of recurrent syncope or sudden cardiac death
Significant ECG and ECHO abnormalities

24. Take Home Message
Palpitations are usually due to an arrhythmia but can also be due to other
causes.
Differentiating between cardiac & noncardiac causes is essential.
All Patients with palpitations warrants a focused history , physical examination
& ECG.
If the ECG shows normal sinus rhythm, most patients warrant an ambulatory
ECG monitor+/- ECHO
Identifying the alarm symptoms for proper referral

25. Thank You