internal medicine series for undergraduate

1. PALPITATION
NUR FARRA NAJWA
BINTI ABDUL AZIM
082015100035

2. LEARNING OBJECTIVES
1. What is palpitation?
2. Approaches to palpitation cases
3. Causes of palpitation in brief.
4. Management of palpitation in brief.

3. INTRODUCTION
• Extremely common among patients
PRESENTATION • Intermittent “thumping” “pounding,” or
“fluttering” sensation in the chest
SENSATION 1. Intermittent
2. Sustained (regular or irregular)
INTERPRETATION • Unusual awareness of the heartbeat
CONCERNED • Had “skipped” or “missing” heartbeats.
OFTEN NOTED • Quietly resting, during which time other
stimuli are minimal.
POSITIONAL • Structural process (Atrial myxoma)
• Adjacent to the heart. (Mediastinal
mass)

6. CAUSES
Cardiac (43%),
Psychiatric (31%),
Miscellaneous (10%),
Unknown (16%)

7. IMPORTANT NOTE
• That most arrhythmias are not associated with
palpitations.
• If present
1. Ask the patient to “tap out” the rhythm of the
palpitations
2. Take his/her pulse during palpitations.

8. PALPITATION IN GENERAL
• Hyperdynamic cardiovascular states caused by
• Catecholaminergic stimulation
1. Exercise
2. Stress
3. Pheochromocytoma

9. CARDIOVASCULAR CAUSES
• Premature atrial and ventricular contractions
• Supraventricular and ventricular arrhythmias
• Mitral valve prolapse (with or without
associated arrhythmias)
• Aortic insufficiency
• Atrial myxoma
• Pulmonary embolism

10. INTERMITTENT
PALPITATIONS
REGULAR, SUSTAINED
PALPITATIONS
IRREGULAR, SUSTAINED
PALPITATIONS
• Premature Atrial or
ventricular
Contractions
• Regular
Supraventricular
tachycardia
• Ventricular
Tachycardias.
• Atrial Fibrillation.

11. PSYCHIATRIC CAUSES
• Panic attacks or disorders
• Anxiety states
• Somatization
• Longer duration of the sensation (>15 min)
• Other accompanying symptoms than do
patients with other causes.

12. MISCELLANEOUS CAUSES
• Thyrotoxicosis,
• Drugs,
• Ethanol,
• Spontaneous skeletal muscle contractions of
the chest wall
• Pheochromocytoma,
• Systemic mastocytosis.

13. OTHERS
• Common among athletes
– Older endurance athletes.
• Enlarged ventricle
– aortic regurgitation and accompanying
hyperdynamic precordium.
• Others that enhance the strength of
myocardial contraction
– Tobacco, caffeine, aminophylline, atropine,
thyroxine, cocaine, and amphetamines,

14. APPROACH TO THE
PATIENT

15. EVALUATION ; PRIMARY GOAL
1. To detect and identify presence and nature of
any underlying arrhythmia.
2. To determine the presence of organic heart
disease.
3. To determine the presence of precipitating
cause

16. HISTORY
• Character
• Mode of onset
• Mode of termination
• Precipitation
• Associated
• Relief with vagal maneuvor
• Family history

17. ASK
1. What do you really feel? (unexpected awareness of
heartbeat)
2. Did you check your pulse by yourself?
3. How does it start? (spontaneous or with activity,
anxiety, emotion, etc.)
4. Is it paroxysmal or persistent?
5. How long does it persist?
6. How is it relieved?
7. Have you ever missed a heartbeat?
8. Do you get breathlessness, chest pain, dizziness or
blackout with palpitation?

20. PRINCIPAL GOAL
• Determine a life-threatening arrhythmia.
• Preexisting coronary artery disease
(CAD) or risk factors for CAD
• Greatest risk for ventricular
arrhythmias
• Symptoms suggesting hemodynamic
compromise
• Syncope or lightheadedness
• Sustained tachyarrhythmias in
patients with CAD
• Angina pectoris or dyspnea
• Ventricular dysfunction (systolic or
diastolic), aortic stenosis,
hypertrophic cardiomyopathy, or
mitral stenosis (with or without CAD),
• Dyspnea from increased left atrial and
pulmonary venous pressure.

21. PHYSICAL EXAMINATION
• Help confirm or refute the presence :
– Arrhythmia as a cause for palpitations
– Its adverse hemodynamic consequences
• Measurement of the vital signs
• Assessment of the jugular venous pressure and
pulse
• Auscultation of the chest and precordium.
• Resting electrocardiogram
• Exercise electrocardiography

22. EXAMINATION
• During symptom-free period.
• Signs of anxiety
• Abnormal vital signs,
• Pale skin,
• Exophthalmos,
• Goitre,
• Jugular venous distension,
• Carotid bruits,
• Diminished carotid upstroke,
• Heart murmurs,
• Gallops and clicks,
• Wheezes,
• Crepitations,
• Lower extremity oedema and calf tenderness.

23. ARRHYTHMIA IS SUFFICIENTLY INFREQUENT
• Haemoglobin
• Serum glucose, electrolytes and thyroid
function tests.
• Continuous electrocardiographic (holter)
monitoring;
• Telephonic monitoring,
• Loop recordings (external or implantable
• Mobile cardiac outpatient telemetry.

24. MANAGEMENT
• Most patients with palpitations do not have
serious arrhythmias or underlying structural
heart disease.
• The physician should note that palpitations are at
the very least bothersome and, on occasion,
frightening to the patient.
• Once serious causes for the symptom have been
excluded, the patient should be reassured that
the palpitations will not adversely affect
prognosis.

25. Cont.
Sufficiently troubling to the
patient
• Occasional benign atrial or
ventricular premature
contractions
• Managed with beta-blocker
therapy
Incited by alcohol, tobacco, or
illicit drugs
• Abstention
Incited by pharmacologic agents • Considering alternative
therapies
Psychiatric causes of palpitations • Cognitive therapy or
pharmacotherapy.

26. SUMMARY

29. REFERENCES
• HARRISON 19TH EDITION
• LONG CASE MEDICINE ABM
• GEORGE MATTHEWS, 9TH EDITION

30. • THANK YOU