Palpitations

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approach to palpitations

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Palpitations

  1. 1. PALPITATIONS Dr POLAMURI TABITHA PG FIRST YR
  2. 2. DEFINITION Uncomfortable awareness of heart beat or undue awareness of heart action. Defined as thumping , pounding or fluttering sensation in the chest. This sensation can be either intermittent or sustained and either regular or irregular
  3. 3.  Most patients interpret palpitations as unusual awareness of the heart beat and become concerned when they sense that they had skipped or missing heartbeats. They are often noted when the patient is quietly resting , during which time other stimuli are minimal.
  4. 4. PHYSIOLOGYPalpitation is due to Alteration in heart rate Eg: sinus tachycardia & bradycardia Alteration in heart rhythm Eg: Atrial fibrillation Augmentation of myocardial contraction Eg: anxiety states & drugs
  5. 5. NATURE OF PALPITATIONSFEATURE SUGGESTSHEART MISSES AND THUMPS ECTOPIC BEATSWORSE AT REST ECTOPIC BEATSVERY FAST REGULAR SVT / VTSUDDEN ONSET SVT / VTOFFSET WITH VAGAL MANOEUVRES SVTFAST AND IRREGULAR AF and ATRIAL FLUTTER with varying blockFORCEFUL AND REGULAR – NOT FAST AWARENESS OF SINUS RHYTHM (ANXIETY)SEVERE DIZZINESS OR SYNCOPE VT or BRADYARRHYTHMIASPRE-EXISTING HEART FAILURE VT
  6. 6. CAUSES OF PALPITATIONS CARDIAC PSYCHIATRI C 43% 31% MISCELLANEOU UNKNOWN S 10% 16%
  7. 7. Cardiovascular CausesArrhythmias Premature atrial and ventricular contractions Supraventicular and ventricular arrhythmias WPW syndrome Atrial fibrillation Atrial flutter with varying block Brady-arrhythmias : complete heart block Sick-sinus syndrome
  8. 8. Non-arrhythmic cardiaccauses Mitral valve prolapse (with or without associated arrhythmias) Aortic insufficiency Atrial myxoma Pulmonary embolism Congenital heart ds Systemic hypertension Pericarditis Pacemaker induced tachycardia
  9. 9. Psychiatric Causes Panic attacks Anxiety states SomatizationPatients with psychiatric causes for palpitations more commonly report a longer duration of sensation >15min & multiplicity of symptoms than do patients with other causes
  10. 10.  The physician must remember that panic disorder and significant arrhythmias are not mutually exclusive, and that cardiac evaluation still may be necessary in patients with suspected panic disorder. Arrhythmic causes must be ruled out before the diagnosis of anxiety or panic disorder can be accepted as the cause of the palpitations.
  11. 11. Miscellaneous Causes Hyperkinetic circulatory states : Anaemia , Fever , Thyrotoxicosis , Hypoglycemia , Phaechromocytoma Drugs : Aminophylline , Atropine , Thyroxine , Tricyclic antidepressants , Vasodilators , Digitalis Others : Caffeine , Cocaine , Amphetamines , Tobacco , Ethanol
  12. 12.  Spontaneous skeletal muscle contractions of the chest wall Systemic mastocytosis Physiological : exertion , excitement , pregnancy Neurocirculatory asthenia or Da costa’s syndrome or Effort syndrome or Soldier’s heart Vaso-vagal attack
  13. 13. APPROACH TO THE PATIENT WITHPALPITATIONS “Principal goal in assessing patients with palpitations is to determine if the symptom is caused by a life threatening arrhythmia”
  14. 14. History“Patients with coronary artery disease or risk factors for CAD are at greater risk for ventricular arrhythmias as a cause for palpitations”In addition , the association of palpitations with other symptoms suggesting haemodynamic compromise including syncope or lightheadedness supports this diagnosis
  15. 15. Remember“All palpitations are not arrhythmias and many arrhythmias do not palpitate”
  16. 16. HOW TO EVALUATE PALPITATIONSTEP 1 Is palpitation continuous or intermittent ? Intermittent P. are commonly caused by premature atrial or ventricular contractions : the post extrasystolic beat is sensed by the patient owing to the increase in ventricular end-diastolic dimension following the pause in the cardiac cycle and the increased strength of contraction (post-extrasystolic potentiation)
  17. 17. STEP 2Is heart beat regular or irregular ? Regular , sustained palpitations can be caused by SVT and VT Irregular , sustained palpitations can be caused by Atrial fibrillation
  18. 18.  STEP 3 : What is the ~ heart rate ? STEP 4 : Does palpitations occur in discrete attacks ? Is onset abrupt? How do attacks terminate? -Ventricular arrhythmias are of sudden onset -Holding breath or vagal manoeuvres decrease palpitations in SVT
  19. 19. STEP 5Are there any associated symptoms ? Chest pain : Arrhythmogenic MI Dyspnoea : Heart failure due to arrhythmias Syncope : low cardiac output during arrhythmias , hypoglycemia , phaechromocytoma Polyuria : SVT Sweating : Anxiety ,hypoglycemia Diarrhoea : Thyrotoxicosis
  20. 20. STEP 6 : Are there any precipitating factors ? exercise , stress (hyperdynamic cardiovascular states caused by catecholaminergic stimulation) alcohol intake , drugsSTEP 7 : Is there a history of structural heart disease ? coronary heart ds , valvular heart ds
  21. 21. “It is often useful either to ask the patient to tap out the rhythm of the palpitations or to take his / her pulse while experiencing palpitations”
  22. 22. Palpitations that are positional generally reflect a structural process within heart Eg : Atrial myxoma or adjacent to the heart Eg : Mediastinal mass
  23. 23. SIMPLE APPROACH TO DIAGNOSIS OF PALPITATION Is heart beat regular ? YES NO Are there any discrete attacks of tachycardia >120/min Irregular heart beat YES NO Ectopic beats SVT Sinus tachycardia AF VT High stroke volume
  24. 24. Physical examinationKey features of physical examination that will help confirm the presence of arrhythmia as a cause for the palpitations include Measurement of vital signs Assessment of the jugular venous pressure and pulse Auscultation of the chest and precordium
  25. 25. INVESTIGATIONS A resting ECG If exertion is known to induce arrhythmia and accompanying palpitations , exercise ECG is useful 2D-ECHOWhen patients complaining of palpitations undergo 24-hour, ambulatory ECG monitoring, 39 to 85 percent manifest a rhythm disturbance (most being benign and clinically insignificant).
  26. 26. Premature ventricular contraction-Bigeminy
  27. 27. If arrhythmia is sufficiently infrequent , other methods must be used like Continuous ECG (Holter) monitoring , Telephonic monitoring , Loop recordings (external or implantable) & Mobile cardiac outpatient telemetry. Event recorder
  28. 28. Holter monitor
  29. 29. Implantable loop recorders
  30. 30. Mobile cardiac outpatient telemetry
  31. 31.  Recent data suggests holter monitoring is of limited clinical utility while implantable loop recorder and mobile cardiac outpatient telemetry are safe and more cost effective in assessment of patients with recurrent , unexplained palpitations
  32. 32. MANAGEMENT Occasional benign atrial or ventricular premature contractions can often be managed with beta blocker therapy if sufficiently troubling to the patient
  33. 33.  Palpitations incited by alcohol , tobacco , illicit drugs need to be managed by abstention , while those caused by pharmacological agents should be managed by considering alternate therapies when possible
  34. 34.  Psychiatric causes of palpitations may benefit from cognitive or pharmacotherapies Once serious causes for the symptom have been excluded , the patient should be reassured that palpitations will not adversely affect prognosis
  35. 35. Management in a Nutshell1. Re-assurance2. Lifestyle modification3. Correction of co-morbid diseases4. Anxiolytics and Beta-blockers5. Anti-arrhythmic drugs / electrical conversion Recurrent life-threatening ventricular arrhythmias are currently being treated with Implantable Cardioverter-defibrillitor devices
  36. 36. Thank You

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