1. PALPITATION

2. A. Definition.
 Abnormal subjective awareness of the heart
beat.
 Thumping, pounding, fluttering, jumping, racing,
skipping)
 But patient may describe palpitation as a feeling
of breathlessness, excitement, fright etc.
 Palpitation ≠ arrythmias

3. B. Causes.
 Palpitation may be due to Rapid heart beat or
Slow heart beat or
Irregular heart beat.
 Palpitation may be due to
Primary cardiac disease (Acute or Chronic) or
Secondary effect on the heart (Systemic disease
or Drugs)

4. Common causes are
(1) Anxiety, Exercise, hyperthyroidism
(2) Drugs (Sympathomimetics, Atropine)
(3) Diet (Tea, coffee, cola)
(4) Nicotine(Smoking)
(5) Abnormal rate
Sinus tachycardia(100-160)
Supraventricular tachycardia(160-220)
Ventricular tachycardia
Sinus Bradycardia

5. (6) Abnormal rhythms
Atrial fibrillation
Ventricular fibrillation
(7) Extrasystole
Atrial extrasystole.
Ventricular extrasystole
(8) Wolff-Parkinson-White (WPW)
(9) Forceful heart beat
Aortic regurgitation.

6. Sinus Tachycardia .
Heart rate = 100 bpm-160bpm
Causes Fever Thyrotoxicosis
Anaemia Phaeochromocytoma
Anxiety Carcinoid tumor
Exercise Heart failure
Pregnancy Drugs

7. Sinus bradycardia
Heart rate = < 60 bpm
Causes Myocardial infarction
Sick sinus syndrome
Hypothermia
Hypothyroidism
Cholestatic jaundice
Raised intracranial pressure
Drugs (Digoxin, Beta blockers.)
Treatment Atropine

8. Supraventricular Tachycardia (SVT)
Ventricular Tachycardia (VT)
Heart rate (140-220)
Causes Coronary artery disease.
Valvular heart disease.
Myocarditis.
Cardiomyopathy.
Drugs.
SVT usually benign.
VT always malignant and need urgent treatment.
DC cardiovertion
Lignocaine, Mexilatine, Flecainide, K, Mg

9. Paroxysmal atrial tachycardia (PAT).
Heart rate is usually about 140-220 during attack.
Clinical feature
Asymptomatic.
Symptomatic Palpitation Dyspnoea
Cheat pain Fainting
Sudden onset and sudden disappear.
Polyuria (due to Atrial Natriuretic peptide)
ECG Normal or WPW syndrome during intervals.
SVT during attack

10. Treatment
 Carotid sinus massage.
 Increases vagal tone by induced vomiting, Valsalva
manoeuvre.
 Inj IV Adenosine or IV Verapamil
 Alternative drugs Beta-blockers.
Disopyramide.
Digoxin.
DC cardioversion.
Prevention
 Above drugs
 Radio frequency ablation.

11. Atrial Fibrillation.
Causes.
Coronary artery disease Alcohol
Valvular heart disease Hypertension
Cardiomyopathy Pulmonary embolism
Pericarditis Congenital heart disease
Thyrotoxicosis Pneumonia
Idiopathic Bronchial carcinoma

12. ECG No P wave.
Fibrillatory wave.
Normal but amplitude of QRS complex.
Treatment Digoxin
Amioderone
Cardioversion
β blocker
Verapamil
Antiplatelets

13. Extrasystoles
Premature beats or premature contractions.
a. Atrial extrasystole.
b. Ventricular extrasystole.
Clinical features
Asymptomatic.
Symptomatic. Palpitation
Irregular beats
Missed beat or Strong beat.
heart sound have missed or
extra beats.

14. ECG
AE Normal QRS complex with preceding
abnormal P wave.
VE Broad and bizarre QRS without preceding
P wave.
Couplet 2 successive ectopic beat.
Triplet 3 successive ectopic beat.
Bigeminy Alternate sinus and ectopic beat.
AE No treated
VE Treatment of underlying diseases

15. VE
 Healthy
more prominent at rest
tend to disappear with exercise
treatment is unnecessary
low dose β blocker may reduce anxiety and palpitation
 Heart disease During AMI
Heart failure
Digoxin toxicity
Mitral valve prolapse (MVP)

16. Wolff-Parkinson-White (WPW) syndrome
Pre-excitation syndrome
 Presence of extra conducting tissue (bundle of Kent).
 ECG 1. Short PR interval (< 0.1 sec.)
2. Delta wave.
3. Wide QRS complex (> 0.1 sec.)
 Complications Paroxysmal atrial tachycardia(PAT).
Atrial fibrillation (Af).
 Trans-venous radiofrequency catheter ablation
 Amiodarone, Disopyramide, Flecainide
 Contrindication – Digoxin, verapamil

17. C. Diagnosis
 Careful and thorough history is important.
 Definitive diagnosis may be obtained by doing
ECG during attacks or ambulatory ECG
monitoring.

18. The evaluation of patient with palpitation.
 Continuous or intermittent?
 Regular or irregular heartbeat?
 Approximate heart rate?
 Discrete attacks or not? If yes, is the onset
abrupt? Or how do attacks terminate?
 Any associated symptoms? Eg. Chest pain,
lightheadedness, polyuria.
 Any precipitating factors? Eg. Exercise, alcohol.
 Evidence of structural heart disease? Eg.
Coronary heart disease, valvular heart disease.

19. Regular heart beat
NO
Yes
Ectopics
Atrial fibrillation Discrete attacks
Yes NO
SVT Sinus tachycardia
High stroke volume
Anaemia
Anxiety
AR