This document discusses the clinical approach to evaluating patients presenting with palpitations. It defines palpitations and describes the physiology and common causes. Cardiac causes account for 43% of cases, while psychiatric conditions cause 31%. The document outlines the diagnostic evaluation including history, physical exam, ECG and ambulatory monitoring. It provides guidance on when to refer to cardiology or admit to the hospital. The management focuses on reassurance, lifestyle changes, treating underlying conditions, anxiolytics, beta-blockers, antiarrhythmics or cardioversion depending on the severity and nature of the arrhythmia.

1. By
Abdelsalam Sherif
MD cardiology
Clinical Approach to Palpitations

3.  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
Definition

4. Physiology
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 states & drugs

5. Causes Of Palpitations

6. Causes Of Palpitations
Cardiac
43%
Psychiatric
31%
Miscellaneous
10%
Unknown
16%

7. Independent Predictors of Cardiac Etiology of
Palpitation
Male sex
Description of an irregular heart beat
History of heart disease
Event duration >5 minutes
1 predictor : 26%
2 predictors: 48%
3 predictors: 71%

8. Psychiatric Causes
 Panic attacks
 Anxiety states
 Somatization
 Depression
Patients with psychiatric causes for palpitations more commonly report a longer duration of sensation
>15min, younger & disabled & multiplicity of symptoms than do patients with other causes with more
visits to ER .

9. Miscellaneous Causes
 Hyperkinetic circulatory states :
Anaemia , Fever , Thyrotoxicosis , Hypoglycemia , Pheochromocytoma
 Drugs :
Aminophylline , Atropine , Thyroxine , Tricyclic antidepressants , Vasodilators , Digitalis
 Others :
Caffeine , Cocaine , Amphetamines , Tobacco , Ethanol

10. Continued
 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

11. Why to evaluate and treat arrhythmias
 Eliminate symptoms.
 Prevent imminent death and hemodynamic collapse due to a life-threatening
arrhythmia.
 Reduce possible risks other than the direct effects of the arrhythmia (eg, reduce
stroke in patients with atrial fibrillation).

12. On facing a patient with palpitation for 1st time
 Is the arrhythmia causing symptoms or could it?
 Does the arrhythmia pose a risk to the patient?
 Which arrhythmia is present?
 Does the arrhythmia require emergent cardioversion?
 Does the patient require urgent hospitalization?
 Is specialist consultation required, and if so, how urgently?
 Should anticoagulation and/or other medical therapy be started?

14. Diagnostic Evaluation
1. History
I. Age of onset
II. Description ( rate , degree of regularity of palpitation)
* rapid and regular —> SVT & VT
* rapid and irregular —> AF , A.flutter or tachycardia with variable block.
* Flip- flopping —>atrial or ventricular PBs.
* rapid fluttering —>sustained VT or SVT
regular : AVNRT , irregular : AF
* pounding in neck —> AV dissociation as in PVC, CHB or VT
rapid and regular pounding in neck ( frog sign ) : SVNRT.
III. Onset and offset
* randomly and episodically and last for an instant : mostly premature beats
* abrupt onset and offset : SVT or VT
* gradual onset and offset : sinus tachycardia
* mode of termination :vagal stimulation —> SVT

15. Continued
IV. Positional palpitation
* palpitation upon standing up straight after bending over and end by lying down : mostly AVNRT.
* intermittent pounding sensation on lying in bed —>atrial or VPBs
V. Palpitation associated with other symptoms.
VI. Palpitations of psychiatric causes :
* younger and disabled patients.
* more somatization.
* palpitations duration > 15 minutes
* accompanied by more ancillary symptoms
* more visits to ER
VI. Medications and habits

16. “All palpitations are not arrhythmias and many
arrhythmias do not palpitate”

17. How To Evaluate Palpitation
Step 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)

18. Step 2
Is heart beat regular or irregular ?
 Regular , sustained palpitations can be caused by SVT and VT
 Irregular , sustained palpitations can be caused by Atrial fibrillation

19. 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 maneuvers decrease palpitations in SVT

20. Step 5
Are there any associated symptoms ?
 Chest pain : Arrhythmogenic MI
 Dyspnea : Heart failure due to arrhythmias
 Syncope : low cardiac output during arrhythmias , hypoglycemia , pheochromocytoma
 Polyuria : SVT
 Sweating : Anxiety ,hypoglycemia
 Diarrhoea : Thyrotoxicosis

21. Step 6
Are there any precipitating factors ?
exercise , stress ( hyperdynamic cardiovascular states caused by catecholaminergic stimulation)
alcohol intake , drugs, Palpitations that are positional, generally reflect a structural process
within heart
e.g. : Atrial myxoma
or adjacent to the heart
e.g. : Mediastinal mass
Step 7
Is there a history of structural heart disease ?
Coronary HD , valvular HD, Cardiomyopathies

22. “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”

23. Nature Of Palpitation
Feature Suggests
HEART MISSES AND THUMPS ECTOPIC BEATS
WORSE AT REST ECTOPIC BEATS
VERY FAST REGULAR SVT / VT
SUDDEN ONSET SVT / VT
OFFSET WITH VAGAL MANOEUVRES SVT
FAST AND IRREGULAR AF and ATRIAL FLUTTER with varying block
FORCEFUL AND REGULAR – NOT FAST AWARENESS OF SINUS RHYTHM (ANXIETY)
SEVERE DIZZINESS OR SYNCOPE VT or BRADYARRHYTHMIAS
PRE-EXISTING HEART FAILURE VT

24. Simple Approach To Diagnosis Of Palpitation
Is heart beat
regular ?
YES
Are there any discrete attacks of
tachycardia >120/min
YES
SVT
VT
NO
Sinus tachycardia
High stroke volume
NO
Irregular heart beat
Ectopic beats
AF

26. 2. Physical examination
Key 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

27. 3. Investigations
 A resting ECG
 If exertion is known to induce arrhythmia and accompanying palpitations ,
exercise ECG is useful
 2D-ECHO
When patients complaining of palpitations undergo 24-hour, ambulatory ECG
monitoring, 39 to 85 percent manifest a rhythm disturbance (most being benign and
clinically insignificant).

28. Continued
If arrhythmia is sufficiently infrequent , other methods must be used like
 Continuous ECG ( Holter ) monitoring ,
 Trans telephonic monitoring ,
 Loop recordings (external or implantable) &
 Mobile cardiac outpatient telemetry.
 Event recorder

29. Further Diagnostic Testing
Diagnostic testing is recommended for three groups of patients:
 Those in whom the initial diagnostic evaluation (history, physical examination, and
electrocardiogram) suggests an arrhythmic cause. Testing is particularly important in
patients who experience syncope or presyncope in association with palpitations.
 Those who are at high risk for an arrhythmia. Patients are considered at high risk
if they have organic heart disease or any myocardial abnormality that can lead to serious
arrhythmias, including scar formation from myocardial infarction, idiopathic dilated cardiomyopathy,
clinically significant valvular regurgitant or stenotic lesions, and hypertrophic cardiomyopathy. These
disorders have all been shown to be associated with the development of ventricular tachycardia .
Other high-risk patients are those with a family history of arrhythmia, syncope, or sudden death
from cardiac causes, such as from a cardiomyopathy or the long QT syndrome. Low-risk patients are
those without a potential substrate for arrhythmias.
 Those who remain anxious to have a specific explanation for their
symptoms.

30. Outpatient Monitoring Systems
 Traditional Holter-continuous recording of 24 or 48 hours.
 Event recorder-patient activated recorder, either looping or non looping. Some newer models have
automatic arrhythmia detection software to store asymptomatic episodes. Data is transmitted over
the phone to a monitoring station.
 Mobile continuous outpatient cardiac telemetry-continuous recording and analysis, with
symptomatic or algorithm defined episodes transmitted automatically via cellular technology to
monitoring station.
 Implantable loop recorder-patient and algorithm defined episodes stored in device, until
interrogated either in office or remotely via home equipment and internet.
 The 1999 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on
ambulatory electrocardiography concluded that there were two main indications for ambulatory
monitoring in the assessment of arrhythmia.
(1) the assessment of unexplained syncope, near syncope, or episodic dizziness
(2) the assessment of unexplained recurrent palpitations

31. Diagnostic Recommendations For Palpitation
* No evidence of HD
*Tolerated and
unsustained
• 1. Reassurance
• 2. Ambulatory
monitoring , better 2
weeks trans telephonic
monitoring
* Evidence of HD
* Unsustained
• Ambulatory Monitoring
* Sustained
*Poorly tolerated
With or without HD
• EPS with or without
prior ambulatory
monitoring

32. Holter monitor

33. Implantable loop recorders

34. Mobile cardiac outpatient telemetry

35. 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

37. Referral to Cardiologist
 Any patient with an arrhythmia when the primary care physician is uncomfortable
with either diagnosis or management
 Candidates for permanent pacing
 Those with an uncertain diagnosis, prognosis, or management strategy
 Those who might benefit from implantation of an implantable Cardioverter
Defibrillator or biventricular pacemaker
 Those who might benefit from a catheter ablation procedure
 Those who might benefit from antiarrhythmic drug therapy

38. Decision for Hospitalization
 The presence and severity of structural heart disease.
 The indication for treatment (eg, etiology of the arrhythmia and type and severity
of associated symptoms). Treatment for ventricular tachycardia is usually started in
the hospital.
 The drug used. For example, the labeling information
for dofetilide and sotalol specify inpatient initiation,
while flecainide , propafenone ,dronedarone , and amiodarone can generally be
initiated outside the hospital in appropriate patients.

39. Management
in a Nutshell
• Re-assurance
• Lifestyle modification
• Correction of co-morbid diseases
• Anxiolytics and Beta-blockers
• Anti-arrhythmic drugs / electrical conversion
Recurrent life-threatening
ventricular arrhythmias are currently
being treated with Implantable
Cardioverter-Defibrillitor devices

40. Thanks