Approach to Palpitation in Emergency Department

1. APPROACH TO
PALPITATION

2. OUTLINE
DEFINITION CASE APPROACH MANAGEMENT REFERENCE

3. DEFINITION
• Palpitation describe a noticeable heartbeat that may be
concerning to the patient, either too fast, irregular or too strong –
Uptodate.com
• Palpitation is an awareness of the heartbeat – Oxford Concise Medical
Dictionary
• Palpitation is awareness of heartbeat, although benign in the vast
majority, palpitations are occasionally a manifestation of a life-
threatening disorder – Differential Diagnosis Churchill’s Pocketbook

4. CASE
• A 32-year-old female patient presented with complaints of
palpitations and exercise intolerance for the past 6 months.
• Palpitations were intermittent and irregular and lasted for hours.

5. CASE
• She has had New York Heart Association class 1 dyspnea on
exertion for the past 6 months.
• She had been very active and was previously able to run a
marathon.
• There was no history of syncope or chest pain.
• She has no other chronic medical problems and had no prior
cardiac history.
• She did not smoke or use illicit drugs, and there was no family
history of sudden cardiac death.

6. APPROACH : HISTORY TAKING
• FOCUSED HISTORY :
- Duration and timing of palpitation
- Is this something that just started or has it been happening for
years?
- Frequency : how frequent are the episodes?
- How long do they last?
- Is the patient experiencing palpitation at this moment?
- Description : fluttering / pounding / skipping a beat?

7. APPROACH : HISTORY TAKING
• SPECIFIC TRIGGER / PRECIPITATING FACTORS:
- Exercise
- Standing up too quickly
- Use of a specific medication (e.g. albuterol)
- Excessive caffeine, smoking and alcohol intake
• QUALITY / REGULARITY OF PALPITATION :
- Too fast
- Irregular
- Too strong
- All the above

8. APPROACH : HISTORY TAKING
• PRESENCE OF ASSOCIATED SYMPTOMS :
- Dyspnea
- Lightheadedness
- Syncope
- Chest pain
- Anxiety
- Profuse sweating
- Reduced effort tolerance
- Altered mental status

9. APPROACH : HISTORY TAKING
• HISTORY OF CARDIAC DISEASE OR CARDIOVASCULAR RISK
FACTORS :
- Ischemic heart disease
- Hypertensive heart disease
- Heart failure
- Heart valve disease
• HISTORY OF RECENT ALCOHOL OR ILLICIT DRUGS USE
• FAMILY HISTORY OF EARLY SUDDEN DEATH
• RECENT LIFE STRESSOR

10. APPROACH : PHYSICAL EXAMINATION
• GENERAL EXAMINATION :
- Assess hemodynamic status (reassess frequently as this may
change rapidly)
- Assess level of consciousness
- Vital signs : orthostatic vital signs if history consistent with
Postural Orthostatic Tachycardia Syndrome (POTS)
- Determine heart rate & rhythm
- Pulse volume
- Orthostatic vital signs
- Temperature : generally heart rate increases by only about 10
bpm for every rise of 1 °C in temperature. Disproportionate
increases in HR should prompt a search for other causes

11. APPROACH : PHYSICAL EXAMINATION
• RESPIRATORY EXAMINATION :
• CARDIAC EXAMINATION :
- Auscultation : murmur & rate at the cardiac apex
- JVP
• THYROID EXAMINATION :
- if history is consistent with hyperthyroidism.
- look for enlargement or tenderness or nodules that could be
associated with a cause of hyperthyroidism.

12. APPROACH : INVESTIGATION
• ECG : all patient should get ECG at time of initial presentation even
if arrhythmia is not currently present
• FBC
• Electrolytes
• RFT
• LFT
• Glucose level
• TFT : if history is consistent with hyperthyroidism
• Cardiac biomarkers

13. APPROACH : INVESTIGATION
• Urine toxicology screen : if history is suggestive of drug
intoxication / withdrawal
• Echocardiogram
• Chest radiography

14. ECG
OTHER ARRHYTHMIA
Bradyarrhythmia or
identifiable
tachyarrhythmia
Work up
arrhythmia as
appropriate :
- AF, A-Flutter, SVT
Unidentifiable
tachyarrhythmia (too
fast to interpret)
Valsalva manoeuvre
Carotid massage
Adenosine
SINUS TACHYCARDIA
BP normal or
elevated
History &
examination usually
reveals aetiology
BP low
Tachycardia is likely a
compensatory
response for
hypotension

15. MANAGEMENT : UNIVERSAL ALGORITHM
Oxygen, IV access,
Defibrillator/monitor,
ECG
Are there any serious symptoms & signs?
Related to the tachycardia?
YES
Immediate
synchronized
cardioversion
NO
Narrow complex
tachydysrhythmias
QRS < 120 ms
Wide complex
tachydysrhythmias
QRS > 120 ms
Reference :
Guide To The
Essentials in
Emergency
Medicine,
Second
Edition

16. Sinus Tachycardia
should NOT be
cardioverted !!

18. NARROW COMPLEX TACHYDYSRHYTHMIAS
REGULAR IRREGULAR
Sinus Tachycardia Atrial Fibrillation (AF)
Paroxysmal Supraventricular Tachycardia
(PSVT)
- AVNRT
- AVRT + WPW
Atrial Flutter with Variable Block
Atrial flutter with regular AV conduction Multifocal Atrial Tachycardia (MAT)

19. NARROW COMPLEX TACHYDYSRHYTHMIAS
Reference :
Guide To The
Essentials in
Emergency
Medicine,
Second
Edition

20. MANAGEMENT : TACHYDYSRHYTHMIAS
• Assess responsiveness
• ABCD survey :
- Assess, clear & support the airway, breathing & circulation
- Give supplemental oxygen
- Establish IV access
- Attach defibrillator/ECG monitor & assess rhythm
- Vital signs, brief targeted history & physical examination
- Obtain 12-lead ECG

21. MANAGEMENT : TACHYDYSRHYTHMIAS
• Look for signs & symptoms associated with tachydysrhythmias :
• If serious signs & symptoms are present and attributable to the
tachydysrhythmia, prepare for synchronized cardioversion.
Chest pain / Breathlessness / Altered mental status
SBP <90 mmHg & clinical features of shock
Clinical features of heart failure

22. MANAGEMENT : TACHYDYSRHYTHMIAS
NARROW COMPLEX TACHYDYSRHYTHMIAS
1) PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
2) ATRIAL FIBRILLATION
3) ATRIAL FLUTTER

23. MANAGEMENT : PAROXYSMAL SVT
• Vagal Maneuvers (non-pharmacological methods) :
- first line of treatment for stable PSVT
- if properly performed, should convert 20-25% of cases
- (1) Valsalva maneuvers
(2) Carotid sinus massage
• Chemical cardioversion :
- if vagal maneuver are unsuccessful
- Adenosine, Verapamil & Diltiazem
• Synchronized Electrical Cardioversion :
- should be performed without delay when patient become
unstable

24. MANAGEMENT : PAROXYSMAL SVT
• Chemical cardioversion :
(1) ADENOSINE
- rapid bolus followed by a 20ml saline flush in a proximal vein
(2) VERAPAMIL
- IV infusion at 1ml/min up to maximum of 20mg
(3) DILTIAZEM
- 2.5mg/min up to 50mg
- stop the infusion when the rhythm converts to sinus

25. MANAGEMENT : PAROXYSMAL SVT
• Before attempting chemical cardioversion, beware of suspected
Atrial Fibrillation with Wolff-Parkinson-White Syndrome.
- Heart rate may be so rapid as to appear regular.
- However, the QRS will exhibit varying morphologies, whereas in
PSVT the QRS should be monomorphic.
• look for a delta wave on the ECG in WPW.

26. MANAGEMENT : AF / A-FLUTTER
• Initial aim of management of acute AF :
- VENTRICULAR RATE CONTROL
- clearly defined target heart rates are not available
- reasonable level would be 100-110 bpm or less
- rhythm control in AF aims to return the patient to sinus rhythm
If no heart failure If there is heart failure
Diltiazem Digoxin
Verapamil Amiodarone
Beta blocker Procainamide

27. MANAGEMENT : AF / A-FLUTTER
• Diltiazem : 2.5 mg IV every 3 minutes up to 50mg maximum.
• Verapamil : 1 mg/min IV up to 20 mg maximum.
• Esmolol : 500 μg/kg IV over 1 minute followed by infusion at 50-200
μg/kg/min.
• Metoprolol : 2-5 mg IV every 5 minutes up to 15 mg.
• Propranolol : 100 μg/kg IV in 3 divided doses at 2-3 minute interval.
• Digoxin : 0.5 mg IV.
• Amiodarone : 150-300 mg IV over 30 minutes followed by 900 mg over
24 hours. Maximum dose is 2.2 g/day.
• Procainamide : 20 mg/min IV until arrhythmia suppression,
hypotension, QRS widened by >50% or maximum dose of 17 mg/kg.

28. MANAGEMENT : AF / A-FLUTTER
• Rhythm control in AF : aims to return to sinus rhythm.
• Conversion to rhythm to sinus would restore organized atrial
contraction (which capable of dislodging and creating an
embolization of clot).
• Main concern : Atrial thrombus – likely to occur if AF >48 hours.
• If a clot is present / any doubt : fully anti-coagulated.
• For thromboprophylactic therapy, the CHA2DS2-VASc score is now
used instead of the CHADS2 score for risk stratification.

29. WIDE COMPLEX TACHYDYSRHYTHMIAS
REGULAR IRREGULAR
Ventricular Tachycardia (VT) AF with aberrancy
SVT with aberrant conduction AF with WPW
SVT with BBB Polymorphic VT & Torsades de Pointes

30. Reference :
Guide To The
Essentials in
Emergency
Medicine,
Second
Edition

31. MANAGEMENT : TACHYDYSRHYTHMIAS
WIDE COMPLEX TACHYDYSRHYTHMIAS
1) VENTRICULAR TACHYCARDIA
2) SUPRAVENTRICULAR TACHYCARDIA WOTH ABERRANCY
3) POLYMORPHIC VENTRICULAR TACHYCARDIA & TORSADES DE
POINTES

32. MANAGEMENT : VT
• Singapore NRC guidelines :
- main drug options : Amiodarone and Lignocaine.
• AHA :
- Procainamide and Sotalol (superior to Lignocaine)
- Procainamide and Sotalol should be avoided in prolonged QRS
intervals and heart failure.
• Do not give more than one anti-arrhythmic agent at any one time.
• If drug fails : elective synchronized cardioversion.
• If unstable : perform synchronized cardioversion without delay.

33. MANAGEMENT : VT
• Amiodarone : 150 mg over 10 minutes, and repeated once if
necessary, followed by an infusion of 1 mg/min for 6 hours then
0.5 mg/min. Maximum daily dose is 2.2 g.
• Lignocaine : 1-1.5 mg/kg IV push, repeated once at half the dose,
if necessary, after about 15 minutes up to maximum of 3 mg/kg.
• Procainamide : 20-50 mg/min or 100 mg every 5 minutes, until
arrhythmia is suppressed, hypotension ensues or QRS is prolonged
by 50%, up to maximum of 17 mg/kg.
• Sotalol : 100 mg or 1.5 mg/kg over 5 minutes.

34. Reference :
CPG :
MANAGEMENT
OF ACUTE
STEMI 4th
EDITION

35. MANAGEMENT : SVT WITH ABERRANCY
• Trial of Adenosine may be given if SVT with aberrancy is strongly
suspected.
• When in doubt / if Adenosine is unsuccessful : the patient should
be treated as for VT.

36. MANAGEMENT : POLYMORPHIC VT &
TORSADES DE POINTES
POLYMORPHIC VT TORSADES DE POINTES
QT INTERVAL Not prolonged Prolonged
TREATMENT AMIODARONE IV MAGNESIUM SULPHATE 1-
2g over 60-90 seconds,
followed by infusion of 1-2
g/hour
MAGNESIUM & LIGNOCAINE
are not likely to be effective
OVERDRIVE PACING
If unstable, use defibrillation
energy doses &
unsynchronized direct current
shock
Drugs that prolonged QT
interval should be avoided

37. Reference :
Advanced
Cardiac Life
Support
Provider
Handbook

38. Evaluation & Management of Palpitations
Yes No
No
Yes
Patient with palpitation
Triage
Perform history, physical exam, ECG
Arrhythmias/ signs of
shock/ in failure/ unstable
vital signs
Relatively
stable patient
Relatively
stable patient
Clinical suspicion of metabolic disorder (eg thyroid disease, anemia, fever), illicit
drug use, pregnancy, medication side effects, syncope, ENT disorder
Treat underlying condition Risk factors/ clinical suspicion of structural/
ischemic heart disease
Symptoms resolved
Observe; KIV discharged
or admission
Normal ECG Abnormal ECG
Reassure/ reevaluate
Admit/ cardiology appt
Stable arrhythmia
Unstable arrhythmia
Rule out ACS
Pharmacological cardioversion
Cardiology referral
Rule out ACS
ACLS algorithm: defibrillation,
synchronized cardioversion
Cardiology referral

39. DIFFERENTIAL DIAGNOSIS OF PALPITATION
Anxiety, Panic disorder Valvular heart disease Cardiac tamponade
Caffeine, Alcohol, Nicotine,
Beta blocker withdrawal
B2 agonists, Calcium channel
blockers, Benzodiazepines
Menopause, Pregnancy
Acute Coronary Syndrome Hypoglycemia Pheochromocytoma
Hyperthyroidism,
Thyrotoxicosis
Cardiomyopathy,
Inappropriate sinus
tachycardia
Postural Orthostatic
Tachycardia Syndrome
Infection, Hyperthermia Anemia Exercise
Hypovolemia, Dehydration Pulmonary embolism Hyperventilation Syndrome

41. CASE
• A 32-year-old female patient presented with complaints of
palpitations and exercise intolerance for the past 6 months.
• Palpitations were intermittent and irregular and lasted for hours.

42. CASE
• She has had New York Heart Association class 1 dyspnea on
exertion for the past 6 months.
• She had been very active and was previously able to run a
marathon.
• There was no history of syncope or chest pain.
• She has no other chronic medical problems and had no prior
cardiac history.
• She did not smoke or use illicit drugs, and there was no family
history of sudden cardiac death.

43. CASE
• Her vitals were normal.
• There was no jugular venous distension or pedal edema.
• Cardiac examination revealed a nondisplaced apical impulse,
normal S1 and S2, and no murmur.
• The remainder of the physical examination was unremarkable.
• Complete blood count and basic metabolic profile were within
normal reference range.
• An electrocardiogram reveled normal sinus rhythm without ST-T
changes.

44. CASE

45. CASE : COR TRIATRIATUM SINISTRUM
• Echocardiography demonstrated the presence of a membrane
traversing the left atrium, dividing it into superior and inferior
chambers.
• The left atrial appendage and fossa ovalis were present distal to
the membrane, which is consistent with cor triatrium.
• There were two fenestrations in the membrane with mild
restriction of blood flow.
• The patient underwent an uncomplicated surgical resection of the
membrane.

46. CASE : COR TRIATRIATUM SINISTRUM
• Rare congenital malformation that occurs in about 0.4% of
patients with congenital heart disease.
• Characterized by three atrial cavities, namely a normal right atrium
and proximal and distal left atrial chambers.
• Embryological basis of this anomaly is abnormal growth of septum
primum or incorporation of embryonic common pulmonary vein
into the left atrium.
• Presentation can range from infancy to late adulthood and is
dictated by the degree of obstruction to flow by the membrane.

47. CASE : COR TRIATRIATUM SINISTRUM
• Mild degree of obstruction may present in adulthood with
dyspnea on exertion.
• In patients with severe obstruction, presentation can mimic mitral
stenosis.
• Patient are at risk for cardioembolic events and atrial arrhythmia.
• Echocardiography is diagnostic.
• In symptomatic patient, surgery is the definitive treatment.

49. SUMMARY
• Do not downplay any patient’s complaints of palpitation even if
they appear well.
• Always assess the hemodynamic status and look for clinical
features of serious signs and symptoms.
• Perform a 12-lead ECG as far as possible when a patient is still
experiencing palpitation as the dysrhythmias or ECG changes may
be transient.
• If the ECG shows normal sinus rhythm, most patients warrant an
ambulatory ECG monitor +/- an echocardiogram to look for
evidence of structural heart disease.

50. SUMMARY
• Reassess the patient’s hemodynamic status frequently as this may
change rapidly.
• Although palpitation are benign in the vast majority of cases, they
can occasionally be a manifestation of life-threatening disorders.
• Sudden onset of tachycardia in childhood or teenage years
associated with breathlessness, dizziness and chest pain suggests
supraventricular tachycardia. Suspect a congenital anomaly.

51. REFERENCE
• www.uptodate.com
• Oxford Concise Medical Dictionary
• Differential Diagnosis Churchill’s Pocketbook
• Approach to Palpitation – Strong Medicine YouTube Channel
(https://www.youtube.com/watch?v=ep7nkE4KvLk)
• American College of Cardiology : Case Quiz –
(https://www.acc.org/education-and-meetings/patient-case-quizzes/a-
32yo-female-patient-presents-with-palpitations)
• Clinical Practice Guideline : Management of Acute ST Segment Elevation
Myocardial Infarction (STEMI) 4th Edition
• Advanced Cardiac Life Support Provider Handbook
• Tintinalli’s Emergency Medicine : A Comprehensive Study Guide 9th
Edition

52. THANK YOU