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approach to palpitations.pptx
- 1. APPROACH TO PALPITATIONS Dr.G.VENKATA RAMANA MBBS DNB FAMILY MEDICINE
- 2. PALPITATION • Defined as a “thumping,” “pounding,” or “fluttering” sensation in the chest • This sensation can be either intermittent or sustained and either regular or irregular • Unusual awareness of the heartbeat • Palpitations are often noted when the patient is quietly resting, during which time other stimuli are minimal • Palpitations that are positional generally reflect a structural process within(e.g., atrial myxoma) or adjacent to (e.g., mediastinal mass) the heart
- 3. NATURE OF PALPITATIONS 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
- 4. PATHOPHYSIOLOGY • Augmentation of heart contractility • Physiological augmentation • Exercising strongly and over nervous • After drinking coffee,tea,alcohol • Taking medicine such as Atropine,Ephedrine,Aminophylline • Pathological augmentation • Ventricular hypertrophy • Preload or afterload increase hypertrophy augmentation of contractilitypalpitation • Thyrotoxicosis : basic metabolism amplify &sympathetic nerve exciteheart rate increases • Anemia: hypoxia heart rate increases • Fever: basic metabolism amplify • Hypoglycemia: palpitation due to release of catecholamine • Arrhythmia • Cardiac neurosis : turbulence of sympathetic nerve and pneumogastric nerve
- 5. ETIOLOGY • Cardiac causes Arrhythmias Nonarrhythmic cardiac cause • Extracardiac causes • Psychiatric causes • Drugs & Diets
- 6. ARRHYTHMIAS • Atrial fibrillation/flutter • Bradycardia caused by advanced AV block or sinus node dysfunction • Bradycardia –tachycardia syndrome • Multifocal atrial tachycardia • Premature supraventricular or ventricular contractions • Sinus tachycardia • Supraventricular tachycardia • Ventricular tachycardia • Wolff –Parkinson-White syndrome
- 7. NONARRHYTHMIC CARDIAC CAUSES • Mitral valve prolapse • Atrial or Ventricular septal defect • Cardiomyopathy • Congenital heart disease • Congestive heart failure • Pacemaker–mediated tachycardia • Pericarditis • Valvular disease-Aortic insufficiency,Stenosis
- 8. EXTRACARDIAC CAUSES • Fever • Anemia • Hyperthyroidism • Pheochromocytoma • Hypovolemia • Hypoglycemia • Electrolyte imbalance • Pulmonary disease • Vasovagal syndrome
- 9. PSYCHIATRIC CAUSES • Panic attacks • Anxiety • Somatization • Patients with psychiatric causes for palpitations more commonly report a longer duration of the sensation (>15 min) and other accompanying symptoms than do patients with other causes
- 10. DRUGS & DIETS • Beta agonists • Phenothiazine • Theophylline • Isotretinoin • Digoxin • Tobacco • Alcohol • Caffeine • Chocolate • Cocaine
- 12. APPROACH TO PALPITAIONS • STEP 1 • Is palpitation continuous or intermittent? • Intermittent palpitation are commonly caused by premature atrial or ventricular contractions • 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
- 13. • 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
- 14. • STEP 5 • Are there any associated symptoms? • Chest pain-Arrhythmogenic MI • Dyspnoea-Heart failure due to arrhythmias • Syncope-Low cardiac output during arrhythmias,hypoglycemia,Pheochromocyto a • Polyuria-SVT • Sweating-Anxiety,Hypoglycemia • Diarrhoea-Thyrotoxicosis
- 15. • STEP 6 • Are there any precipitating factors? • Exercise,stress,alcohol intake,drugs • STEP 7 • Is there a history of structural heart disease,coronary heart disease,valvular heart disease?
- 16. EXAMINATION • Pallor • Thyroid swelling • Pulse • Blood pressure • Heart murmurs • Signs of left/right ventricular dysfunction • Features of endocrine abnormality
- 18. INVESTIGATIONS • CBC • Thyroid function test • RBS • Resting ECG • Exercise ECG (If exertion is known to induce arrhythmia and accompanying palpitations) • Continuous ECG monitoring (Holter) • Telephonic monitoring • Loop recordings- External or Implantable • 2D ECHO
- 24. MANAGEMENT • Beta blocker – Symptomatic atrial or ventricular premature contractions • Sustained arrhythmias –Pharmacologic or Invasive electrophysiologic study • Treat underlying cause for the noncardiac, psychiatric or nonarrhythmia cardiac etiology • Abstain from caffeine,alcohol,foods or stressful situations that appear to trigger palpitations