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Palpitation
Palpitations are a common symptom experienced by patients as an awareness of heartbeat. They can be caused by cardiac, psychiatric, or miscellaneous factors in about equal proportions. Evaluation involves determining if there is an underlying arrhythmia or structural heart disease through history, physical exam, ECG and monitoring tests. For most patients where serious causes are excluded, reassurance is provided, though beta-blockers may be used if palpitations are frequent or troubling.
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Palpitation
- 1. PALPITATION NUR FARRA NAJWA BINTIABDUL AZIM 082015100035
- 2. LEARNING OBJECTIVES 1. Whatis palpitation? 2. Approaches to palpitation cases 3. Causes of palpitation in brief. 4. Management of palpitation in brief.
- 3. INTRODUCTION • Extremely commonamong patients PRESENTATION • Intermittent “thumping” “pounding,” or “fluttering” sensation in the chest SENSATION 1. Intermittent 2. Sustained (regular or irregular) INTERPRETATION • Unusual awareness of the heartbeat CONCERNED • Had “skipped” or “missing” heartbeats. OFTEN NOTED • Quietly resting, during which time other stimuli are minimal. POSITIONAL • Structural process (Atrial myxoma) • Adjacent to the heart. (Mediastinal mass)
- 6. CAUSES Cardiac (43%), Psychiatric (31%), Miscellaneous(10%), Unknown (16%)
- 7. IMPORTANT NOTE • Thatmost arrhythmias are not associated with palpitations. • If present 1. Ask the patient to “tap out” the rhythm of the palpitations 2. Take his/her pulse during palpitations.
- 8. PALPITATION IN GENERAL •Hyperdynamic cardiovascular states caused by • Catecholaminergic stimulation 1. Exercise 2. Stress 3. Pheochromocytoma
- 9. CARDIOVASCULAR CAUSES • Prematureatrial and ventricular contractions • Supraventricular and ventricular arrhythmias • Mitral valve prolapse (with or without associated arrhythmias) • Aortic insufficiency • Atrial myxoma • Pulmonary embolism
- 10. INTERMITTENT PALPITATIONS REGULAR, SUSTAINED PALPITATIONS IRREGULAR, SUSTAINED PALPITATIONS •Premature Atrial or ventricular Contractions • Regular Supraventricular tachycardia • Ventricular Tachycardias. • Atrial Fibrillation.
- 11. PSYCHIATRIC CAUSES • Panicattacks or disorders • Anxiety states • Somatization • Longer duration of the sensation (>15 min) • Other accompanying symptoms than do patients with other causes.
- 12. MISCELLANEOUS CAUSES • Thyrotoxicosis, •Drugs, • Ethanol, • Spontaneous skeletal muscle contractions of the chest wall • Pheochromocytoma, • Systemic mastocytosis.
- 13. OTHERS • Common amongathletes – Older endurance athletes. • Enlarged ventricle – aortic regurgitation and accompanying hyperdynamic precordium. • Others that enhance the strength of myocardial contraction – Tobacco, caffeine, aminophylline, atropine, thyroxine, cocaine, and amphetamines,
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- 15. EVALUATION ; PRIMARYGOAL 1. To detect and identify presence and nature of any underlying arrhythmia. 2. To determine the presence of organic heart disease. 3. To determine the presence of precipitating cause
- 16. HISTORY • Character • Modeof onset • Mode of termination • Precipitation • Associated • Relief with vagal maneuvor • Family history
- 17. ASK 1. What doyou really feel? (unexpected awareness of heartbeat) 2. Did you check your pulse by yourself? 3. How does it start? (spontaneous or with activity, anxiety, emotion, etc.) 4. Is it paroxysmal or persistent? 5. How long does it persist? 6. How is it relieved? 7. Have you ever missed a heartbeat? 8. Do you get breathlessness, chest pain, dizziness or blackout with palpitation?
- 20. PRINCIPAL GOAL • Determinea life-threatening arrhythmia. • Preexisting coronary artery disease (CAD) or risk factors for CAD • Greatest risk for ventricular arrhythmias • Symptoms suggesting hemodynamic compromise • Syncope or lightheadedness • Sustained tachyarrhythmias in patients with CAD • Angina pectoris or dyspnea • Ventricular dysfunction (systolic or diastolic), aortic stenosis, hypertrophic cardiomyopathy, or mitral stenosis (with or without CAD), • Dyspnea from increased left atrial and pulmonary venous pressure.
- 21. PHYSICAL EXAMINATION • Helpconfirm or refute the presence : – Arrhythmia as a cause for palpitations – Its adverse hemodynamic consequences • Measurement of the vital signs • Assessment of the jugular venous pressure and pulse • Auscultation of the chest and precordium. • Resting electrocardiogram • Exercise electrocardiography
- 22. EXAMINATION • During symptom-freeperiod. • Signs of anxiety • Abnormal vital signs, • Pale skin, • Exophthalmos, • Goitre, • Jugular venous distension, • Carotid bruits, • Diminished carotid upstroke, • Heart murmurs, • Gallops and clicks, • Wheezes, • Crepitations, • Lower extremity oedema and calf tenderness.
- 23. ARRHYTHMIA IS SUFFICIENTLYINFREQUENT • Haemoglobin • Serum glucose, electrolytes and thyroid function tests. • Continuous electrocardiographic (holter) monitoring; • Telephonic monitoring, • Loop recordings (external or implantable • Mobile cardiac outpatient telemetry.
- 24. MANAGEMENT • Most patientswith palpitations do not have serious arrhythmias or underlying structural heart disease. • The physician should note that palpitations are at the very least bothersome and, on occasion, frightening to the patient. • Once serious causes for the symptom have been excluded, the patient should be reassured that the palpitations will not adversely affect prognosis.
- 25. Cont. Sufficiently troubling tothe patient • Occasional benign atrial or ventricular premature contractions • Managed with beta-blocker therapy Incited by alcohol, tobacco, or illicit drugs • Abstention Incited by pharmacologic agents • Considering alternative therapies Psychiatric causes of palpitations • Cognitive therapy or pharmacotherapy.
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- 29. REFERENCES • HARRISON 19THEDITION • LONG CASE MEDICINE ABM • GEORGE MATTHEWS, 9TH EDITION
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