This document discusses palpitations, which are an uncomfortable awareness of heartbeat caused by alterations in heart rate, rhythm, or contractions. It describes approaches to evaluating palpitations by determining if they are cardiac or non-cardiac in origin, if they are paroxysmal or persistent, and associated symptoms. Potential causes of palpitations include arrhythmias, valvular lesions, structural heart disease, drugs, electrolyte imbalances, and extracardiac factors like anxiety. The examination should include vitals and cardiac auscultation, with ECG, Holter monitoring, or event monitoring used to document any arrhythmias.

1. PALPITATION
THE UNCOMFORTABLE AWARENESS OF HEARTBEAT.

2. Due to..
 Alteration in the heart rate
 Alteration in rhythm
 Augmentation of contraction

3. APPROACH
 Is it palpitation or some other symptom simulating it?
 Chest discomfort of MI or dypnea can be confused for palpitation.
 Did it precede or follow the knowledge of heart disease?
 Psychogenic , situational anxiety

4.  Is it paroxysmal or persistent?
 Paroxysmal –arrhythmia
 Persistent-volume overload like aortic regurgitation or persistent
arrhythmia like atrial fibrillation
 What is the nature of palpitation?
 Missing a beat,thump in chest – premature ventricular contraction
 Rapid regular palpitation-sinus tachycardia,SVT,VT
 Rapid irregular –AF ,
 Sudden onset and sudden cessation-sick sinus syndrome
 Giddiness or syncope-bradyarrythmias

5.  What are the associated symptoms?
 Syncope-low cardiac output during arrhythmias / hypoglycmia
 Dyspnea -HF due to arrhythmia if palp preceded dyspnea
if dyspnea preceded then HF ppt arrhythmia(MI)or acute
pulm embolism , acute episode of asthma with respiratory insuf
Chest pain – following palpitation is due to angina
precedes palp-MI ppt arryth
Polyuria – atrial fibrillation (ANP)
Sweating –anxiety, hypoglycemia
Diarrhea – thyrotoxicosis , hypokalemia induced arryth

6.  Is there an extracardiac cause for palptation?
 Anemia
 Fever
 Thyrotoxicosis
 Anxiety
 Hypoglycemia
 Pheochromocytoma
 Is the patient taking any drugs that produce
arrhythmias?
 Sympathomimetic
 Vasodilators
 Digitalis
 TCS

7.  Any ppt factors?
 Exercise , alcohol
 History of structural heart disease?
 CAD , valvular heart disease
 Cardiovascular causes of palpitation Arrythmias
 Regurgitant lesions( AR ,MR) atrial fibrillation
 Left to right shunts complete heart block
 Hyperkinetic heart syndrome extrasystoles
 Prosthetic heart valves paroxysmal atrial tachy
 Electronic pace maker wpw syndromes
 Aortic aneurysm

8. Palpitation in normal people
 Exercise ,emotional excitability , anxiety
 In acute anxiety states palp usually relieved spontaneously or with
reassurance
 Chronic anxiety ( da costa syn, soldiers heart , effort syn )is relatively
resistant to therapy
 Clinical features :symp-palpitation, shortness of breath ,chest
tightness, weakness ,insomnia , giddiness
signs-tachycardia , high pulse pressure , sweating ,
hyperventilation , hyperkinetic apical impulse , ejection murumurs
 Chronic nature , deep sighing respiration , atypical chest pain
distinguishes it from cardiac diseases.

9. Palpitation in valvular heart disease
 Regurgitant lesions – volume overload
 Stenotic lesions – MS-causes atrial fib(arrhythmia initially paroxysmal
later persistent)
 Palpitaion indicates chronic severe MS in young patients
 But In case of AF with mild MS assoc causes like ASD , thyrotoxicosis ,
sick sinus synd to be looked for
 Increased incidence of peripheral embolism
 Indication for long term anticoag
 Paroxysmal palp explains ‘unexplained’ peripheral embolism with
sinus rhythm or rec pulm embolism.

10. Palpitation In hypertension
 Commonest cause – drug therapy (vasodilators) or knowledge of
hypertension
 Recurrent palp and sweating – r/o pheochromocytoma
 Causes
 Isolated use of vasodilators
 Ass CAD (arryth , angina equivalent)
 Hypokalemia (diuretic induced , primary aldosteronism)
 Psychogenic

11. Examination and investigation
 Vitals-JVP , pulse , auscultation of chest
 Resting ECG to document arrhythmias
 Holter monitoring – in infrequent arrhythmias continuous ECG monit
 Loop recording (external or implantable)-captures the ECG event
 Mobile cardiac outpatient telemetry

15. THANKYOU
GAURI KULKARNI