“Palpitations” Cases Tom Gamble ST2 Small Group 15/6/11 “Palpitations” Cases Tom Gamble

Case Study 1: Tiffany Darwish 25 year old medical student. Recently noticed palpitations lasting a few seconds, getting several a day. No associated Sx but has to gasp for breathe. What more would you like to know? How would you examine/investigate and manage this lady?

Case Study 2: Jane Wiedlin Jane Wiedlin: 38 year old lady. Has had several episodes of palpitations, describes feeling heart racing for between 2 and 15 minutes. Feels very panicky when it happens and short of breathe. How would you approach this case?

Case Study 3: Howard Jones 54 year old patient, marathon runner. Complaining of palpitations since yesterday. Chest feels a little tight also. On examining him you notice his heart rate is about 130-140. What would you do?

Case Study 4: Stuart Goddard 62 year old gentleman with a history of an MI two years ago, and anxiety. Complains of episodes of a ‘missed heart beat’, feels it 3 or 4 times a day. How would you investigate this? You arrange an ECG at the surgery, which shows some old T-wave inversion, but is otherwise unremarkable except for a single ventricular ectopic beat. What would you do next.

Palpitations - Summary History most important source information Hierarchy of investigation: ECG – bloods (TFT/FBC/U&E) - cardiac monitoring – echocardiogram/exercise tolerance test Re-assurance often only necessary treatment (but this may include an ECG) Consideration of risk of underlying heart disease important part of assessment

Differential Diagnosis: Common: Anxiety/ sinus tachycardia Atrial ectopics Ventricular ectopics (?underlying problem but can be normal) SVT (AF, atrial flutter with rapid ventricular response, AV re-entrant tachycardia) Occasional: Thyrotoxicosis; menopause; iatrogenic (digoxin, nifedipine) Rare: Heart Block; sick sinus syndrome; drug abuse; VT

Tips: Teach patients to take their own pulse Suggest they attend A&E/GP surgery when event happens to capture ECG Remember red flags previous CV disease especially recent MI FHx sudden death/arrythmias Associated falls/syncope or Sx on exercise If found to be in AF probably paroxysmal or recent onset AF – consider urgent referral for anticoagulation