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

2. 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?

3. 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?

4. 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
What would you do?

5. 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.

6. 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

7. 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

8. 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