1. Palpitations

2. Overview / Goals Define Statistics / Epidemiology History Exam
Differential Dx
Tests
Put It All Together
Sample Cases

3. Definition
sensations of a rapid or irregular heartbeat

4. Differential Diagnosis of Palpitations
Arrhythmias
Psychiatric causes
Drugs and medications
Nonarrhythmic cardiac causes
Extracardiac causes

5. Differential Diagnosis of Palpitations/ Drugs and medications
Alcohol, Caffeine
beta agonists, phenothiazine, theophylline, isotretinoin, digoxin
Cocaine
Tobacco

6. Dietary Supplement Causing Palpitation
Chocolate
Ephedra/Diet pills
Ginseng
Bitter Orange
Valerian
Hawthorn

8. Differential Diagnosis of Palpitations/ Arrhythmias
Atrial fibrillation/flutter
Bradycardia caused by advanced AV block or sinus node dysfunction
Bradycardia-tachycardia syndrome(sick sinus syndrome)
Multifocal atrial tachycardia
Premature supraventricular or ventricular contractions
Sinus tachycardia
Supraventricular tachycardia
Ventricular tachycardia
Wolff-Parkinson-White syndrome

9. Differential Diagnosis of Palpitations/ Nonarrhythmic cardiac causes
Atrial or ventricular septal defect
Cardiomyopathy
Congenital heart disease
Congestive heart failure
Mitral valve prolapse
Pacemaker-mediated tachycardia
Pericarditis
Valvular disease (e.g., aortic insufficiency,stenosis)

10. Differential Diagnosis of Palpitations /Extracardiac causes
Anemia,
Electrolyte imbalance
Fever
Hyperthyroidism
Hypoglycemia
Hypovolemia
Pheochromocytoma
Vasovagal syndrome

11. History/PE of Palpitation
Description : Fluttering, pounding, or uncomfortable sensation in the chest or neck, or simply an increased awareness of the heartbeat
Knowing the circumstances, precipitating factors, and associated symptoms

12. Exam General Appearance?
Vitals: Pulse, BP, febrile or afebrile?, tachypneic?
Neck: JVP?, bruits?, carotid exam?, thyroid palpable and normal?
Pulmonary: Clear, rales or wheezing?
Cardiovascular: Apical pulse – regular, irregular, mostly regular with some ectopy?, normal heart sounds?, murmurs?, gallups?, rub?, PMI location?
Abdomen: Masses?, bruits?
Extremities: Edema – pitting or nonpitting? …

13. Differential Diagnoses
Arrhythmia (tachy / brady / SV / ventricular)
Heart Blocks (higher grade)
PVC’s / PAC’s
Sinus Tachycardia
Valvular Disease (usually arrythmias)
Structural Heart Disease (Ex.) HCM)
Anxiety
Depression
Hypoglycemia
Thyrotixicosis
Fever
Illicit Drugs
Prescribed Medications
Pheochromocytoma …

14. Diagnostic Implications
Overall:
-84% of cases received a diagnosis
43% - Cardiac
31% - Psychiatric
10% - “Other” (Medications, drugs, etc…)
-16%  No diagnosis found
ER or ambulatory setting? (differences p < 0.002)
ER (87% diagnosis)
Ambulatory (72% diagnosis)
47% - Cardiac
21% - Cardiac
27% - Psychiatric
45% - Psychiatric
13% - “Other”
6% - “Other”
13% - No diagnosis
28% - No diagnosis

15. ECG EVALUATION All patients who complain of palpitations
ECG findings warrant further cardiac investigation ; evidence of previous myocardial infarction, left or right ventricular hypertrophy, atrial enlargement, AV block, short PR interval and delta waves (Wolff-Parkinson-White syndrome), prolonged QT interval

16. ECG EVALUATION
ECG exercise testing is appropriate in patients who have palpitations with physical exertion and patients with suspected coronary artery disease or myocardial ischemia.

17. Further Diagnostic Testing
CONTINUOUS ECG MONITORS
(Holter monitor)
- continuously to record data for 24 or 48 hours
- diary of any symptoms that occur during the monitoring
- most expensive
- maintained and operated by hospitals or larger outpatient clinics
TRANSTELEPHONIC EVENT MONITORS
- save data only for the previous and subsequent few minutes when the patient manually activates the monitor

18. Holter monitor VS Event monitor

19. Choosing an Ambulatory Monitoring Device
Diagnostic yield was 66 to 83 percent when event monitors were used for monitoring, and 33 to 35 percent when Holter monitors were used
Event monitors more cost effective
83 to 87 percent of patients had diagnostic transmissions within the first two weeks of using a transtelephonic event monitor

20. When to use Holter
to event monitoring in patients who reliably experience palpitations every day
who are not willing to wear an event monitor for two weeks
if event monitoring is not available locally

21. What if ? palpitations are sustained poorly tolerated
Referal cardiologist for an electrophysiologic evaluation

22. Management
If the evaluation of the heart is otherwise normal, ventricular premature contractions or brief episodes of ventricular tachycardia are not associated with increased mortality
Appropriate patient education
Sustained arrhythmias ;pharmacologic or invasive electrophysiologic study
Treat underlying for the noncardiac, psychiatric, or nonarrhythmia cardiac etiology

23. Management
If fail to reveal any abnormality or etiology for palpitations
-advised to abstain from caffeine and alcohol, as well as foods or stressful situations that appear to trigger palpitations
the majority of patients with palpitations have benign diagnoses and can be treated with reassurance

24. What about children?
Thinking Child

25. Approach to the child with palpitation
Typically arises from physiologic mechanisms, such as fever, exercise, anxiety, or anemia, rather than true life threatening causes (eg. Cardiac arrythmia)

26. Approach to the child with palpitation/History
From true tachyarrhythmias often start and stop abruptly
“Butterfly in the chest”
“My heart is beating so fast that it will come out of the chest”
Rushing or pounding in the ears, esp. when the pt is supine
Heart “flip-flop” or “stops”

27. Summary Get a good history and physical exam Get an EKG
Think about heart
Think about other than the heart( diet, medication, other medical condition to contribute)
Holter or Event monitor for further evaluation
Treat heart or underlying issuses

28. Tests / Procedures Carotid Massage Valsalva DA Method EKG Fingerstick
Echo
Basic chemistries
Thyroid functions
Urine metanephrines
Holter monitor (most common test after EKG)
-Only 24 hrs.  best for daily symptoms
Loop recorder / Event monitor
Stress testing
Patient education (pulse)
?Psychiatry referral