9: 50-year-old woman with palpitations

Question 1

Palpitations - History & Physical Exam

Answer 1

When a patient presents with palpitations, the history and physical exam may be inadequate for diagnosing or ruling out dysrhythmias. Since physicians rarely see the patient at the time palpitations are occurring, a major goal of the examination is to look for any evidence to suggest structural heart disease or evidence of a systemic disease.

Palpitations can be a symptom of serious illness or can mean only that the patient is more aware of his or her heartbeat. In one study where the authors went to great lengths to achieve a diagnosis, no specific cause for palpitations could be identified in 16% of patients.

Question 2

Highlights of ACC/AHA Recommendations (2013)

Answer 2

Increased evidence-based rigor.

Atherosclerotic cardiovascular disease (both stroke and myocardial infarction) targeted for prevention.

Low density lipoprotein cholesterol (LDL-c) goals no longer recommended as treatment targets.

Only one pharmacologic agent recommended for lowering cholesterol: HMG Co-A Reductase Inhibitors (statins).

Question 3

Atypical Angina in Women

Answer 3

1. The association between exercise and angina is well established in the literature. (According to one study, chest pain precipitated by exercise has a positive likelihood ratio of 4.7 for acute coronary syndrome (ACS).)
2. There are no clinical trials linking palpitations during exercise to CHD. But, there is anecdotal mention of palpitations precipitated by exercise being due to CHD. Furthermore, the presentation of women with palpitations has been suggested to be a non-chest pain symptom of CHD.
3. Retrospective studies have shown clinically important differences between women and men in the presentation of CHD. Angina reported by women is much more likely to be atypical .

Some characteristics of chest pain history are more likely to be associated with acute coronary syndrome (ACS) or ischemic cardiac pain than others. These symptoms include chest pain that radiates to one or both shoulders or arms and pain that is precipitated by exertion. Heberden originally describes typical chest pain or ischemic chest pain in 1768. He described “a painful sensation in the breast accompanied by a strangling sensation, anxiety, and occasional radiation of pain to the left arm.”

Atypical chest pain is less easily characterized and has been described as any symptom of angina that is not considered typical. There is no standard definition. There are, however, pain characteristics that decrease the likelihood of ACS.

Question 4

4 “P’s”: Pain Characteristics That Decrease the Likelihood of ACS

Answer 4

1. Pleuritic – worsened by respiration and may be exacerbated when lying down. Causes of pleuritic chest pain include pulmonary embolism, pneumothorax, viral or idiopathic pleurisy, pneumonia, and pleuropericarditis.
2. Pulsating.
3. Positional – could be pericarditis, which typically improves with sitting up and leaning forward; pleuritic
   chest pain, which may be exacerbated when lying down; or musculoskeletal pain, which body position or
   movement may exacerbate.
4. Reproduced by Palpation – musculoskeletal pain.

Another characteristic that speaks against pain of CHD is stabbing pain, but it is not a “P”!

Pressure-like pain is only associated with positive likelihood ratios of 1 to 2 and is less helpful.

Question 5

Coronary Heart Disease in Women

Answer 5

In a landmark article on women and prodromal symptoms of myocardial infarction, McSweeny and colleagues noted that 95% of women reported prodromal symptoms, but only 29.7% reported chest discomfort.

Prodromal symptoms of ACS in women may include:
fatigue
dyspnea
neck and jaw pain 
palpitations
cough
nausea and vomiting 
indigestion
back pain
dizziness
numbness

These symptoms are reported less frequently by men prior to myocardial infarction

Although CHD deaths in the US have declined in men , the number of deaths due to CHD in women has increased. Although men are still diagnosed more often with CHD, the proportion of women presenting with clinically and angiographically significant disease has increased over the last 20 years.

Women are less aggressively treated than men and have worse outcomes. The fact that women are usually older at presentation than men and that women tend to wait longer before seeking treatment may be part of the reason. Women are also less likely to participate in cardiac rehabilitation. Unfortunately, one study showed that in ambulatory care setting, women were less likely to be treated with a beta-blocker, aspirin or a statin even after having a heart attack. Effective early diagnostic strategies for diagnosing CHD earlier in women are critical, as 40 percent of initial cardiac events in women are fatal.

Question 6

Stress

Answer 6

The American psychologist Erik Erikson identified seven physical, emotional and psychological stages of human development; whereas family development theory focuses on the systematic and patterned changes experienced by families as they move through their life course.

Acute stress affects the cardiovascular, nervous and endocrine systems. When stress is prolonged, physiologic coping strategies can have a negative impact. Chronic stress has been linked to increased risk of CHD and adverse cardiac events. In addition, people who are stressed often don’t take good care of themselves.

Question 7

Importance of Educating Women About CHD Risk Factors

Answer 7

Educating patients regarding risk factors is extremely important given the prevalence of risk factors in women.

The Nurses Health Study, which examined over 84,000 women without CHD or diabetes, found only 3% of women at low risk. (Low risk was defined as having the following characteristics: not currently smoking, had a BMI of less than 25, consumed an average of one-half drink of alcohol per day, engaged in moderate to vigorous physical activity for at least 30 minutes a day, scored highest in the cohort for consumption of cereal fiber.)

In one study, only one third of women interviewed could identify specific risk factors for heart disease. Seventy percent of women said their physician had never discussed CHD with them.

Question 8

Aspirin for Primary Prevention of CHD

Answer 8

The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10 percengt or greater 10-year CVD risk; are not at increased risk for bleeding; have a life expectancy of at least 10 years; and are willing to take low- dose aspirin daily for at least 10 years.

Question 9

Exercise and Dietary Recommendations for Cardiovascular Health

Answer 9

24-Hour Dietary Recall
Quick nutritional assessment. Ask the patient to recount what she ate, while asking clarifying questions regarding spreads, condiments, beverages, and snacks.

Question 10

Cardiovascular

Answer 10

Check blood pressure, heart rate, and heart rhythm.

Assess central venous pulsations in the neck. Visible neck pulsations would increase your concern for an arrhythmic cause of the palpitations.

Listen for murmurs.

1. A midsystolic click with a holosystolic murmur would suggest mitral valve prolapse, the most common structural heart abnormality presenting with palpitations.
2. A systolic murmur at the left sternal border that increases with Valsalva maneuver would suggest hypertrophic obstructive cardiomyopathy that may be associated with atrial fibrillation as a cause of palpitations.
3. A harsh crescendo-decrescendo that radiates into the carotid arteries would suggest aortic stenosis that can cause palpitations and dizziness.

Question 11

Pulmonary

Answer 11

Crackles would suggest congestive heart failure that can occur with rapid atrial fibrillation and other dysrhythmias.

However, if CHF were present, you would expect dyspnea, orthopnea, and possibly ankle edema to be part of the patient’s history.

Question 12

Endocrine

Answer 12

Examine thyroid gland for enlargement or mass.

Question 13

Hematologic

Answer 13

Look for pallor in conjunctiva and hands. Pallor would suggest severe anemia.

Question 14

Musculoskeletal

Answer 14

Palpate the chest wall for tenderness. If present, this might suggest a musculoskeletal cause for the patient’s chest discomfort.

Question 15

Skin

Answer 15

Check for evidence of sweating. Diaphoresis can be associated with vasomotor symptoms of menopause, anxiety, and hyperthyroidism.

Check for hair loss that might occur with hyperthyroidism.

Question 16

Psychiatric

Answer 16

Note any mannerisms that would suggest anxiety such as: fidgeting, hand wringing, difficulty making eye contact, worried facies.

Question 17

Evaluation of Palpitations

Answer 17

Electrocardiogram, if readily available, may show unanticipated information such as a conduction abnormality. But, the electrocardiogram is unlikely to identify dysrhythmia, if this is the cause of symptoms, unless the patient is experiencing palpitations at the time the EKG is done.

In order to increase the chances of capturing a dysrhythmia, the Holter monitor is a portable electrocardiograph machine that allows readings to be made over a 24 to 48-hour period, while the patient is performing the usual activities of daily living at home or at work.

Loop recorders increase the diagnostic yield with regard to detecting dysrhythmias in patients with palpitations and may be more cost effective. These recorders can monitor heart activity for weeks to months, while the patient goes about her regular daily activities. A permanent record is kept only when the patient activates the recorder during periods when symptoms are felt.

An echocardiogram could be considered to rule out valvular and other structural defects.

Complete blood count (CBC) to answer the question of anemia and a TSH would help rule out hyperthyroidism.

Depending on the patient, a urine drug screen may be indicated. Have a low threshold for ordering this test.

Question 18

Deciding When to Order an Exercise Stress Test

Answer 18

The value of a test is based on the pre-test probability of detecting disease. In other words, doing an exercise stress test (EST) on a population with more disease will increase the probability that a positive test is predictive of disease.

The American College of Cardiology/American Heart Association (ACC/AHA) provides some practice guidelines for exercise testing based on the level of risk utilizing symptoms, age, and sex. Please link here for the Pretest Probability of CAD by Age and Symptoms Among Women.

In a study of almost 400,000 both men and women without known cardiac disease, it was determined that a positive stress test added little over using a model including clinical risk factors (FRS) and symptoms in predicting obstructive cardiac disease.

Question 19

Dysrhythmias

Answer 19

Frequently cause palpitations, though many patients with dysrhythmias may not report palpitations

Question 20

Valvular heart disease

Answer 20

Can cause palpitations. Examples: aortic insufficiency or stenosis, mitral valve prolapse, atrial or ventricular septal defects, and congenital heart disease

Question 21

Hyperthyroidism

Answer 21

Can cause sinus tachycardia, atrial fibrillation, and other kinds of supraventricular tachycardias - all of which can cause palpitations

(Hypothyroidism can cause bradycardia but would not present with palpitations)

Question 22

Coronary heart disease (CHD)

Answer 22

Palpitations may be included in an atypical presentation of CHD

Historical items can suggest a cardiac cause of palpitation:

1. Duration of palpitations greater than five minutes
2. Description of an irregular beat (for example, the patient can tap it out with their fingers)
3. Previous history of heart disease
4. Male sex

History of palpitations affecting sleep or during work would increase the likelihood that an arrhythmia is the cause of palpitations

Question 23

Anxiety / panic disorder

Answer 23

Frequent cause of palpitations
In a prospective cohort study of 190 patients at a university medical center who complained of palpitations:
1. 31% had palpitations caused by anxiety or panic disorder
2. 43% percent had palpitations due to cardiac causes (40% dysrhythmias and 3% other cardiac causes)
3. 6% due to prescription or recreational use

Question 24

Vasomotor symptoms of the climacteric (menopause)

Answer 24

May cause palpitations in peri-menopausal women

Associated with heat intolerance and sweating during a hot flash

Question 25

Anemia

Answer 25

Particularly if it is acute and associated with tachycardia may present in this fashion

Question 26

Drugs

Answer 26

Including caffeine, alcohol, tobacco, street drugs such as cocaine as well as numerous prescription drugs used to treat the cardiovascular system

Sympathomimetics, vasodilators, anticholinergic drugs or withdrawal from beta blockers can cause palpitations

Question 27

Main Causes of Palpitations

Answer 27

1. Cardiac arrhythmias
2. Structural heart disease
3. Psychosomatic disorders
4. Systemic causes
5. Effects of medical or recreational drugs

Question 28

Differential for a 50-Year-Old Woman with Palpitations

Answer 28

Dysrhythmia, valvular heart disease, coronary artery disease, vasomotor symptoms of menopause, and anxiety/panic disorder are all diagnoses that should be considered based on the history.
»A normal physical examination and EKG do not rule out either coronary artery disease or dysrhythmia, especially when symptoms are not present at the time of presentation. Exercise treadmill testing would be likely to identify CHD and two week loop monitoring would be likely to capture any dysrhythmias.
»The absence of a heart murmur makes valvular heart disease less likely although in rare cases serious structural cardiac abnormalities can be present without murmurs or with very subtle murmurs. An echocardiogram could identify any structural heart abnormalities.