Case 9: 50 yo F with Palpitations

Question 1

Assessing CV disease risk factors

Answer 1

• assess ASCVD risk factors (age, gender, HTN, SBP, total and HDL cholesterol, diabetes smoking status) every 4 to 6 years in adults 20 to 79 yrs old
• estimate 10 yr ASCVD risk every 4 to 6 years in adults 40 to 79 yrs old in pts without ASCVD

Question 2

Pts requiring statin (4)

Answer 2

• Individuals with clinical ASCVD (MI or unstable angina), stroke or TIA, peripheral vascular disease
• 40 to 75 with diabetes
• > 21 + LDL 190
• 40 to 75 with ASCVD 10 yr risk > 7.5%

Question 3

5 Ps that decrease likelihood of ASC

Answer 3

• pleuritic chest pain (more likely PNX, PE, PNA, pleurisy, pleuropericarditis)
• reproducible with palpation on exam (MSK)
• pulsating
• positional (more likely pericarditis, pleuritic, or MSK)
• stabbing PAIN

Question 4

Chest pain that is precipitated by exercise…

Answer 4

has a positive likelihood of 4.7 for ACS (association b/w exercise and angina is well established)

Question 5

Women with angina

Answer 5

Have an atypical presentation, can present with palpitations rather than classic chest pain that radiates to the left arm/jaw

Question 6

95% of women with acute coronary syndrome report prodromal symptoms (whereas 30% report chest pain). These prodromal Sx include…

Note: these symptoms are reported less frequently by men prior to MI

Answer 6

fatigue
dyspnea
neck/jaw pain
palpitations
cough
N/V
indigestion
back pain
dizziness
numbness

Question 7

_______ _______ has been linked to increased risk of CHD and adverse cardiac events

Answer 7

Chronic stress

Question 8

Chest discomfort/angina history (PQRST)

Answer 8

Provoking factors: cold, emotional stress, meals, sex
Quality: squeezing, tightness, pressure (elephant sitting on chest)
Radiation: to neck, jaw, arm, CL arm
Assoc symptoms: sweating, SOB, nausea

Question 9

Valvular abnormalities associated with palpitations

Answer 9

1. Aortic insufficiency
2. Aortic stenosis
3. Mitral valve prolapse
4. ASD
5. VSD
6. HCOM

Question 10

Midsystolic click with crescendo decrescendo murmur

Answer 10

Mitral valve prolapse (most common structural heart abnormality presenting with palpitations)

Question 11

Harsh holosystolic murmur at left sternal border that increases with Valsalva

Answer 11

Hypertrophic obstructive cardiomyopathy that leads to atrial fibrillation causing palpitations

Question 12

Harsh holosystolic murmur that radiates to carotid

Answer 12

Aortic stenosis –> palpitations, dizziness

Question 13

Anything that predisposes to afib can precipitate palpitations. Examples include

Answer 13

HCOM
Mitral regurg
CHF

Question 14

What can relieve palpitation symptoms before initiating drug therapy?

Answer 14

Attitudinal and behavioral change

Question 15

DDx for palpitations in 50 year old woman (8)

Answer 15

1. Cardiac arrhythmias (affect sleep, at work)
2. Structural heart disease
3. Coronary artery disease
4. Vasomotor symptoms of menopause
5. Anxiety/panic disorder
6. Hyperthyroidism
7. Anemia
8. Drugs

Question 16

Hyperthyroidism can cause

Answer 16

palpitations via sinus tachy, afib, other supraventricular tachycardias

Question 17

suspect palpitations pointing to coronary artery disease if…

Answer 17

• duration of palpitations is > 5 min
• description of an irregular beat that pt can tap out with their fingers
• previous Hx of heart disease

Question 18

vasomotor symptoms of climacteric (menopause) cause palpitations and associated with

Answer 18

heat tolerance and swelling during a hot flash

Question 19

Drugs

Answer 19

• caffeine, alcohol, tobacco
• cocaine
• sympathomimetics
• vasodilators
• anticholinergic drugs
• withdrawal from beta blockers

Question 20

Does a normal EKG and physical exam rule out CAD or dysrhythmia as cause of palpitations?

Answer 20

No!
Exercise treadmill testing will identify CAD
Loop monitoring will catch dysrhythmia

Question 21

Methods to evaluate palpitations (6)

Answer 21

1. EKG (helpful if pt is presently experiencing palps)
2. Holter monitor: detect dysrhythmia (24-48 hrs)
3. Loop recorders: detect dysrhythmia (over weeks)
4. Echo (valvular etiologies)
5. CBC (anemia)
6. TSH
   +/- urine drug screen
   +/- stress test (can use clinical risk factors and symptoms to predict CAD instead)

Question 22

USPSTF aspirin recommendations

Answer 22

• aspirin in men 45 to 79 (reduce risk of MI) and women in 55 to 79 (reduce risk of ischemic stroke)
• in both groups, benefits must outweigh increased threat of GI hemorrhage

Question 23

European Guidelines on CV disease prevention in clinical practice aspirin recommendations

Answer 23

Aspirin CANNOT BE RECOMMENDED for primary prevention in individuals without overt cardiovascular or cerebrovascular disease due to increased risk of major bleeding