Palpitation Flashcards
Arrhythmia
A heart rhythm that results from abnormal or
disorganized cardiac conduction
Supraventricular tachycardia (SVT)
An arrhythmia originating in
the atria or the atrioventricular node
Ventricular tachycardia (VT)
An arrhythmia originating from the
ventricles, usually denoting serious cardiac pathology
Syncope
Transient loss of consciousness with spontaneous
recovery
Causes of Palpitation
- Rhythm Disorders:
Extrasystoles.
Tachycardia.
Bradycardia.
Heart block.
Pacemaker Malfunction.
- Structural heart diseases:
Aortic/ Mitral disease.
Mitral valve prolapse.
Congenital shunt.
Heart failure.
Cardiomyopathy
- Systemic Conditions:
Thyrotoxicosis.
Pyrexia.
Hypoglycemia.
Anaemia.
Pregnancy.
Hypotension.
Hypovolemia.
AV fistula.
Postmenopausal.
Pheochromocytoma.
- Drugs:
Sympathomimetic drugs.
Inhalers.
Vasodilators.
B-Blocker withdrawal.
Caffeine.
Alcohol.
Cocaine.
Nicotine.
Weight loss drugs.
- Psychosomatic Causes:
Anxiety.
Panic Attack.
Depression.
History
First, confirm that what the patient is experiencing are indeed palpitations.
Next, the history of the presenting complaint should be taken including a
systematic description of the episodes from start to finish.
Precipitating factors.
o What was the patient doing when the episode came on? (e.g. exercising,
drinking alcohol or coffee, taking medical or other drugs, experiencing
emotional or physical stress, was the patient standing or sitting?).
Red flags
- Palpitations associated with syncope or presyncope.
- A family history of sudden cardiac death or known
arrhythmia. - Use of any medications known to prolong the QT interval,
such as methadone, antiarrhythmic agents, or antipsychotics. - A personal history of heart disease, including coronary artery
disease, congenital or valvular heart disease, hypertrophic
cardiomyopathy, or dilated cardiomyopathy.
Examination
The examination follows standard procedures: Observe, inspect,
palpate and auscultate.
Thorough cardiovascular exam, checking for signs of disease
(hypertension, murmur, oedema, etc.) and also to examine for other
systemic diseases.
If a patient does experience palpitations during a consultation, the rate
and rhythm of the pulse should be examined, followed by an
assessment of the patient’s cardiovascular state during the episode.
ALARM signs
- Reduced consciousness level.
- Chest pain.
- Systolic BP <90 mmHg.
- Heart failure.
Investigations
Electrocardiography (if symptoms present at time of recording).
Exercise testing (if exertion typically precipitates the sense of
palpitation or if underlying CAD is suspected).
Echocardiography (if structural heart disease is suspected).
If symptoms are episodic, ambulatory electrocardiographic
monitoring can be diagnostic, including use of a Holter monitor (24–
48 h of monitoring), event/loop monitor (for 2–4 weeks), or
implantable loop monitor (for 1–2 years).
Helpful laboratory studies may include testing for hypokalemia,
hypomagnesemia, and/or hyperthyroidism.
Treatment
o Benign arrhythmia with no underlying heart disease: Reassure the patient and
arrange follow up.
o Anxiety: Reassure the patient, discuss stress reduction and refer for psychiatric
assessment/treatment if required.
o Caffeine, alcohol, drugs: Reassure the patient, encourage cessation of use of the
responsible substance. Refer for specialist care if necessary.
o Systemic conditions: Treat the systemic condition where possible.
o Structural abnormalities: Assess the patient’s clinical picture. If appropriate,
surgery can be offered to repair abnormalities.
o Arrhythmias: Anti-arrhythmic drugs, implantable cardiac defibrillators, and
endocardial or surgical ablations could be considered.
Causes of Syncope
o Cardiac causes include vascular disease, cardiomyopathy,
arrhythmias, or valvular dysfunction.
o Noncardiac causes include vasovagal response to pain,
dehydration with orthostasis, situational syncope,and
autonomic dysfunction.
Syncope and seizure
Occur with warning only on sitting or
standing
Sudden onset at any position.
Convulsion after loss of consciousness.
Convulsion occur at the onset of
loss of consciousness.
Short duration usually < 15 seconds
Longer duration.
Rapid recovery
Post-ictal confusion.
Ongoing lethargy but no confusion
Tongue bite & incontinence.
Past medical history
complete list of medications, whether they are prescription drugs,
over-the-counter medications, street drugs, vitamins, and/or health
supplements.
the usual inquiry relating to disease states such as hypertension,
coronary artery disease, diabetes mellitus, prior stroke, deep vein
thrombosis, and anemia should be made.
If the patient is a woman of childbearing age, the possibility of
pregnancy should be determined.
It is important to specifically inquire about a family history of
sudden death, heart disease, and diabetes mellitus, especially in first-
degree relatives
Physical examination
A complete physical examination is always
necessary when a patient presents with syncope.
Vital signs including mental status should be
obtained.
Syncope as a presenting complaint always
necessitates a head to toe examination; specifically
looking for previous or present trauma, cardiac,
pulmonary, abdominal, and/or neurologic
abnormalities.
Rectal examination should be performed along
with a test for occult blood.
