Palpitations Flashcards
Probability diagnosis
Anxiety
Premature beats (ectopics)—atrial and ventricular
Sinus tachycardia, e.g. fever, exercise
Supraventricular tachycardia
Drugs (e.g. stimulants)
Serious disorders not to be missed
Myocardial infarction/angina
Arrhythmias:
- atrial fibrillation or flutter
- ventricular tachycardia
- bradycardia/heart block
- sick sinus syndrome
- torsade de pointes
Long QT syndrome
Wolff–Parkinson–White (WPW) syndrome
Electrolyte disturbances:
- hypokalaemia
- hypomagnesaemia
- hypoglycaemia (type 1 diabetes)
Pitfalls (often missed)
- Fever/infection
- Pregnancy
- Menopause
- Drugs (e.g. caffeine, cocaine)
- Mitral valve disease
- Aortic incompetence
- Hypoxia/hypercapnia
Rarities:
- tick bites (T1–5)
- phaeochromocytoma
Masquerades checklist
Depression
Diabetes (indirect)
Drugs (see list)
Anaemia
Thyroid disorder, hyperthyroidism
Spinal dysfunction
Is the patient trying to tell me something?
Quite likely. Consider cardiac neurosis, anxiety.
Key history
Ask pt to describe the onset and offset of the palpitations, the duration of each episode and any associated features.
Then ask them to tap out on the desk the rhythm and rate of the heartbeat experienced during the ‘attack’.
If pt is unable to do this, tap out the cadence of the various arrhythmias to find a matching beat.
An irregular tapping ‘all over the place’ suggests AF
While an isolated thump or jump followed by a definite pause on a background of a regular pattern indicates premature beats (ectopics), usually ventricular.
Take PMHx and FHx including;
- caffeine intake
- smoking
- alcohol
- social drugs such as marijuana or cocaine
Prescribed drugs;
- β blockers
- antipsychotics
- antidepressants
- thyroxine
- digoxin
- nifedipine
- sympathomimetic
Key examination
The ideal time to exam is during the palpitations.
If not, the examination is usually normal
Assess the pulse rate, rhythm, volume and character
Check for anaemia, anxiety, tremors, dyspnoea and thyroid disease
Look for evidence of mitral valve prolapse
Key investigations
- FBE
- TFTs
- serum glucose
- urea, electrolytes and magnesium
- cardiac enzymes
ECG
Echo
Holter monitoring
Diagnostic tips
A relatively non-specific symptom.
Consider hyperthyroidism as a cause of AF or sinus tachycardia even if the clinical manifestations are not apparent.
Arrhythmia of sudden onset suggests;
- paroxysmal SVT
- atrial flutter/fibrillation
- ventricular tachycardia
Common triggers for premature beats and PVST are;
- smoking
- anxiety
- excessive caffeine
