Palpitations Flashcards
non-cardiac risk factors associated with palpitations
exercise caffeine diet pills cocaine tobacco alcohol decongestant diuretics: electrolyte abnormalities digoxin B agonist theophylline phenothiazine stress anemia (+ fatigue, lighthedness, GI blood loss, menorrhagia) hyperthyroidism, hypothyroidism (+ both: fatigue, depression, menstrual irregularites) hypoglycemia hypovolemia fever pheochromocytoma (24 hr urine collection for catecholamines and metanephrines) pulmonary disease vasovagal syncope labs: CBC, BMP, TSH
structural cardiac causes of palpitations (dysrhythmias)
hypertrophic CM (AD): most common cause of sudden cardiac death in teens, +/- chest pain, syncope, systolic murmur accentuated by Valsalva maneuver, echo with thickened IV septum
MVP syndrome: midsystolic click +/- late systolic murmur (usually asymptomatic or + fatigue, chest discomfort, dyspnea, panic attacks, manic-depressive syndrome)
MR: progression of MVP, left heart enlargement, afib, LV dysfunction → heart failure, pulmonary HTN, infective endocarditis
ASD or VSD
congenital heart disease
pericarditis
aortic stenosis, aortic insufficiency
congestive heart failure
subjective sensation of strong, slow, rapid, or irregular heartbeats that may be related to cardiac arrhythmias
lasts sec, min, hrs, days
d/t change in heart’s electrical system
palpitations
etiology of palpitations
#1 primary arrhythmia 2 anxiety, panic d/o 3 unknown 4 meds 5 structural heart problem: valve, CM
tachycardia not originating from ventricle: narrow QRS
includes sinus tachycardia (gradual onset)
may be caused by stress, fever, hyperthyroidism
tx: B blocker (if short-lived episode, can use short-acting PRN) or CCB, digoxin to slow down rapid ventricular response to afib or aflutter
SVT
type of SVT with sudden onset and regular rhythm
feel heart rate go from 60-200 after quick movement (pick something off of floor)
most often a AV nodal reentrant tachycardia or WPW (may not be evident on resting EKG)
tx: vagal CN X stimulation techniques: carotid sinus massage, valsalva maneuver, cold applications to face (diver reflex)
if unsuccessful: IV adenosine (if works = reentry SVT, if doesn’t work → use B blocker or CCB)
paroxysmal SVT
accessory track between atria and ventricles that conducts impulses in addition to AV node
upstroke of QRS wave: delta wave
can lead to sudden cardiac death
WPW (type of paroxysmal SVT)
Asian male
R BBB, elevation at J point > 2mm, slowly descending ST segment with flat or negative T waves in precordial: V1-V3
can lead to sudden cardiac death
Brugada syndrome
SA node dysfunction
bradycardia type: bradycardia, fatigue, syncope
bradycardia-tachycardia type: SVT, palpitations, angina pectoris
sick sinus syndrome
AD most common in females palpitations and/or syncope family hx: syncope, sudden death risk for ventricular arrhythmias and sudden death
prolonged QT syndrome
QT >470 msec men, >480 msec female
meds that prolong QT
quinidine procainamide sotalol amiodarone TCA
benign rhythm disorders - don’t need to refer to cardiologist
premature atrial contractions
sinus tachycardia
sinus bradycardia appropriate for activity/stress level
sinus pauses less than 3 seconds
isolated PVC: occasional extra beat, if occur at rest and disappear with exercise (benign) vs in presence of cardiac sx or syncope or seizures (↑ risk vtack, vfib) - refer to cardio
childbearing age female
brief, overwhelming panic, impending doom
tachycardia, dyspnea, dizziness
still need formal workup since acts like primary rhythm disturbance
panic disorder
tall scoliosis pectus excavatum long, thin digits (arachnodactyly) high-arched palate arm span exceeding height MVP aortic root dilation → aortic arch aneurysm
marfan syndrome
if > 50 yo + palpitations think
CAD
if palpitation + syncope
usually pathologic, hospitalize
work up for palpitations
bp, HR, orthostatics
thyroid gland, resting tremor, brisk reflexes (hyper)
PMI (if enlarged then cardiomegaly), rate, rhythm, murmurs
EKG - even if currently asymptomatic: LVH, delta waves, atrial enlargement, AV block, old MI, prolonged QT
holter monitor: EKG rhythym monitoring for 24-72 hrs if daily palpitations
30 day cardiac event monitor: activated when patient feels palpitation if infrequent
echo: if think structural
TEE to r/o thrombus before cardioversion
exercise stress test: if think arrhythmia triggered by exercise and suspect CAD (symptomatic PVC), do echo before stress test to r/o structural issues, contraindications to stress test: suspected HCM, severe AS, or marfan
EP study: recreate rhythm disturbance and identify hyperactive foci and accessory tracts (like WPW)
tx of afib
rate control PREFERRED strategy (keep
acute tx of vfib
electrical defibrillation
acute tx of vtach
cardioversion if unstable (low bp, high HR, not confused)
IV amiodarone if stable and if just cardioverted
(lidocaine if allergic to amiodarone)
ventricular arrhythmias most often due to
ischemia
long-term tx of ventricular arrhythmias caused by dilated CM, long QT, HCM, Brugada
implanted cardioverter-defibrillator
