Palpitations Flashcards
what are palpitations
awareness of heart beating in your chest
palpitations can be normal
yes
describe your approach to the patient with ‘palpitations’
take a history and perform a full examination
history taking for palpitations
- what is it like
- tap it out
- how long have you had it
- how long does it last
- how does it start or stop
- associated symptoms
- ask about past cardiac history - symptoms and interventions
- DH
- S/E - endocrine, GI, GU
what is the commonest heart rhythm disturbance
ectopic beats
/ extrasystoles
(most common cause of palpitations)
how would patients classically describe ectopics
skip / stop / miss in heartbeat
followed by thump / forceful beat
what is the SAN
the heart’s pacemaker
normal PR interval
0.12-0.20s
120-200ms
3-5 small squares
bundle of His splits into?
left and right bundle
left bundle branch splits into?
left anterior and posterior fascicles
why do you get narrow QRS
fast electrical conduction
narrow is normal
yes
normal QRS complex duration
<120ms
wide might be worrying…
…because it might be coming from the Wentricle
ventricular ectopic may be so weak that..
you cant feel the pulse or patient might not be able to feel the extra beat
compensatory pause
compensatory pause
after an ectopic to get back on track
what is the first beat after an ectopic going to feel like
very strong ie the ‘thump’ because of the compensatory pause
narrow complex ectopic?
atrial ectopic beat
has the same effect as a ventricular ectopic beat
diagnosis
awareness of ectopic beat
p wave followed by ‘wide M shaped’ QRS
right bundle branch block
aberrant conduction
right bundle goes to sleep leading to BBB
rhythm you can spot coming from the top of the heart but conduction gets stuck/slow
regular broad complex tachycardia..
ventricular tachycardia
what can you ask the patient to do to describe the rhythm
tap out the rhythm
define tachycardia + bradycardia in bpm
> 100bpm
<60bpm
profound bradycardia
<40bpm
irregularly irregular
AF
some people can be aware of normal sinus rhythm, true or false
true
tachycardia
150bpm
D.Dx
atrial flutter
sinus tachycardia
VT
SVT - Atrial tachycardia, AVNRT
in the AVN, the fast pathway is slower to recover than the slower pathway
yes
remember the rowboat
what could cause a AVNRT
ectopic
it finds the faster pathway has not recovered and the slow pathway has
therefore forms reentrant electrical circuit and fires off atria back to front resulting in an inverted p wave after the QRS ‘retrograde’ p wave
atrial flutter
reentrant electrical circuit set up in the right atrium
organised = regular rhythm
atrial fibrillation
chaotic atrial activity
what is the rate of atrial flutter
300bpm
atrial rate of AF
300-600bpm
maximum target heart rate calculations
220 - age
what is the ventricular rate of atrial flutter
150bpm
2:1 conduction, 3:1, 4:1…
300:150
will always be regular
4 things to ask for /adverse features in a patient with a fast heart rate
heart failure
ischaemia
syncope
BP <90
vagal maneouvres
carotid sinus massage
valsalva
cold icy water
what is the valsalva
deep breath in
shut mouth and nose
breath against this for 5 sec
and release violently
20ml syringe
blow the plunger out
alternative valsalva
valsalva breaks the AVNRT circuit
period where nothing happens then restoration of normal sinus rhythm
what do you do if vagal maneouvres dont work
IV adenosine
have to warn the patient of impending doom sensation
fleeting
ectopic
triggers of palpitations
anxiety - difficult to tease out caffeine alcohol IVDU prescribed drugs
relieving factors
rest deep breath squat down vomiting all sound vagal
associated symptoms with palpitations
cardiac syncope - LOC
near syncope
chest pain
what is cardiac syncope
palpitations and pass out
no pro or post drome
wake up like what happened
endocrine causes of palpitations
hyperthyroidism
menopause
GI / GU causes of palpitations
pregnancy - 2nd trimester
anaemia
what two conditions make palpitations more likely
anaemia
hyperthyroidism
loss of nail bed angle, increased pulp density, increased nail bed fluctuation and increased curvature of the nails
finger clubbing
what might you look for in the hands in a CVS examination
pallor sweating koilonychia leukonychia finger clubbing erythema cyanosis splinter haemorrhages rheumatoid hand
cause of palmar erythema
too much oestrogen in the blood liver cirrhosis - cant break down oestrogen oestrogen producing breast tumour pregnancy contraception
features of examining pulse
rate rhythm character volume R and L radial delay
cause of regularly irregular pulse
Mobitz type 1 heart block aka Wenkebach’s
trigemy
cause of irregularly irregular pulse
atrial fibrillation
completely unpredictable pulse in rhythm and volume
causes of a thready weak pulse
hypovolaemia
shock
causes of a bounding pulse
vasodilatation
CO2 retention
conditions causing obstruction to ventricle pumping blood
aortic stenosis
describe the pulse in aortic stenosis
slow rising low volume pulse
‘plateau pulse’
describe the BP in aortic stenosis
narrow pulse pressure e.g. 90/70
DBP in aortic regurgitation
low
pulse pressure in aortic regurgitation
large pulse pressure
because blood falls back into ventricle
describe the pulse in aortic regurgitation
collapsing pulse
how do you test for a collapsing pulse
press with the MCP heads of your hand then raise the patients arm perpendicular
should feel a whoosh and then tapping
what is a useful clue when assessing pulse
pulse pressure - check BP
cause of asynchronous radial pulse
coarctation of the aorta
investigations for palpitations
FBC - anaemia U+E - electrolyte abnormalities TFT - hyperthyroidism 12 lead ECG if normal, 24/48hr/7day ECG tracing/holter/ambulatory Loop recorder implantable loop recorder exercise tolerance test
ECG potential findings in palpitations
ectopics
AF
WPW
what is a loop recorder
record when patient feels symptomatic
done for weekly/fortnightly symptoms
what is a PVC
premature ventricular complex / ventricular ectopic / ventricular extrasystoles / ventricular premature beats
ECG features of a PVC
broad QRS complex with abnormal morphology
premature
discordant ST segment and T wave changes
usually followed by a compensatory pause
+- retrograde capture of the atria (p wave inversion)
what is bigemy
every other beat is a PVC/ectopic
what is trigemy
every 3rd beat is a PVC/ectopic
what is quadrigeminy
every 4th beat is a PVC/ectopic
https://litfl.com/premature-ventricular-complex-pvc-ecg-library/
useful link
frequent PVCs may cause palpitations, true or false
true
causes of symptomatic / frequent PVC
anxiety sympathomimetics B agonists excess caffeine hypokalaemia hypomagnesaemia digoxin toxicity MI
