Palpitations

1. Palpitations

2. Overview / Goals • Define • Statistics / Epidemiology • History • Exam • Differential Dx • Tests • Put It All Together • Sample Cases

3. Definition sensations of a rapid or irregular heartbeat

4. Differential Diagnosis of Palpitations Arrhythmias Psychiatric causes Drugs and medications Nonarrhythmic cardiac causes Extracardiac causes

5. Differential Diagnosis of Palpitations/ Drugs and medications Alcohol, Caffeine beta agonists, phenothiazine,theophylline, isotretinoin, digoxin Cocaine Tobacco

6. Dietary Supplement Causing Palpitation Chocolate Ephedra/Diet pills Ginseng Bitter Orange Valerian Hawthorn

8. Differential Diagnosis of Palpitations/ Arrhythmias Atrial fibrillation/flutter Bradycardia caused by advanced AV block or sinus node dysfunction Bradycardia-tachycardia syndrome(sick sinus syndrome) Multifocal atrial tachycardia Premature supraventricularor ventricular contractions Sinus tachycardia Supraventricular tachycardia Ventricular tachycardia Wolff-Parkinson-White syndrome

9. Differential Diagnosis of Palpitations/ Nonarrhythmic cardiac causes Atrial or ventricular septal defect Cardiomyopathy Congenital heart disease Congestive heart failure Mitral valve prolapse Pacemaker-mediated tachycardia Pericarditis Valvular disease (e.g., aortic insufficiency,stenosis)

10. Differential Diagnosis of Palpitations /Extracardiac causes Anemia, Electrolyte imbalance Fever Hyperthyroidism Hypoglycemia Hypovolemia Pheochromocytoma Vasovagal syndrome

11. History/PE of Palpitation Description : Fluttering,pounding, or uncomfortable sensation in thechest or neck, or simply an increased awarenessof the heartbeat Knowing the circumstances,precipitating factors, and associated symptoms

12. Exam • General Appearance? • Vitals: Pulse, BP, febrile or afebrile?, tachypneic? • Neck: JVP?, bruits?, carotid exam?, thyroid palpable and normal? • Pulmonary: Clear, rales or wheezing? • Cardiovascular: Apical pulse – regular, irregular, mostly regular with some ectopy?, normal heart sounds?, murmurs?, gallups?, rub?, PMI location? • Abdomen: Masses?, bruits? • Extremities: Edema – pitting or nonpitting? • …

13. Differential Diagnoses • Arrhythmia (tachy / brady / SV / ventricular) • Heart Blocks (higher grade) • PVC’s / PAC’s • Sinus Tachycardia • Valvular Disease (usually arrythmias) • Structural Heart Disease (Ex.) HCM) • Anxiety • Depression • Hypoglycemia • Thyrotixicosis • Fever • Illicit Drugs • Prescribed Medications • Pheochromocytoma • …

14. Diagnostic Implications • Overall: -84% of cases received a diagnosis 43% - Cardiac 31% - Psychiatric 10% - “Other” (Medications, drugs, etc…) -16%  No diagnosis found • ER or ambulatory setting? (differences p < 0.002)

15. ECG EVALUATION All patients who complain of palpitations ECG findingswarrant further cardiac investigation ; evidence of previous myocardialinfarction, left or right ventricularhypertrophy, atrial enlargement, AV block, short PR interval and deltawaves (Wolff-Parkinson-White syndrome), prolonged QT interval

16. ECG EVALUATION ECG exercise testing isappropriate in patientswho have palpitationswith physical exertion andpatients with suspectedcoronary artery disease ormyocardial ischemia.

17. Further Diagnostic Testing CONTINUOUS ECG MONITORS (Holter monitor) - continuously torecord data for 24 or 48 hours - diary of any symptoms thatoccur during the monitoring - most expensive - maintained andoperated by hospitals or larger outpatient clinics TRANSTELEPHONIC EVENT MONITORS - save data only for theprevious and subsequent few minutes whenthe patient manually activates the monitor

18. Holter monitor VS Event monitor

19. Choosing an AmbulatoryMonitoring Device Diagnostic yield was 66 to83 percent when event monitors were usedfor monitoring, and 33 to 35 percent whenHolter monitors were used Event monitors more cost effective 83 to 87percent of patients had diagnostic transmissionswithin the first two weeks of using atranstelephonic event monitor

20. When to use Holter to event monitoring in patients whoreliably experience palpitations every day who are not willing to wear an event monitorfor two weeks if event monitoring is not available locally

21. What if ? palpitations aresustained poorly tolerated Referal cardiologist for an electrophysiologic evaluation

22. Management If the evaluation of theheart is otherwise normal, ventricular premature contractions or brief episodes of ventricular tachycardia arenot associated with increased mortality Appropriate patient education Sustainedarrhythmias ;pharmacologicor invasive electrophysiologic study Treat underlying for the noncardiac,psychiatric, or nonarrhythmia cardiacetiology

23. Management If fail to reveal any abnormalityor etiology for palpitations -advised to abstain from caffeineand alcohol, as well as foods or stressfulsituations that appear to trigger palpitations the majority of patients withpalpitations have benign diagnoses and canbe treated with reassurance

24. What about children? Thinking Child

25. Approach to the child with palpitation Typically arises from physiologic mechanisms, such as fever, exercise, anxiety, or anemia, rather than true life threatening causes (eg. Cardiac arrythmia)

26. Approach to the child with palpitation/History From true tachyarrhythmias often start and stop abruptly “Butterfly in the chest” “My heart is beating so fast that it will come out of the chest” Rushing or pounding in the ears, esp. when the pt is supine Heart “flip-flop” or “stops”

27. Summary Get a good history and physical exam Get an EKG Think about heart Think about other than the heart( diet, medication, other medical condition to contribute) Holter or Event monitor for further evaluation Treat heart or underlying issuses

28. Tests / Procedures • Carotid Massage • Valsalva • DA Method • EKG • Fingerstick • Echo • Basic chemistries • Thyroid functions • Urine metanephrines • Holter monitor (most common test after EKG) -Only 24 hrs.  best for daily symptoms • Loop recorder / Event monitor • Stress testing • Patient education (pulse) • ?Psychiatry referral