Approach To PALPITATION

Approach To PALPITATION

Palpitation is a perceived abnormality of the heartbeat characterized by awareness of heart muscle contractions in the chest: hard beats, fast beats, irregular beats, and/or pauses. They are both a symptom reported by the patient and a medical diagnosis. 

Palpitations should be considered as potentially more serious if they are associated with dizziness, near-syncope, or syncope.

History

1. Circumstances prior to the beginning of palpitations

• Activity (rest, sleeping, during sport or normal exercise, change in posture, after exercise)
• Position (supine or standing)
• Predisposing factors (emotional stress, exercise, squatting or bending)

2. Onset of palpitations

• Abrupt or slowly arising
• Preceded by other symptoms (chest pain, dyspnoea, vertigo, fatigue, etc.)

3. Episode of palpitations

• Type of palpitations (regular or not, rapid or not, permanent or not)
• Associated symptoms (chest pain, syncope or near syncope, sweating, pulmonary oedema, anxiety, nausea, vomiting, etc.)

4. End of the episode

• Abrupt or slowly decreasing, end or perpetuation of accompanying symptoms, duration, urination
• Spontaneously or with vagal manoeuvres or drug administration

5. Background

• Age at the first episode, number of previous episodes, frequency during the last year or month
• Previous cardiac disease
• Previous psychosomatic disorders
• Previous systemic diseases
• Previous thyroid dysfunction
• Family history of cardiac disease, tachycardia or sudden cardiac death
• Medications at the time of palpitations
• Drug abuse (alcohol and/or others)
• Electrolytes imbalance

Causes Of Palpitation 

1. Extra-cardiac stimulation of the sympathetic nervous system (inappropriate stimulation of the parasympathetic nervous system, particularly the vagus nerve (which innervates the heart), can be caused by anxiety and stress due to acute or chronic elevations in glucocorticoids and catecholamines. Gastrointestinal distress such as bloating or indigestion, along with muscular imbalances and poor posture, can also irritate the vagus nerve causing palpitations)
   
   
2. Sympathetic overdrive (panic disorders, low blood sugar, hypoxia, antihistamines (i.e. levocetirizine), low red blood cell count, heart failure, mitral valve prolapse).
   
   
3. Hyperdynamic circulation (valvular incompetence, thyrotoxicosis, hypercapnia, high body temperature, low red blood cell count, pregnancy).
   
   
4. Abnormal heart rhythms (ectopic beat, premature atrial contraction, junctional escape beat, premature ventricular contraction, atrial fibrillation, supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, heart block).

Etiologies Of Palpitation

1. Arrhythmias

• Atrial fibrillation/flutter
• Bradycardia caused by advanced arteriovenous
• block or sinus node dysfunction
• Bradycardia-tachycardia syndrome (sick sinus syndrome)
• Multifocal atrial tachycardia
• Premature supraventricular or ventricular contractions
• Sinus tachycardia or arrhythmia
• Supraventricular tachycardia
• Ventricular tachycardia
• Wolff-Parkinson-White syndrome

2. 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)

3. Extracardiac causes

• Anemia
• Electrolyte imbalance
• Fever
• Hyperthyroidism
• Hypoglycemia
• Hypovolemia
• Pheochromocytoma
• Pulmonary disease
• Vasovagal syndrome

4. Psychiatric causes

• Anxiety disorder
• Panic attacks
• Drugs and medications
• Alcohol
• Caffeine
• Certain prescription and over-the-counter agents (e.g., digitalis, phenothiazine, theophylline, beta agonists)
• Street drugs (e.g., cocaine)
• Tobacco

Diagnosis of palpitation 

Key Clinical Findings with Palpitations and Suggested Diagnoses

Management 

Treating palpitation will depend on the severity and cause of the condition , usually will be treated with one of three treatment options:

1. Preventive care (for non-severe palpitations) – Try eliminating smoking, excess caffeine, and alcohol from your daily regimen; practice general deep breathing and yoga; get plenty of sleep and exercise; regularly schedule “you” time
   
2. Medications –  Antiarrhythmic drugs such as beta blockers and calcium channel blockers, both of which have a safe track record. Occasionally these drugs don’t work effectively and stronger antiarrhythmic drugs that directly act on the sodium and potassium channels of the heart might be necessary.
   
3. Catheter ablation – Small wires are threaded through the leg veins into the heart to trigger an arrhythmia, identify the cause, and cauterize the problem area. This treatment is highly effective when the physician can identify an arrhythmia in a specific region of the heart (such as supraventricular tachycardia).

Source : www.aafp.org