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CHAPTER Practical Approach to the Patient with Palpitations

14 MS Aditya, K Sarat Chandra

Palpitations as a symptom is a common cause for To evaluate a particular patient it is important to known consultation in general, casualty and practice. the potential causes of palpitations. Possible aetiologies10-16 The term Palpitation has its roots in the Latin verbs have beenlisted in Figure 1. ‘palpare’, ‘palpitare’ meaning patted or touch gently. The diagnostic and therapeutic management of palpitations is CLINICAL EVALUATION OF PALPITATIONS often frustrating and confusing both to practitioner and As in any clinical situation a thorough history and patient. This is because of myriad causes of this symptom examination will help to arrive at an appropriate and poor reproducibility. From the management point of diagnosis. view causes could range from psychosomatic disorders to For the purpose of clinical clarity four types of life threatening .1-3 palpitations have been identified in practice. Though Palpitation has been defined as a disagreeable sensation no clear differentiation is possible four types have been 17-18 of pulsation or movement in the chest and/or adjacent identified Figure 2. areas. In resting conditions one does not usually perceive Extrasystolic palpitation are usually sudden in onset heartbeat. During intense physical or emotional stress it perceived as a skipped or jumped beat usually interspersed is quite normal to be aware of one’s own cardiac activity with normal periods. making them physiological. Outside of these situations palpitations are abnormal. Tachycardiac palpitations are perceived as rapid flapping movements over the chest could be irregular or regular Palipitations are a frequent clinical presentation and be associated with , and fatigue. accounting for upto 15-20% of general practice and second to in cardiology setups. Palpitations related palpitations are usually associated with originate from a variety of causes, cardiac related in slight increase in heart rates and associated with tingling approximately 43% of cases, psychosomatic in 30% and sensations in hands and feet, atypical chest pain etc. unknown/miscellaneous cause in 27%4-8. Arrhythmias Pulsation is a feeling felt after strong contraction of the cause palpitations often but significant number of patients heart following increased contractility or stroke volume. with arrhythmias don’t report palpitation as a symptom. There is every need to have a evidence based structured History should be focused and directed to achieve evaluation of patients presenting with palpitations to help reasonable success in arriving at possible diagnosis. us identify patients with more serious conditions. SITUATIONS LEADING TO PALPITATIONS Palpitations are perceived with still less understood • Functional state -sleep, during sport or normal sensory afferent pathways with receptors in myocardial, , change inposture, after exercise. pericardial or peripheral receptors. These stimuli are • Positional variation or trigger. transmitted to sub cortical areas and base of frontal lobes9. Receptors could be triggered for a variety of reasons as • Precipitating factors -emotion, exercise, squatting. listed in Table 1. • Onset of palpitations-Abrupt or slowly arising. Table 1: Triggers of Arrhythmias • Premonitory symptoms -Angina, dyspnea, vertigo, Variation in Arrhythmias (Tachy and Brady), Sinus fatigue. (systemic illness , thyrotoxicosis, anxiety etc) TYPE OF PALPITATIONS Regular, rapid or permanent. Increase in Large increase in stroke volume intensity of secondary to Regurgitantvalvular ASSOCIATED SYMPTOMS contraction lesions, congenital Shunt lesions, Chest pain, syncope or near syncope, sweating, pulmonary Arteriovenous malformation, edema, anxiety, nausea, . hyperdynamic states(, etc) TERMINATION EVENTS Altered Psychosomatic disorders Deceleration or sudden, urination, change in other perception of symptoms. heartbeat CHAPTER 14 69

,Hypertrohiccardiomyo ,

Severe Aortic,Mitral Severe Aortic,Mitral regurgitation proplapse like Shunt lesions VSD/ASD/PDA Ebsteins anomaly Dilated pathy Psychosomatic Sympathomimetic agents in Sympathomimetic agents inhalers Alcohol, , Anorexics 1. 2. 3. 4. 5. 4. 5. 1. 2. 3. Cardiac structural anomalies structural Cardiac

Drugs and others Drugs and

19-21 ECG CLUES TO CAUSE OF PALPITATIONS OF CAUSE TO CLUES ECG INVESTIGATIONS Short PR interval-AVRT, Atrial Short PR interval-AVRT, premature complexes-Atrial Atrial abnormalities, P-wave fibrillation 3: ECG to assess appropriate investigation the most ECG remains a patient of palpitation. During an episode of useful information on rate, ECG provides rhythm and suitably temporally done also onset or tests with adenosine or pharmacological maneuvers and offset. Vagal other drugs under ECG monitoring provide valuable insights into mechanism and triggers of arrhythmia. valuables arrhythmia ECG provides of In the absence clues about structural heart arrhythmic substrates disease, and chanellopathies. rhythm or , to evaluate the presence of the presence tachycardia, to evaluate sinus rhythm or systemic disease. In the absence of palpitations, signs of structural heart (murmur, clicks, disease thatcould explain the etiology heart signs of heart disease, , valvular failure). help to get Systematic analysis of clinical clues idea into the nature of palpitations they are summarized in Figure

Palpitations

Fig. 1: Aetiology of Arrhythmias 1: Aetiology Fig.

Tachycardiac

sinus -

Pulsation Palpitations Extrasystolic enticular/supraventricular enticular/supraventricular rthostatic syndromes nemia heochromocytoma ever Bradyarrhythmias V tachyarrhythmias ,sinus pause,AV pause,AV bradycardia,sinus blocks mediated Pacemaker O P Pregnancy F A Fig. 2: Types of palpitations Types 2: Fig. 2. 1. 3. 4. 5. 6. 1. 2. 3.

Cardiac arrhythmias Cardiac

Systemic causes Systemic

Anxiety

EXAMINATION PAST HISTORY PAST Goal is to evaluate the tolerance of a arrhythmia (blood Goal is to evaluate pressure, pulmonary edema, etc), and in case of a sinus Age onset of symptoms, frequency, cardiac disease, frequency, cardiac symptoms, Age onset of systemic diseases, disorders, psychosomatic tachycardia disease, family history of cardiac disorders, or sudden cardiac death, medications at the time of palpitations drug abuse. Spontaneously or with vagal maneuvers or drug maneuvers Spontaneously or with vagal administration.

CARDIOLOGY 70 ahlgcl wv, pio wave(ARVD) epsilon wave, Q Pathological Atrial fibrillation Left -, brady- dependent polymorphicventricular tachycardia A-V block,tri- orbifascicularblock-Complete heartblock, HOCM Large voltagesinprecordial leads,Twave changes- Long orshortQT-Polymorphic ventricular tachycardia brugadapattern*-Ventricular tachycardia/fibrillation AVNRT/AVRT termination Vagal maneuver Polyuria &frogsign from childhood nature. Onsetofsymptoms posture induced,regularin Sudden onset.Exerciseor Fig. 3:AVRT- reentrant atrio-ventricular tachycardia; AT- Atrial tachycardia, AF-;VT- tachycardiaVentricular Fig. 4:Holter monitoring Fig. 5:Event recorder AF Polyuria nature induced. Irregularin Effort, alcoholormeal Continuous orparoxysmal. # , AT/AFL nature exceptinAVblock continuous.Regular in Paroxoysmal or eliminating several triggersFigure4. activity may limitpatient cumbersome installation 1-2 to limited days, usefulwhenpalpitationsaredailyoccurrence, usually is Monitoring leads. several via perform to able electrocardiographic monitoring continuousbeat-to-beat are recorders these electrodes; skin of means by Holter-Recorders connectedtothepatient or beswitchedonattheonsetofpalpitation. ECG. Devices can record ECG data on a continuous basis sense to use devices which can record and transmit/archive and inconclusiveWhen symptomsareinfrequent makes it provides astructural and functional clue definite by deviceitself give to activatedcould beexternally or automatically bypatient fail modalities implantable recorders are used. The trigger to record other all and yearly and associated with hemodynamic compromise is monthlyor that When symptomsareless frequent and lesstolerated,Figure6. automatic triggering. Long term usage is inconvenient Asymptomatic arrhythmias canberecorded with hemodynamic impairment. and thosewith palpitations occur weeklyUseful forshortlasting or lessfrequently. trigger and after is recorded. Useful when palpitations by patientorautomatically.ECGrecordbefore the triggered a memoryloopwhichcanbe equipped with Connected to thepatienton a continuous basis and impairment occurs(Figure5). when hemodynamic are notrecorded,suitable is switchedon.ECGqualitymaynotbegood,triggers happens weekly ormoreandlastlongenoughtilltrigger onset whose palpitations for Useful transmitted. and/or single leaddataisrecorded patient, experienced by devices appliedtoskinwhensymptomsare Portable Arrhythmogenic rightventricular dysplasia in seen leads ARVD-ECG precordial right the in ms >110 #epsilonwave and/orT-wave inversion withQRSduration ST segmentelevation intherightprecordialECGleads. type covedtype/saddle with block branch bundle Right * ECG MONITORING DEVICES ECHOCARDIOGRAPHY IMPLANTABLE LOOP RECORDERS LOOPEXTERNAL RECORDER EVENT RECORDERS 22-25 Figure7. VT compromise Hemodynamic nature Effort induced,regularin CHAPTER 14 71

Fig. 7: Implantable loop recorder 7: Implantable loop Fig. MRI MRI is emerging as a useful investigation in diagnosing of structural and functional cardiac diseases. a variety arrhythmogenic of diagnosis the in proven utility is Its tachyarrhythmias. The sympathetic state associated with tachyarrhythmias. stress identifies triggers to a particular arrhythmia and clues to diagnosis. Hemodynamic provides valuable tolerance to a particular arrhythmia could also be studied during stress testing. Suggested diagnostic workup for palpitations for Suggested diagnostic workup Fig. 6: External loop recorder 6: External Fig. ILR-implantable loop recorder, EPS-Electrophysiological study, AECG-Ambulatory electrocardiogram AECG-Ambulatory EPS-Electrophysiological study, loop recorder, ILR-implantable STRESS TESTING STRESS Treadmill or pharmacological stress testing may sometimes testing may stress pharmacological or Treadmill as inducible of to identify presence be used as catecholamenergic a cause of palpitations, as well assessment of the heart, such as heart disease of the heart, valvular assessment prolapse, mitral and aortic regurgitation. mitral valve function, Congenital shunt lesions, left ventricular useful corroborative etc provide ARVD features of etiology of palpitations. possible evidence towards CARDIOLOGY 72 2. 1. devices, phonesetccouldprove useful inthefuture. diagnostic yield and accuracy. Simple tools like handheld ECG monitoring improving especially forambulatory cause as of palpitations.Newer toolsareincreasinglyavailable attributed are conditions benign more before Potentially lifethreateningcauses should be ruledout clinical diagnosisandfollowwithrelevant investigations. examination is required toarrive at an appropriate etiology. Thoroughhistoryandphysical wide ranging Palpitations areacommon clinical presentationwith severe structuralcardiacabnormality. failure and malfunctions, signsandsymptomsofheart include hospitalize hemodynamic compromise, pacemaker/ICD to arrhythmias, supraventricular arrhythmiaswith indications brady arrhythmiasrequiringpacemaker,ventricular serious More studies etc. and catheterization cardiac hemodynamic assessment, EPS, in hospital telemetry of purpose the for disease purpose. therapeutic and Diagnostic indicationsmayincludestructuralheart diagnostic for hospitalized Patients withpalpitationsmaysometimes need tobe symptoms. the benignnatureof the disorder can markedly reduce and symptoms control should beconsidered. Reassurance ofthepatienton to useful be may counselling) cardiologic therapies (e.g.anxiolyticdrugsorpsychiatric changes in lifestyle (e.g. reducing coffee or alcohol) or non- and influence may modulate thefrequencyandseverityof thesymptoms. factors general of number a beats), of treatment arrhythmias (e.g.premature choice. Inmanybenign the is this arrhythmias), supraventricular known andalow-riskcurative therapyisavailable (e.g. disorders, or systemicdiseases. When aclearcauseis arrhythmias, structuralheartdiseases,psychosomatic Therapy isfocused on thecause(treatmentofcardiac of awiderangetachyarrhythmias. arrhythmia. EPS also allows for potential ablative therapy and consequentlydiagnosethenatureof heart totrigger protocols aredeliveredpacing andentrainment tothe after exhaustingallotherdiagnostictools.Various Electrophysiological studies are usuallythelastresort, cause could turn in various ventricular which arrhythmias. them, characterize tissue various lesionslikesarcoidgranulomas,tumorsand of Ventricular tachycardia.Itisalsousefultoidentify right ventricular dysplasiawhichisanimportantcause REFERENCES CONCLUSIONS TREATMENT OF PALPITATIONS ELECTROPHYSIOLOGICAL STUDY ndo M. h ntrl itr o pliain i a in palpitations of history family practice. JFamPract natural The MP. Knudson The AD. Mangelsdroff adequacy oftherapy. ArchInternMed ME, Arrington prevalenceand the ofsymptomsinmedicaloutpatients K, Kroenke 1987;24:357–60. 1990;150:1685–9. 20. 19. 18. 17. 16. 15. 14. 13. 12. 11. 10. 9. 8. 7. 5. 4. 3. practice. 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