Management of the Patient Presenting with Palpitation
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Management of the Patient Presenting with
Palpitation
Samir Saba, MD
Director, Cardiac Electrophysiology
University of Pittsburgh
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Definition
Perceptible unpleasant forcible pulsation of the heart, usually with an increase in frequency or force, with or without irregularity in rhythm.
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Presentation
• Most common outpatient complaint in patients presenting to PCP and cardiologists
• 16% in one study of 500 patients
• Terminology used:– Rapid fluttering in the chest– Flop-flopping in the chest– Pounding in the neck
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Etiology
• Cardiac:– Arrhythmias– Cardiac and extracardiac
shunts– Valvular heart disease– Pacemaker– Atrial myxoma– Cardiomyopathy
• Psychiatric:– Panic disorders– Anxiety disorders– Somatization– Depression
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Etiology• Medication:
– Sympathomimetic– Vasodilators– Anticholinergic -blocker withdrawal
• Catecholamine Stress:– Exercise– Stress
• Habits:– Cocaine– Amphetamines– Caffeine– Nicotine
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Etiology
• Metabolic disorders:– Hypoglycemia– Thyrotoxicosis– Pheochromocytoma– Mastocytosis– Scombroid Food
Poisoning
• High output states:– Anemia– Pregnancy– Fever– Paget’s disease
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Arrhythmic Etiologies
• PAC/PVC
• Sinus arrhythmias
• SVT (AF, Aflutter, ORT, AVNRT, AT)
• Idiopathic ventricular arrhythmias (RVOT, LVOT, fascicular VT)
• Life-threatening ventricular arrhythmias (MMVT, PMVT, TdP, VFlutter, VF)
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Approach to the Patient
1. Is the cause of palpitations possibly a life-threatening condition? (Usually cardiac etiology)
• Majority of outpatients have benign etiologies
2. How can we make the patient feel better?
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Predictors of Cardiac Etiology
• Male gender
• Reporting irregular heart beats
• History of heart disease
• Event duration > 5 minutes
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History
• Circumstances:– Association with anxiety or panic (20% of palpitations
are due to panic attacks and 67% of patients with SVT where diagnosed at some point with panic disorder)
– Association with stress (arrhythmias benign and fatal)– Association with position (AVNRT pr PAC/PVC)– Association with syncope or near-syncope (high level
of suspicion for VA)
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Evaluation• Detailed History:
– Age – Onset– Duration– Circumstances – Symptoms– Termination – Maneuvers (CSM, valsalva)– Regularity (tap out the rhythm)– Medications– Habits– Psychiatric disorders
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Evaluation
• Physical Exam:– Rarely during
palpitations– Auscultation (MVP,
HCM, chronic AF)– Evidence of CMP,
valvular disease, congenital abnormalities
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Evaluation
• 12-Lead ECG:– PAC/PCV/SVT/VT– WPW– LVH/LAE/RAE– Long QT, Brugada,
ARVD– Old MI– Conduction
abnormalities predisposing to TdP
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ECG 1
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ECG 2
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ECG 3
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ECG 4
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ECG 5
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ECG 6
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ECG 7
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Evaluation: Further Diagnostic Testing
• The diagnostic yield of history, P/E, and ECG is 1/3.
• Further diagnostic testing is needed in 3 groups of patients:
1. Those in whom the initial dx suggests arrhythmias
2. Those at high risk of arrhythmias
3. Those who remain anxious about arrhythmias
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Diagnostic Testing
• Rule out structural abnormalities of the heart– Echo– Stress test– Cardiac Cath– MRI
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Diagnostic Testing
• Document arrhythmia in the setting of symptoms– Ambulatory monitors
(HM (yield is 33-35%),, Event recorder, Loop monitor (yield is 66-88%), continuous ambulatory monitors)
– ILR, EP testing
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Testing
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Diagnostic Yield of Loop Monitor
Yield =100%
Yield = 78%
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ILR 1: Palpitations
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ILR 2: Palpitations and Syncope
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EP Study 1
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EP Study 2
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EP Study 3
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Therapy
• No therapy-Blockers, CCB
• Anti-arrhythmic drugs (IC, III)
• Ablation
• Devices
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Inappropriate Sinus Tachycardia
• Diagnosis of exclusion after ruling out:– Thyrotoxicosis, anemia, fever, dehydration,
arrhythmias, etc…
• Formulas:– HR max = 220 - age– HR max = 205.8 − (0.685 X age)
• Therapy: -blockers or CCB– Sinus node modification (high recurrence rate, need a
PM, paralysis of phrenic nerve)
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Take Home Points
1. Palpitations are very common
2. Differentiating between cardiac and non cardiac causes is essential
3. History, PE, ECG are essential with a yield of 1/3
4. Continuous event monitors are a good adjunct tool with a good diagnostic yield (up to 88%)
5. Therapy can be directed to cause but also empiric (-blockers)
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Questions?