Palpitations

Jeff Ascenzo, PGY-32/11/2008

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

“Code Blue”

Palpitations

• “A sensation of rapid or irregular beating of the heart” – Taber’s

Chief Complaints• “fluttering”• “pounding”• “thudding”• “throbbing”• “quivering”• “skipping beats”• “my chest is going to explode”• “can’t catch my breath”• …

Chief Complaint Clues• “skipped beats” or “flopping”: PAC’s / PVC’s

-PAC’s/PVC’s compensatory pause

-pause ’d LV volume-post-extrasystolic potentiation ’d contractility

• “sustained bursts”: ventricular or SV tachyarrhythmias

• “irregular”: Atrial Fibrillation• “abrupt”: Sustained ventricular or SV

tachyarrhythmias• “gradual”: Sinus tachycardia

Statistics• Represent ~16% of all medical

encounters (ER & outpatient ambulatory has diagnostic consequences)

• 1-Year Mortality: 1.6% (3/190)• 1-Year CVA Rate: 1.1% (2/190)

• 75% recurrence rate within 1 year

Next Step• Focus the chief complaint

-Is this life-threatening?-Hemodynamic consequences (syncope, pre-syncope or

dyspnea)

-Risk factors (CAD, HFailure or other heart disease)

-Is it not?• “Patients do not read Harrison’s” – Dr.

Hafner• Zebras are not always zebras, they may be

the zebra presentation of the horse

History• Conditions of symptom onset (rest, exertional, stressors,

recent illnesses…)• Associated symptoms• Duration• Conditions of symptom termination• PMH• Medications (especially at the VA)• Social History:

-Job-Coffee / tea / caffeine-Smoking-Alcohol-…

History - Importance• Study – Predictors of a “cardiac”

etiology to palpitations (p < 0.05):1) > 5-minute duration2) Known history of “heart

disease”3) “Irregular beats”4) Male

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?• …

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• …

Diagnostic Implications• Overall:

-84% of cases received a diagnosis43% - Cardiac31% - Psychiatric10% - “Other” (Medications, drugs,

etc…)-16% No diagnosis found

• ER or ambulatory setting? (differences p < 0.002)ER (87% diagnosis) Ambulatory (72% diagnosis)

47% - Cardiac 21% - Cardiac

27% - Psychiatric 45% - Psychiatric

13% - “Other” 6% - “Other”

13% - No diagnosis 28% - No diagnosis

Diagnoses

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

Putting It All Together• “This is what you get paid the big bucks

for” – Dr. Doug Phelps• I think it’s this because A,B & C

• ~65% of cases – diagnosis can be determined from the history, exam & EKG alone (123/190)

Can’t Put It All Together?

• 16% of cases no diagnosis!-13% in ER presentations-28% in Ambulatory presentations

• Beta-blockers are useful

Questions?

Case #1• A 75 y.o. man with long-standing

hypertension diagnosed 30 years ago, comes to your office complaining of fatigue and a sense of his “heart pounding” for the past day. He has never had this feeling before.

• His pulse is rapid and irregularly, irregular

• EKG…

Case #1

• Diagnosis: Atrial Fibrillation with RVR

Case #2• A 28 y.o. resident comes to your clinic

describing an incident of “fluttering” in her chest that began this morning after an overnight call. She has no relevant past medical history and takes no medications.

• Her pulse is 136 and regular.• She drank a full 2-liter bottle of Mountain Dew

this AM before rounds to “wake up.”

• EKG…

Case #2

• Diagnosis: Atrial Flutter (2:1)

Case #3• A 36 y.o. successful businessman comes to the

ER because of a one-week history of his “heart pounding out of his chest.” He has noticed these symptoms mostly at rest but also with exertion. He has no real significant past medical history, takes no medications, denies any use of illicit drugs, but does mention that he was recently promoted to a new job.

• His exam is normal.

• EKG…

Case #3

• A Holter is also unremarkable• Diagnosis?

Case #4• A 66 y.o. man presents to the ER with a

6-hour history of being unable to catch his breath. He also feels as if his “heart is racing.” He is a type 2 diabetic and has had multiple NSTEMI’s in the past but without any bypass targets seen at cardiac catheterization.

• EKG…

Case #4

• Diagnosis: Ventricular Tachycardia

Case #5• A 79 y.o. woman presents to your clinic

complaining of fatigue and sensations that began earlier today that her “heart is skipping.” She takes Digoxin for a history of atrial fibrillation, Lopressor for a history of an MI sustained several years ago, Cardizem for hypertension. She has a known old LBBB.

• EKG…

Case #5

• Diagnosis: Complete Heart Block

References• Weber BE, Kapoor WN. Evaluation and Outcomes of Patients With Palpitations.

Amer Jour Med. 1996: 100 (2): 138-148.• Surawicz B & Knilans TK. Chou’s Electrocardiography in Clinical Practice. W.B.

Saunders Company. Philadelphia, PA. 2001.• Harvard Medical School Online ECG Web Maven: http://ecg.bidmc.harvard.edu

/maven/mavenmain.asp• Dubin D. Rapid Interpretation of EKG’s: 6th Edition. COVER Publishing Company.

Tampa, FL. 2000.• Braunwald et al. Harrison’s Principles of Internal Medicine: 15th Edition. McGraw-Hill.

New York, NY. 2001.• Guyton & Hall. Textbook Of Medical Physiology - 10th Edition. Saunders.

Philadelphia, PA. 2000.• Zipes, Libby, Bonow & Braunwald. Braunwald’s Heart Disease: A Textbook Of

Cardiovascular Medicine – 7th Edition. Elsevier Saunders. Philadelphia, PA. 2005.• Topol EJ et al. Textbook of Cardiovascular Medicine. Lippincott Williams & Wilkins.

Philadelphia, PA. 1998.• Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of symptoms in medical

outpatients and the adequacy of therapy. Arch Intern Med. 1990: 150 (8):1685-1689.

• Zimetbaum P, Josephson ME. Evaluation of Patients with Palpitations. NEJM. 1998: 338 (19): 1369-1373.

Questions / Comments / Concerns?