PALPITATIONS

1. Dr.RUHUL AMIN
Department of Medicine
JRRMCH,SYLHET.

2. To be discussed…..
Definition
Introduction
Pathophysiololgy
Aetiology
Diagnostic pathway
History
Examination
Resting ECG
ECG with symptoms
Additional investigations
Management

3. Definition
These represent an increased awareness of the normal
heartbeat or the sensation of slow, rapid or irregular
heart rhythms.

4. Introduction
Palpitation does not means heart disease.

The degree of palpitation is not equal to the severity
of heart disease.

Patients with anxiety states often exhibit a lowered
threshold at which disorders of rate and rhythm
result in palpitation.

5. Introduction contd.

Persistent tachycardia and/or atrial fibrillation
may not be accompanied by continual palpitation.

A sudden, brief alteration in cardiac rate or rhythm
which often causes considerable subjective
discomfort.

6. Pathophysiology

Augmentation of heart contractility

Arrhythmia

Cardiac neurosis

7. Augmentation of heart contractility

Physiological augmentation

Pathological augmentation

8. Physiological augmentation

Exercising strongly and over nervous

After drinking coffee, tea, alcohol

Taking medicine such as ephedrine,
aminophylline, atropine etc.

9. Pathological augmentation
Ventricular hypertrophy: such as hypertensive
heart disease, valvular insufficiency, PDA, VSD
etc.
Preload or afterload increase hypertrophy→ →
augmentation of contractility palpitation→

10. Pathological augmentation contd.Other diseases which increase cardiac output:
Thyrotoxicosis: basic metabolism amplify & sympathetic
nerve excite heart rates→ ↑
Anemia: hypoxaemia heart rates→ ↑
Mild, chronic anemia may cause palpitation during
exertion. severe, acute anemia may cause palpitation at
rest.

11. Pathological augmentation contd.
Fever: basic metabolism amplify
Hypoglycemia: Palpitation is often a prominent
feature of the condition and appears to be release of
catecholamine.

12. Arrhythmia
Tachycardia: sinus, supraventricular, ventricular
Bradycardia: SSS, AVB, sinus bradycardia
Diastolic period prolong EDV augmentation of→ ↑ →
heart contractility
Arrhythmia: premature beat, atrial fibrillation
Irregular beat

13. Cardiac neurosis
Turbulence of sympathetic nerve & pneumogastric
nerve
Various symptom: palpitation, chest pain, tire,
insomnia, headache, dizziness etc
Usually seen in female
Inducement: anxiety, excitement

14. Etiology
 Extracardiac causesExtracardiac causes
 Cardiac causesCardiac causes
– ArrhythmiasArrhythmias
– Nonarrhythmic cardiac causeNonarrhythmic cardiac cause
 Psychiatric causesPsychiatric causes
 Drugs & DietsDrugs & Diets

15. Extracardiac causesExtracardiac causes
 AnemiaAnemia
 Electrolyte imbalanceElectrolyte imbalance
 FeverFever
 HyperthyroidismHyperthyroidism
 HypoglycemiaHypoglycemia
 HypovolemiaHypovolemia
 PheochromocytomaPheochromocytoma
 Vasovagal syndromeVasovagal syndrome

16. Cardiac cause:Cardiac cause: ArrhythmiasArrhythmias
 Atrial fibrillation/flutterAtrial fibrillation/flutter
 Bradycardia caused by advancedBradycardia caused by advanced AVAV block orblock or
sinus node dysfunctionsinus node dysfunction
 Bradycardia-tachycardia syndrome (SSS)Bradycardia-tachycardia syndrome (SSS)
 Multifocal atrial tachycardiaMultifocal atrial tachycardia
 Premature supraventricularPremature supraventricular or ventricularor ventricular
contractionscontractions
 Sinus tachycardiaSinus tachycardia
 Supraventricular tachycardiaSupraventricular tachycardia
 Ventricular tachycardiaVentricular tachycardia
 Wolff-Parkinson-White syndromeWolff-Parkinson-White syndrome

17. CARDIAC Cause:CARDIAC Cause:
ARRHYTHMIASARRHYTHMIAS
 Episodes of ventricular tachycardiaEpisodes of ventricular tachycardia andand supraventricular tachycardiasupraventricular tachycardia
maymay causecause palpitations but also can bepalpitations but also can be asymptomatic or lead toasymptomatic or lead to
syncope.syncope.
 PalpitationsPalpitations associated with dizziness, near-syncope, or syncopeassociated with dizziness, near-syncope, or syncope
suggest tachyarrhythmiasuggest tachyarrhythmia and are potentially more serious.and are potentially more serious.
 OrthostaticOrthostatic intolerance or inadequate cerebral perfusionintolerance or inadequate cerebral perfusion on uprighton upright
posture may result in palpitations,posture may result in palpitations, tachycardia, headache,tachycardia, headache, nausea, pre-nausea, pre-
syncope, and, occasionally, syncope.syncope, and, occasionally, syncope.
 Orthostatic intolerance in women of childbearing ageOrthostatic intolerance in women of childbearing age

18. Nonarrhythmic cardiac causesNonarrhythmic cardiac causes
 Atrial or ventricular septal defectAtrial or ventricular septal defect
 CardiomyopathyCardiomyopathy
 Congenital heart diseaseCongenital heart disease
 Congestive heart failureCongestive heart failure
 Mitral valve prolapseMitral valve prolapse
 Pacemaker-mediated tachycardiaPacemaker-mediated tachycardia
 PericarditisPericarditis
 Valvular disease (aortic insufficiency, stenosis)Valvular disease (aortic insufficiency, stenosis)

19. PsychiatricPsychiatric CauseCause
Anxiety disorderAnxiety disorder
Panic attacksPanic attacks

20.  PPrevalence of panic disorder in patientsrevalence of panic disorder in patients with palpitations iswith palpitations is
15 to 31 percent15 to 31 percent
 Screening question:Screening question: Have youHave you experienced brief periods, forexperienced brief periods, for
seconds orseconds or minutes, of an overwhelming panic or terrorminutes, of an overwhelming panic or terror thatthat
was accompanied by racing heartbeats,was accompanied by racing heartbeats, shortness ofshortness of
breath, or dizziness?breath, or dizziness?
 PPanic disorderanic disorder and significant arrhythmias are notand significant arrhythmias are not mutuallymutually
exclusive, and that cardiac evaluationexclusive, and that cardiac evaluation still may bestill may be
necessary in patients withnecessary in patients with suspected panic disordersuspected panic disorder
ANXIETY OR PANIC DISORDERANXIETY OR PANIC DISORDER

21. Drugs and DietsDrugs and Diets
 Beta agonists,Beta agonists, pphenothiazine,henothiazine, theophylline,theophylline,
isotretinoin, disotretinoin, digigoxinoxin
 Tobacco, AlcoholTobacco, Alcohol
 Caffeine,Caffeine, ChocolateChocolate
 CCocaineocaine

22. Diagnostic pathway
History
Examination
Resting ECG
ECG with symptoms
Additional investigations

24. History
Is the palpitation continuous or intermittent?
Is the heart beat regular or irregular?
What is the approximate heart rate?
Do symptoms occur in discrete attacks?
Is the onset abrupt?
How do attacks terminate?
Are there any associated symptoms?
e.g. Chest pain
Lightheadedness
Polyuria (a feature of supraventricular tachycardia)
Are there any precipitating factors, e.g. exercise, alcohol?
Is there a history of structural heart disease, e.g. coronary
artery disease, valvular heart disease?

25. Accompanying symptoms
Palpitation with chest pain: It is often present in
coronary heart disease (angina, myocardial
infarction), myocarditis, pericarditis. It is also
present in cardiac neurosis.

26. Accompanying symptoms
Palpitation with fever: It is observed in acute
infection, rheumatic fever, myocarditis,
pericarditis, infective endocarditis.

27. Accompanying symptoms
Palpitation with syncope or twitch: It is present in
high-degree AVB, ventricular fibrillation,
paroxysmal ventricular tachycardia, SSS.

28. Accompanying symptoms
Palpitation with anemia: It happens after
acute hemorrhage, which accompanys with
sweat, hypotension, shock.
Palpitation with weight loss and sweating: It
suggests thyrotoxicosis.

29. Clinicalfindings&Diagnosis

30. Examination
Cardiovascular
Pulse
Blood Pressure
Heart murmurs
Signs of left / right ventricular dysfunction
Features of endocrine abnormality

31. ECG EVALUATIONECG EVALUATION
 AAll patientsll patients who complain of palpitationswho complain of palpitations
 ECG findingsECG findings warrant further cardiacwarrant further cardiac
investigationinvestigation;; evidence of previous myocardialevidence of previous myocardial
infarction, left or right ventricularinfarction, left or right ventricular hypertrophy,hypertrophy,
atrial enlargement,atrial enlargement, AVAV block, short PR intervalblock, short PR interval
and deltaand delta waves (Wolff-Parkinson-Whitewaves (Wolff-Parkinson-White
syndrome)syndrome),, prolonged QT intervalprolonged QT interval

32. ETTETT
 ECG exercise testing isECG exercise testing is appropriate inappropriate in
patientspatients who have palpitationswho have palpitations withwith
physical exertion andphysical exertion and patients withpatients with
suspectedsuspected coronary artery disease orcoronary artery disease or
myocardial ischemia.myocardial ischemia.

33. PR interval
Normal 3 to 5 small squares
(0.12 to 0.2s)
QRS interval
Normal up to 3 small squares
(0.12s)

34. QT
interval
QT interval
Normal up to 12 small
squares (dependent rate)
(0.450s)

35. Sinus tachycardiaSinus tachycardia

36. Sinus bradycardia with premature atrialSinus bradycardia with premature atrial
contractionscontractions

37. Atrial Fibrillation

38. Atrial fibrillation with prematureAtrial fibrillation with premature
ventricular contractionsventricular contractions

39. Wolff-Parkinson-White Syndrome

40. Further Diagnostic TestingFurther Diagnostic Testing
 CONTINUOUS ECG MONITORCONTINUOUS ECG MONITOR (Holter monitor)(Holter monitor)
-- continuously tocontinuously to record data for 24 or 48 hoursrecord data for 24 or 48 hours
-- diary of any symptoms thatdiary of any symptoms that occur during the monitoringoccur during the monitoring
-- most expensivemost expensive
- maintained andmaintained and operated by hospitals or larger outpatientoperated by hospitals or larger outpatient
clinicsclinics

41. Holter monitoring
Most of use if symptomatic during study
May detect asymptomatic abnormalities

42. Additional Investigations
Echocardiogram
Cardiac MRI
Heart Catheterisation / angiography

43. Echocardiographic risk stratification
Septal
thickness
<30mm
Aortic
Gradient
<30mmh
g

44. ManagementManagement
 IIf the evaluation of thef the evaluation of the heart is otherwiseheart is otherwise
normal,normal, ventricular premature contractions orventricular premature contractions or
brief episodes of ventricular tachycardiabrief episodes of ventricular tachycardia areare
not associated with increased mortalitynot associated with increased mortality
 Appropriate patient educationAppropriate patient education

45. Management
Sustained arrhythmias; pharmacologic or invasive
electrophysiologic study
Treat underlying for the noncardiac, psychiatric,
or nonarrhythmia cardiac etiology

46. ManagementManagement
 IfIf fail to reveal any abnormalityfail to reveal any abnormality or etiology foror etiology for
palpitationspalpitations
--advised to abstain from caffeineadvised to abstain from caffeine and alcohol,and alcohol,
as well as foods or stressfulas well as foods or stressful situations thatsituations that
appear to trigger palpitationsappear to trigger palpitations

47. Management
the majority of patients with palpitations have
benign diagnoses and can be treated with
reassurance