Approach to Palpitations

Approach to Palpitations 2018-01-30T16:37:04+08:00

Differential diagnosis

  • Cardiovascular
    • Benign palpitations
    • Ectopics
    • Arrhythmia
      • Atrial fibrillation / flutter
        • Underlying valvular heart disease
      • Wolff-Parkinson-White syndrome
      • Multi-focal atrial tachycardia
      • Tachy-brady syndrome (sick sinus syndrome)
      • Ventricular tachyarrhythmia (especially if there is a focus, e.g. ischaemic scar)
    • Hypertrophic obstructive cardiomyopathy
  • Respiratory
    • Pulmonary embolism
  • Endocrine
    • Hyperthyroidism
    • Hypoglycaemia
    • Phaeochromocytoma
      • MEN-2A: medullary thyroid carcinoma, phaeochromocytoma, parathyroid adenoma
      • MEN-2B: medullary thyroid carcinoma, phaeochromocytoma, marfanoid habitus
  • Drugs
    • Caffeine
    • Nicotine
    • Salbutamol
    • Theophylline
    • Illicit drugs
      • Amphetamine
      • Cocaine
      • Ecstasy
  • Pregnancy
  • Infection (fever)
  • Symptomatic anaemia
  • Electrolyte imbalance
  • Psychosocial
    • Anxiety disorder
    • Panic attacks

Relevant points in the history

  • Palpitations
    • What were you doing when you first noticed the palpitations?
    • Have you had them before?
    • Have they been getting more frequent?
    • Irregular or regular
    • Forceful beats or sensation of fast heart rate?
    • Does anything bring the attacks on or stop them?
    • Do you feel dizzy when the attacks happen?
    • Have you every fainted because of the palpitations?
    • What do you think is causing the palpitations?
    • What effect have they had on your life?
  • Underlying cause
    • Cardiac
      • Do you have any chest pain?
      • Do you feel breathless when you have these palpitations?
      • Are the palpitations worsened by exercise?
      • Do you have any heart problems?
      • Has anyone in your family ever died suddenly or unexpectedly?
    • Pulmonary embolism
      • Have you had any recent long-haul flights?
      • Have you injured yourself or been relatively immobile recently?
    • Endocrine
      • Do you feel like it is abnormally hot?
      • Have your periods become heavier?
      • Do you have tremors in your hands?
      • Have you had problems with your bowels? Any diarrhoea?
      • Have you noticed that you are sweating more than usual?
      • Have you been having headaches more frequently than usual?
      • Do you have diabetes?
      • Have you ever experienced episodes where your blood sugar is too low?
      • Did you have any symptoms similar to that episode with the palpitations?
    • Do you have any fever?
    • Have you ever experienced brief periods of overwhelming panic or terror accompanied by palpitations, difficulty in breathing, dizziness or tingling in your hands?
    • When was the first day of your last menstrual period?
    • Drugs
      • Are you allergic to any medication?
      • Do you take any regular medications?
      • Have you ever used a puffer for asthma or shortness of breath?
      • Do you drink coffee or tea?
      • Have you ever used any illicit drugs?
    • Do you have any medical conditions?

Examination

  • Vitals
    • Fever
    • Heart rate
    • Blood pressure – if low and arrhythmia present, requires urgent cardioversion
  • Pulse
    • Rate
    • Rhythm
  • Eyes for conjunctival pallor
  • Cardiovascular
    • Mitral facies
    • Presence of implantable cardiac device
    • Right ventricular heave – pulmonary hypertension
    • Apex beat (character and location)
    • Heart sounds for any murmurs (e.g. systolic click of mitral valve prolapse, ESM of HOCM)
  • Endocrine
    • Observe for proptosis, lid lag
    • Look for tremor
    • Look and palpate for goitre
    • Check for thyroid surgery scars
    • Look for pre-tibial myxedema
  • Neurological
    • Pronator drift as a screen for cardioembolic disease if in AF

Investigations

  • FBC to look for anaemia, signs of infection
  • Electrolytes as electrolyte imbalance may precipitate palpitations
  • Thyroid function tests
  • 24 hours urine metanephrines if phaeochromocytoma suspected
  • Electrocardiogram
    • Wolff-Parkinson-White
    • May capture arrhythmia
    • Look for signs of ischaemic heart disease, which may precipitate scar VT
  • Holter or Reka monitoring if no abnormalities seen on ECG
    • Longer duration of recording increases chance of capturing arrhythmia
  • Echocardiogram to look for structural heart disease
  • May require electrophysiological studies if the above are non-diagnostic

Management

  • Can usually be managed outpatient, unless index of suspicion of malignant arrhythmia is very high
  • Treat the underlying cause
  • Beta blockers if symptomatic
  • If in AF, will need anticoagulation if CHADSVASC score ≥2
    • Congestive heart failure – 1
    • Hypertension – 1
    • Age 65 – 74  – 1
    • Age ≥ 75 – 2
    • Diabetes – 1
    • Previous stroke / TIA – 2
    • Vascular disease (MI/PVD) – 1
    • Female sex – 1
  • If hyperthyroid, will require carbimazole to control thyroid function
    • Will need to warn patient about the risk of neutropaenia
    • Repeat FBC after starting carbimazole
  • May need AICD if arrhythmia is malignant
  • May need accessory pathway ablation if SVT is confirmed on EPS

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This Sliding Bar can be switched on or off in theme options, and can take any widget you throw at it or even fill it with your custom HTML Code. Its perfect for grabbing the attention of your viewers. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile.