Palpitation history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]Cafer Zorkun, M.D., Ph.D. [3]

Overview

Many times, the person experiencing palpitations may not be aware of anything apart from the abnormal heart rhythm itself. But palpitations can be associated with other things such as tightness in the chest, shortness of breath, dizziness or lightheadedness. Depending on the type of rhythm problem, these symptoms may be just momentary or more prolonged. Actual blackouts or near blackouts, associated with palpitations, should be taken seriously because they often indicate the presence of important underlying heart disease. There are certain key questions that need to be asked while taking a patient's history.

History and Symptoms

• Palpitations are transient in nature.
• Therefore, it is important to elicit the answers of specific questions during one’s history taking as patients are often asymptomatic on arrival.
• History taking along with a thorough physical examination and 12 lead ECG form an important trio that would help the physician determine whether the patient requires further investigations, admission or can be sent home with the advice to follow up.
• Arrhythmia related cardiac disorders, anxiety and panic disorder are the immediate diagnoses that often come to a physician’s mind.
• It is important to keep an open-minded,step-wise approach and suspect cardiac etiologies even in patients with psychiatric symptoms.
• Often physicians employ the use of standardized screening questionnaires to identify panic disorder.

Key History taking questions

• Age of onset – Young or elderly?
  • Palpitations occurring in childhood suggests a supraventricular tachycardia, atrioventricular re-entry tachycardia and Wolff Parkinson White syndrome
  • Palpitations occurring in the elderly would more likely point to a structural heart disease, atrioventricular nodal re-entrant tachycardia (AVNRT), atrial fibrillation and atrial tachycardia.
• Duration of episode – Momentary or sustained?
  • Palpitations lasting less than 5 minutes make cardiac etiology less likely.
• Rhythm – Regular or Irregular?
  • Patients should be encouraged to tap out the rhythm of the palpitations as this provides key diagnostic insight.
  • Rapid regular rhythm – Paroxysmal supraventricular or ventricular tachycardia
  • Rapid irregular rhythm – Atrial fibrillation, atrial flutter, Tachycardia with variable block
• Sensation in the chest – Flip flop, pounding, fluttering, thud?
  • A brief flip flopping sensation is likely to be associated with premature supraventricular or ventricular contractions.
  • A more sustained fluttering is likely to be associated with a long lasting ventricular or supraventricular arrythmia.
  • Pounding sensations in the chest increased when sitting or lying down suggest premature ventricular contractions.
  • Sensation of one’s heartbeat all over the chest may be due to atrial fibrillation.
  • A sinking feeling followed by an unknown feeling of apathy may correspond to an extra- systolic compensatory pause.
• Onset and offset – Sudden or gradual?
  • Palpitations with an abrupt onset or offset suggest a paroxysmal supraventricular tachycardia.
  • Sustained palpitations are more likely due to atrial fibrillation.
• Activity at the time of onset – Sleep, work, sport squatting or bending?
  • Palpitations that occur at work or during sleep are suggestive of a cardiac cause.
• Aggravating factors
  • Palpitations aggravated by exertion suggest channelopathies, cardiomyopathies or underlying ischemia.
• Relieving factors- Vagal Maneuvers or rest?
  • Palpitations terminated by vagal maneuvers are likely due to supraventricular tachycardias.
• Associated Symptoms- Chest Pain, Syncope, Neck Pulsations, Dizziness, Nausea, Vomiting?
  • Palpitations associated with chest pain may be due to myocardial ischemia, exacerbated mitral valve prolapse, cardiomyopathy or dehydration.
  • Palpitations associated with presyncope, syncope, light headedness and dizziness suggest tachyarrhythmias or hypertrophic cardiomyopathy.
  • Palpitations associated with orthostatic intolerance suggest cerebral hypoperfusion and are commonly seen in women of child bearing age.
  • Palpitations associated with elevated jugular venous pressure, pedal edema and breathlessness suggest congestive heart failure.
  • Palpitations associated with polyuria may be due to atrial fibrillation that caused the release of atrial natriuretic peptide.
  • Visible transmitted pounding neck pulsations and an associated ‘frog sign’ are likely to be the result of AV dissociations such as AV nodal re-entry tachycardia that would cause the contraction of atria against closed AV valves.
  • Palpitations associated with pupillary dilation, sweating, aberrant behavior and dry mouth such as the use of drugs such as cocaine, MDMA and methamphetamines.
• Medication History
  • Caffeine, alcohol, tobacco, beta agonists, cocaine, amphetamines, methylxanthines, ADHD medication, coenzyme Q inhibitors, carnitine and omega 3 polyunsaturated fatty acids can cause palpitations.
• Family History – Sudden death, cardiac disease, Psychiatric condition?
  • Inherited conditions such as Arrhythmogenic right ventricular cardiomyopathy, Brugada syndrome
• Past History