Palpitations resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D.

Wolff-Parkinson-White Syndrome Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts
EKGs

Overview

Palpitations are one of the most common complains of patients when visiting outpatient clinics and emergency rooms.[1][2] The causes of palpitations can range from benign (most common) to life-threatening conditions if not managed properly.[2] Palpitations are described differently by each patient, usually as an uncomfortable awareness of rapid, pounding heart beats, but also described as flip-flopping of the chest, rapid fluttering in the chest or pounding in the neck.[1][2] The diagnosis is made by a detailed history, physical examination and a surface 12-lead EKG. The management of palpitations consists in treating the underlying cause.

Causes

Life-Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common causes

  • Cardiac causes
  • Non-arrhythmic cardiac causes
  • Malfunctioning or wrong programing of pacemakers
  • Psychiatric causes
  • Drug and medications
  • Systemic causes

Click here for a complte list of causes for palpitations.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[1][2][3][4][5][6][7]
Boxes in the red signify that an urgent management is needed.

Abbreviations: AS: Aortic stenosis; AR: Aortic regurgitation; EKG: Electrocardiogram; IV: Intravenous; NSTEMI: Non ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction; TTE: Trasthorasic echocardiography WPW: Wolff-Parkinson-White syndrome

 
 
 
 
 
 
 
 
 
Identify cardinal symptoms and signs that increase the pre-test probability of palpitations

Symptoms:
❑ Flip-flopping of the chest
❑ Rapid fluttering of the chest
❑ Pounding in the neck
❑ Pulsation palpitations
Signs:
❑ Increased heart rate with regular or irregular rhythm
❑ Cardiological findings suggestive of a cardiological disease

Murmurs
S3 sound
Muffled heart sounds
❑ Displaced apex beat
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the followign findings that require urgent management?

❑ Palpitations asociated with syncope (suggestive of VT of structural heart disease)
Chest discomfort suggestive of ischemia
❑ Decompensated heart failure


❑ Consider electrical cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue with the complete duagnostic apporoach shown below
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings suggesting of hemodynamic instability?

Hemodynamic instability
Hypotension
Cold extremities
Peripheral cyanosis
Mottling

Altered mental status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stabilize the patient

❑ Assess circulation, secure airway and breathing
❑ Secure IV line
❑ Offer oxygen
❑ Cardiac monitor to identify rhythm

❑ Monitor blood pressure and oximetry
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order an EKG immediately

Does the patient has any EKG findings suggestive of an arrhythmia?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any EKG findings suggestive of myocardial ischemia or pericarditis?

STEMI
ST elevation in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads
ST depression in at least two precordial leads V1-V4 (suggestive of posterior MI)
ST depression in several leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery)
❑ New LBBB


NSTEMI:
Non specific ST / T wave changes
❑ Flipped or inverted T waves
ST Depression


Pericarditis
ST segment elevation in leads I, II, aVL, aVF, and V3-V6
PR segment depression
Low QRS voltage (in large pericardial effusion and constrictive pericarditis)
Cardiac tamponade: electrical alternans

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
STEMI
NSTEMI
 
Pericarditis
 
Order a TTE
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any structural heart disease?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute heart failure
AS
Acute AR
 
Does the patient have history of consuming any toxic substance that can explain the palpitations and hemodynamic instability?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Look for systemic diseases than can cause palpitations and hemodynamic instability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Electrolyte disturbances
Hyperthyroidism
Hypoglycemia
Hypovolemia
 
 
 
 
 

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1][2][3][4][5][6]

Abbreviations: AF: Atrial fibrillation; AVRT: AV reentry tachycardia; AVNRT: AV nodal reentry tachycardia; BP: Blood pressure; CBC: Complete blood count; EKG: Electrocardiogram; EPS: Electrophysiological study SVT: Supraventricular tachycardia TSH: Thyroid stimulating hormone; TTE: Transthorasic echocardiography; VT: Ventricular tachycardia; WPW: Wolff-Parkinson-White syndrome

 
 
 
 
 
 
 
Characterize the symptoms:

Duration

❑ Breif: spontaneous termination
❑ Persistent: need appropriate tratment for controlling the symptoms

Frequency: (daily, weekly, monthly)
Onset

❑ Sudden (suggestive of SVT or VT)
❑ Gradual (suggestive of anxiety or excerise induced sinus tachycardia)

Termination: with vagal maneuvers (suggestive of SVT)
Type of palpitations

❑ Flip-flopping of the chest (suggestive of extrasystole)
❑ Rapid fluttering of the chest (suggestive of tachycardia)
❑ Pounding in the neck (suggestive of AVRT and AVNRT)
❑ Pulsation palpitations (suggestive of structural heart disease)
Anxiety-related palpitations

Prodrome

Chest pain
Dizziness
Syncope
Dyspnea
Vertigo
Fatigue

Position

❑ After standing up (suggestive of orthostatic hypotension or AVNRT)
❑ Pounding sensation while lying in bed (suggestive of AVNRT)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Search for associated symptoms and circumstances

❑ Sudden changes of posture (suggestive of intolerance to orthostasis or AVNRT)
Syncope (suggestive of SVT or structural heart disease)
Angina, dyspnea, fatigue (suggestive of structural heart disease or ischemic heart disease)
Polyuria (suggestive of AF)
❑ Rapid regular pulse in the neck (suggestive of AVNRT)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inquire about drugs that can cause palpitations:

Sympathomimetic agent pump inhalers (asthmatic patients)
Vasodilators
Anticholinergic agents
❑ Withdrawal of beta-blockers
Alcohol
Cocaine
Heroin
Amphetamines
Caffeine
Nicotine
Cannabis
❑ Synthetic drugs
❑ Weight reduction drugs

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain a detailed past medical history:

❑ Previous episodes of palpitations

❑ First episode
❑ Childhood (suggestive of AVRT or AVNRT)
❑ Adult patients (suggestive of AF or VT)
❑ Number of episodes
❑ Time since last episode
❑ Circumstances of past episodes

Cardiac arrhythmia
Structural heart disease

Hypertrophic cardiomyopathy
Valvular disease
Congenital heart disease
Cardiomegaly

Systemic diseases

Hyperthyroidism
Pheochromocytoma

❑ History of panic attacks
❑ History of depression
❑ Family history of arrhythmias and structural heart disease

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Vitals
Pulse

Rhythm
❑ Regular (suggestive of SVT or VT)
❑ Irregular (suggestive of extrasystole)
❑ Irregularly irregular (suggestive of AF)
Rate
Tachycardia
❑ Over 220 minus the patient's age (suggestive of SVT or VT)
❑ Under 220 minus the patient's age (suggestive of anxiety or panic attack)
Bradycardia (suggestive of sinus bradycardia, AV block)
Pulse deficit (suggestive of AF or premature ventricular beats)

Blood pressure

Hypotension (suggestive of hypovolemia)
Orthostatic hypotension (Fall in systolic BP ≥ 20 mmHg and/or in diastolic BP of at least ≥ 10 mmHg between the supine and sitting BP reading)
Hypertension

Temperature

Fever (suggestive of infection)

Respiratory rate (non-specific)
Face
Exophthalmos (suggestive of Graves disease)
Neck
Goiter (suggestive of hyperthyroidism)
Jugular venous pulse: cannon A wave (suggestive of AV dissociation)
Skin
❑ Hot and sweaty (suggestive of hyperthyroidism)
Hair
❑ Thin (suggestive of hyperthyroidism)
Respiratory
Rales (suggestive of heart failure)
Wheezing (non-specific)
Cardiovascular
Muffled heart sounds (suggestive of pericarditis)
Pericardial friction rub (suggestive of pericarditis)
Murmurs (suggestive of valve disease)

❑ Associated with midsystolic click (suggestive of mitral valve prolapse)
Holosystolic murmur in the left sternal border that increases with valsalva menuver (suggestive of hypertrophic obstructive cardiomyopathy)

❑ Displaced apex beat (suggestive of cardiomegaly
S3 (suggestive of heart failure)
Neurologic
Tremors (suggestive of panic attacks or hyperthyroidism)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order labs and tests:

EKG

❑ Determine if the rhythm is regular or irregular
❑ Assess the p wave and QRS morphology
❑ Rate over 100 bpm, QRS <120 ms (suggestive of narrow complex tachycardia)
❑ Search for short PR intervals and delta waves (suggestive of WPW)
❑ Irregular rhythm, change in p wave morphology (suggestive of AF)
❑ Regular rhythm, saw-tooth appearance (suggestive of atrial flutter)
❑ Rate over 100 bpm, QRS >120 ms (suggestive of wide complex tachycardia)
❑ Presence of prior myocardial infarction Q waves (suggestive of VT)
❑ Search for deep septal Q waves in I, V4 to V6 and signs of left ventricular hypertrophy (suggestive of hypertrophic obstructive cardiomyopathy)
❑ Normal EKG (suggestive of anxiety or panic attack)

CBC (to rule out anemia or infection)
Electrolytes (to rule out hypokalemia and hypomagnesemia)
TSH (to rule out hyperthyroidism)
Glucose level (to rule out hypoglycemia)
Cardiac enzymes (to rule out MI)


Order imaging studies
TTE (to rule out structural heart disease)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider hospitalization

❑ Recurrent episodes when no ambulatory EKG devices are available

Severe structural heart disease, family history of sudden cardiac death and/or heart conduction abnormalities
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have EKG findings or TTE findings suggestive of a cardiac cause for the palpitations?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have EKG findings of an arrhythmia?
 
 
 
 
 
 
Does the patient have history signs of a psychiatric disorder?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Arrhythmia

Click in each link for the specific diagnostic approach and management

Extrasystole
Narrow complex tachycardia
Wide complex tachycardia
Bradyarrhythmias
Wolff-Parkinson-White syndrome

 
 
 
Non-arrhythmic cardiac cause

Click in each link for the specific diagnostic approach and management

Acute coronary syndrome
Congenital heart disease
Cardiomyopathy
Congestive heart failure
Mitral valve prolapse
Pericarditis
Valvular disease

Aortic stenosis
Aortic regurgitation
 
Psychiatric cause

Click in each link for the specific diagnostic approach and management

Anxiety
Panic attack
Depression
Somatization

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have history of taking drugs or medications that can cause palpitations?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Drugs or medication intake

Click in each link for the specific diagnostic approach and management

Alcohol
Caffeine
❑ Medications

Sympathomimetic agents
Vasodilators
Anticholinergic agents
❑ Withdrawal of beta-blockers
Beta-agonists
Digitalis

❑ Recreational drugs

Cocaine
Heroin
Cannabis
Amphetamines

Nicotine

 
 
Systemic disease

Click in each link for the specific diagnostic approach and management

Anemia
Electrolyte disturbances
Fever
Hyperthyroidism
Hypoglycemia
Hypovolemia
Pheochromocytoma
Vasovagal reflex

 
 
 

Treatment

The management of palpitations will be directed to the specific underlying cuase. If the etiology can be determined and low risk, potentialy curative treatments are available that should be the first choice of management. For benign arrhythmias, such as extrasystole, lifestyle changes may be sufficient to prevent future episodes. For patients in whom no clear disease has been established, advise should be made for them to avoid possible triggers for palpitations as caffeine, alcohol, nicotine, recreational drugs.[1][2][3][4][6]
Abbreviations: NSTEMI: Non ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction

 
 
 
 
 
 
 
Determine the cause of the palpitations
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardiac cause
 
 
 
 
 
 
 
Extracardiac cause
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Drugs or medication intake

Alcohol
Caffeine
❑ Medications

Sympathomimetic agents
Vasodilators
Anticholinergic agents
❑ Withdrawal of beta-blockers
Beta-agonists
Digitalis

❑ Recreational drugs

Cocaine
Heroin
Cannabis
Amphetamines

Nicotine

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider hospitalization

❑ Implantations or replacement of pacemakers for bradyarrhythmias
VT and SVT which require urgent electrical cardioversion or catheter ablation therapy
❑ Symptoms of hemodynamic instability or heart failure
❑ Patients with structural heart disease who requires surgical or transcatheter intervention
❑ Severe psychiatric conditions
❑ Severe systemic disease

 
 
 
 
 
 
 

Do's

Don'ts

EKG examples

Narrow complex tachycardia

Type of Arrhythmia EKG (lead II)† Clues
Sinus tachycardia Onset and termination: gradual
Rhythm: regular
Rate: >220 minus the age of the patient
Response to adenosine: transient decrease of the rate
Atrial fibrillation Onset and termination: abrupt
Rhythm: irregular
Rate:100-180 bpm
Response to adenosine: transient decrease of the ventricular rate
Atrial flutter Onset and termination: abrupt
Rhythm: regular
Rate: >150 bpm
Response to adenosine: transient decrease of the rate
Presence of saw-tooth appearance
AVNRT Onset and termination: abrupt
Rhythm: regular
Rate: 150-250 bpm
Response to adenosine: termination of the arrhythmia
AVRT Onset and termination: abrupt
Rhythm: regular
Rate: 150-250 bpm
Response to adenosine: termination of the arrhythmia
Focal atrial tachycardia Onset and termination: abrupt
Rhythm: regular
Rate: 150-250 bpm
Nonparoxysmal junctional tachycardia Rhythm: regular
Retrograde P wave
Most commonly due to ischemia or digitalis toxicity
Multifocal atrial tachycardia Onset and termination: gradual
Rhythm: irregular
Rate: 100-150 bpm
Response to adenosine: no effect
3 different P wave morphologies

ECG strips are courtesy of ECGpedia.

Wide complex tachycardia

Example Regularity Atrial frequency Ventricular frequency Origin (SVT/VT) p-wave Effect of adenosine
Wide complex (QRS > 0.12)
Ventricular Tachycardia regular (mostly) 60-100 bpm 110-250 bpm ventricle (VT) AV-dissociation no rate reduction (sometimes accelerates)
Ventricular Fibrillation irregular 60-100 bpm 400-600 bpm ventricle (VT) AV-dissociation none
Ventricular Flutter regular 60-100 bpm 150-300 bpm ventricle (VT) AV-dissociation none
Accelerated Idioventricular Rhythm regular (mostly) 60-100 bpm 50-110 bpm ventricle (VT) AV-dissociation no rate reduction (sometimes accelerates)
Torsade de Pointes regular 150-300 bpm ventricle (VT) AV-dissociation no rate reduction (sometimes accelerates)
Bundle-branch re-entrant Tachycardia* regular 60-100 bpm 150-300 bpm ventricles (VT) AV-dissociation no rate reduction
* Bundle-branch re-entrant tachycardia is extremely rare

STEMI

Shown below is an EKG demonstrating the evolution of an infarct on the EKG. ST elevation, Q wave formation, T wave inversion, normalization with a persistent Q wave suggest STEMI.

Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:AMI_evolutie.png

NSTEMI

Shown below is an EKG showing an ST depression in V2, V3, V4 and V6.

Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page

Pericarditis

Shown below is an EKG with ST elevation in lead I, II, V2, V3, V4, V5 and V6.

ST elevation in leads I, II, V2, V3, V4, V5, and V6 depicting acute pericarditis

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L; et al. (2011). "Management of patients with palpitations: a position paper from the European Heart Rhythm Association". Europace. 13 (7): 920–34. doi:10.1093/europace/eur130. PMID 21697315.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Zimetbaum, P.; Josephson, ME. (1998). "Evaluation of patients with palpitations". N Engl J Med. 338 (19): 1369–73. doi:10.1056/NEJM199805073381907. PMID 9571258. Unknown parameter |month= ignored (help)
  3. 3.0 3.1 3.2 "http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf" (PDF). Retrieved 16 April 2014. External link in |title= (help)
  4. 4.0 4.1 4.2 Abbott, AV. (2005). "Diagnostic approach to palpitations". Am Fam Physician. 71 (4): 743–50. PMID 15742913. Unknown parameter |month= ignored (help)
  5. 5.0 5.1 5.2 Thavendiranathan, P.; Bagai, A.; Khoo, C.; Dorian, P.; Choudhry, NK. (2009). "Does this patient with palpitations have a cardiac arrhythmia?". JAMA. 302 (19): 2135–43. doi:10.1001/jama.2009.1673. PMID 19920238. Unknown parameter |month= ignored (help)
  6. 6.0 6.1 6.2 6.3 "http://www.turner-white.com/pdf/hp_jan03_methods.pdf" (PDF). Retrieved 25 April 2014. External link in |title= (help)
  7. "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 3 April 2014.


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