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.

Palpitations Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Gallery

Overview

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
  • Arrhythmic
  • Non-arrhythmic
  • Psychiatric causes
  • Substance - drug causes
  • Systemic causes

Click here for a complete list of causes.

FIRE: Focused Initial Rapid Evaluation

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

Abbreviations: EKG: Electrocardiogram; IV: Intravenous; NSTEMI: Non ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction; TTE: Transthoracic echocardiography; VT: Ventricular tachycardia; WPW: Wolff-Parkinson-White syndrome

 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings that require urgent management?

Syncope
(suggestive of VT, complete AV block)
Hypotension or shock
(suggestive of VT)
Chest pain
(suggestive of ischemia, complete AV block)

Shortness of breath
(suggestive of PE, cardiac tamponade, complete AV block)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stabilize the patient
❑ Consider intubation if the patient's airway is compromised, has a Glasgow coma scale (GCS < 8) or profound hemodynamic instability

❑ Administer oxygen and maintain a saturation >90%
❑ Secure 2 large-bore intravenous lines (IVs) and initiate fluid resuscitation
❑ Consider vasopressors only if patient remains hypotensive despite fluids


Obtain the following

❑ 12 lead ECG
❑ Blood for CBC, electrolytes, troponin I, CK-MB, free T3/T4, toxicology screen

❑ Consider CTA if patient has a Wells score >4
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any characteristic signs and symptoms or any ECG / lab abnormalities?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Continue supportive care
❑ Place patient on cardiac monitor
❑ Re-evaluate if status worsens
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tachyarrhythmia

❑ Abnormal rhythm w/ a ventricular rate of ≥100/min


 
Ischemia

❑ ST-segment deviation
❑ Elevated cardiac biomarkers
 
Cardiac Tamponade

❑ Elevated JVP
❑ Pulsus paradoxus
❑ Low-voltage QRS complexes
❑ Electrical alternans
❑ PR segment depression
 
Thyroid Storm

❑ Suppressed TSH
❑ Elevated free T3/T4



 
Pulmonary Embolism

❑ Tachypnea
❑ Wells Score >4
❑ Positive chest CTA

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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][3][4][5][6][7]

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: Transthoracic echocardiography; VT: Ventricular tachycardia; WPW: Wolff-Parkinson-White syndrome

 
 
 
 
 
 
Characterize the symptoms:

Character of palpitations

❑ Flip-flopping of the chest
❑ Rapid fluttering of the chest
❑ Pounding in the neck
❑ Pulsation palpitations
Anxiety-related palpitations

Onset

❑ Sudden
❑ Gradual

Duration

❑ Brief
❑ Persistent

Frequency

❑ Daily
❑ Weekly
❑ Monthly

Termination

❑ Successful with vagal maneuvers (suggestive of SVT)

Associated with

❑ Sudden changes of posture (suggestive of intolerance to orthostasis or AVNRT)
Syncope
Angina, dyspnea, fatigue, vertigo, dizziness
Polyuria (suggestive of AF)
❑ Rapid regular pulse in the neck
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inquire about drugs that can cause palpitations:

Sympathomimetic agents
❑ Inhaled beta-agonists
Vasodilators
Anticholinergic agents
Beta-blocker withdrawal
❑ Recreational drugs

Alcohol
Cocaine
Heroin
Amphetamines
Caffeine
Nicotine
Cannabis
❑ Synthetic drugs

❑ Weight reduction drugs

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain a detailed past medical history:

❑ Previous episodes of palpitations

❑ First episode
❑ 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 premature ventricular beats)
❑ Irregularly irregular (suggestive of AF)
Rate
Tachycardia
Bradycardia (suggestive of sinus bradycardia, AV block)
Pulse deficit (suggestive of AF or premature ventricular beats)

Blood pressure

Hypotension
Orthostatic hypotension
Hypertension

Temperature

Fever (suggestive of infection)

Tachypnea (non-specific)
Eyes
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 or fever)
Hair
❑ Thin (suggestive of hyperthyroidism)
Respiratory
Rales (suggestive of heart failure)
Wheezing (non-specific)
Cardiovascular
Muffled heart sounds
Pericardial friction rub (suggestive of pericarditis)
Murmurs (suggestive of valve disease)
❑ Displaced apex beat (suggestive of cardiomegaly
S3 (suggestive of heart failure)
S4
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)
❑ 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 potassium and magnesium imbalances)
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 clinical or EKG findings suggestive of a cardiac cause of the palpitations?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Myocardial ischemia

Acute coronary syndrome

STEMI
NSTEMI
Unstable angina
 
Other EKG findings
 
 
 
 
Does the patient have a history of psychiatric disorders?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EKG findings suggestive of pericarditis

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)

 
Non-specific EKG findings
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order a TTE
 

Consider the following if all diagnostic tests are normal:

Anxiety
Panic attack
Depression
Somatization

 
Is the patient taking any substances/drugs that can cause palpitations?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Click in each link for the specific diagnostic approach and management
Alcohol
Caffeine
❑ Medications

Sympathomimetic agents
Vasodilators
Anticholinergic agents
Beta-blocker withdrawal
Beta-agonists
Digitalis

❑ Recreational drugs

Cocaine
Heroin
Cannabis
Amphetamines

Nicotine

 
 
 

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 should be directed towards the underlying cause. If the etiology can be determined and low risk, potentially curative treatments are available these 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, patients should be advised to avoid possible triggers of palpitations such as caffeine, alcohol, nicotine, recreational drugs.[1][3][4][5][7]
Abbreviations: NSTEMI: Non ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction

 
 
 
 
 
 
 
Determine the cause of the palpitations
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardiac cause
 
 
 
 
 
 
 
Non-cardiac cause
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Substance/drug intake

Alcohol
Caffeine
❑ Medications

Sympathomimetic agents
Vasodilators
Anticholinergic agents
Beta-blocker withdrawal
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


EKG gallery

Narrow complex tachycardia

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

Wide complex tachycardia

Example Regularity Atrial frequency Ventricular frequency Origin (SVT/VT) p-wave Effect of adenosine
Wide complex (QRS > 0.12)
Ventricular Tachycardia Vt small.svg regular (mostly) 60-100 bpm 110-250 bpm ventricle (VT) AV-dissociation no rate reduction (sometimes accelerates)
Ventricular Fibrillation Vf small.svg irregular 60-100 bpm 400-600 bpm ventricle (VT) AV-dissociation none
Ventricular Flutter Vflutt small.svg regular 60-100 bpm 150-300 bpm ventricle (VT) AV-dissociation none
Accelerated Idioventricular Rhythm Aivr small.svg regular (mostly) 60-100 bpm 50-110 bpm ventricle (VT) AV-dissociation no rate reduction (sometimes accelerates)
Torsade de Pointes Tdp small.svg regular 150-300 bpm ventricle (VT) AV-dissociation no rate reduction (sometimes accelerates)
Bundle-branch re-entrant Tachycardia* Bb reentry small.svg 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.

STEMI evolution.png

NSTEMI

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

Unstable-angina.jpg

Shown below is an EKG showing an inversion in the T wave at leads V4, V5 and V6.

T wave inversion in V4, V5 and V6.png

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. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 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. "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 3 April 2014.
  3. 3.0 3.1 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)
  4. 4.0 4.1 "http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf" (PDF). Retrieved 16 April 2014. External link in |title= (help)
  5. 5.0 5.1 Abbott, AV. (2005). "Diagnostic approach to palpitations". Am Fam Physician. 71 (4): 743–50. PMID 15742913. Unknown parameter |month= ignored (help)
  6. 6.0 6.1 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)
  7. 7.0 7.1 7.2 "http://www.turner-white.com/pdf/hp_jan03_methods.pdf" (PDF). Retrieved 25 April 2014. External link in |title= (help)


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