Palpitations resident survival guide: Difference between revisions

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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Wolff-Parkinson-White Syndrome Resident Survival Guide Microchapters}}
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align="center" | {{fontcolor|#2B3B44|Palpitations Resident Survival Guide Microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Palpitations resident survival guide#Overview|Overview]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | [[Palpitations resident survival guide#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Palpitations resident survival guide#Causes|Causes]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | [[Palpitations resident survival guide#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Palpitations resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | [[Palpitations resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Palpitations resident survival guide#Complete Diagnostic Approach|Diagnosis]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | [[Palpitations resident survival guide#Complete Diagnostic Approach|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Palpitations resident survival guide#Treatment|Treatment]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | [[Palpitations resident survival guide#Treatment|Treatment]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Palpitations resident survival guide#Do's|Do's]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | [[Palpitations resident survival guide#Do's|Do's]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Palpitations resident survival guide#Don'ts|Don'ts]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | [[Palpitations resident survival guide#EKG gallery|Gallery]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Palpitations resident survival guide#EKG examples|EKGs]]
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==Overview==
==Overview==
[[Palpitations]] are one of the most common complains of patients when visiting outpatient clinics and emergency rooms.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref>  The causes of [[palpitations]] can range from benign (most common) to life-threatening conditions if not managed properly.<ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref>  [[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.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref>  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==
==Causes==
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Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.  
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.  


*[[Ventricular arrhythmia]]
*[[Cardiac tamponade]]
*[[Acute coronary syndrome]]
*[[Acute coronary syndrome]]
*[[Diseases of the valvular structures|Aortic valve disease]]
*[[Cardiac tamponade]]
*[[Hypovolemia]]
*[[Third degree AV block]]
*[[Third degree AV block]]
*[[Ventricular arrhythmia]]


===Common causes===
===Common causes===
*Cardiac causes
*'''Cardiac causes'''
:* [[Arrhythmia]]
:*Arrhythmic
::* [[Premature ventricular contraction]]
::* [[Premature ventricular contraction]]s
::* [[Narrow complex tachycardia resident survival guide|Narrow complex tachycardia]]
::* [[Supraventricular tachycardia causes|Narrow complex tachycardia]]
::* [[Wide complex tachycardia|Wide complex tachycardia]]
::* [[Wide complex tachycardia causes|Wide complex tachycardia]]
:* Non-arrhythmic cardiac causes
:* Non-arrhythmic
::* [[Diseases of the valvular structures]]
::* [[Diseases of the valvular structures|Valvular disease]]
::* [[Pericarditis resident survival guide|Pericarditis]]
::* [[Pericarditis causes|Pericarditis]]
::* [[Structural heart disease]]
::* Structural heart disease
:* Malfunctioning or wrong programing of pacemakers
::* Malfunctioning pacemaker
*Psychiatric causes
*'''Psychiatric causes'''
:* [[Anxiety]]
:* [[Anxiety]]
:* [[Panic attack]]
:* [[Panic attack]]
*Drug and medications
*'''Substance - drug causes'''
:* [[Cardiac glycoside|Cardiac Glycosides]]
:* [[Antiarrhythmics]]
:* [[Sympathomimetics]]
:* [[Insulin]]
:* [[Thyroxine]]
:* [[Alcohol]]
:* [[Alcohol]]
:* [[Caffeine]]
:* [[Caffeine]]
:* Recent withdrawal of [[beta-blockers]]
:* [[Beta-blocker]] withdrawal
:* Recreational drugs
:* [[Amphetamines]]
::* [[Amphetamines]]
:* [[Cannabis]]
::* [[Cannabis]]
:* [[Cocaine]]
::* [[Cocaine]]
*'''Systemic causes'''
::* [[Heroin]]
*Systemic causes
:* [[Anemia]]
:* [[Anemia]]
:* [[Fever]]
:* [[Fever]]
:* [[Hyperthyroidism]]
:* [[Hyperthyroidism]]
:* [[Hypoglycemia]]
:* [[Hypoglycemia]]
:* [[Hypoxia]]
:* [[Hypercapnia]]


Click [[Palpitation causes#Causes|here]] for a complte list of causes for palpitations.
Click [[Palpitation causes#Causes|here]] for a complete list of causes.


==FIRE: Focused Initial Rapid Evaluation==
==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref><ref name="har">{{Cite web  | last =  | first =  | title = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | url = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | publisher =  | date =  | accessdate = 16 April 2014 }}</ref><ref name="Abbott-2005">{{Cite journal  | last1 = Abbott | first1 = AV. | title = Diagnostic approach to palpitations. | journal = Am Fam Physician | volume = 71 | issue = 4 | pages = 743-50 | month = Feb | year = 2005 | doi =  | PMID = 15742913 }}</ref><ref name="Thavendiranathan-2009">{{Cite journal  | last1 = Thavendiranathan | first1 = P. | last2 = Bagai | first2 = A. | last3 = Khoo | first3 = C. | last4 = Dorian | first4 = P. | last5 = Choudhry | first5 = NK. | title = Does this patient with palpitations have a cardiac arrhythmia? | journal = JAMA | volume = 302 | issue = 19 | pages = 2135-43 | month = Nov | year = 2009 | doi = 10.1001/jama.2009.1673 | PMID = 19920238 }}</ref><ref name="turner">{{Cite web  | last =  | first =  | title = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | url = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | publisher =  | date =  | accessdate = 25 April 2014 }}</ref><ref name="ACLS">{{Cite web  | last =  | first =  | title = Part 8: Adult Advanced Cardiovascular Life Support | url = http://circ.ahajournals.org/content/122/18_suppl_3/S729.full | publisher =  | date =  | accessdate = 3 April 2014 }}</ref><br>
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="ACLS">{{Cite web  | last =  | first =  | title = Part 8: Adult Advanced Cardiovascular Life Support | url = http://circ.ahajournals.org/content/122/18_suppl_3/S729.full | publisher =  | date =  | accessdate = 3 April 2014 }}</ref><br>
<span style="font-size:85%">Boxes in the red signify that an urgent management is needed.</span><br>
<span style="font-size:85%">Boxes in the red signify that an urgent management is needed.</span>


<span style="font-size:85%">'''Abbreviations:''' '''AS:''' [[Aortic stenosis]]; '''AR:''' [[Aortic regurgitation]]; '''EKG:''' [[Electrocardiogram]]; '''IV:''' [[Intravenous therapy|Intravenous]]; '''NSTEMI:''' [[Non ST elevation myocardial infarction]]; '''STEMI:''' [[ST elevation myocardial infarction]]; '''TTE:''' [[Echocardiography|Trasthorasic echocardiography]] '''WPW:''' [[Wolff-Parkinson-White syndrome]]</span>
<span style="font-size:85%">'''Abbreviations:''' '''EKG:''' [[Electrocardiogram]]; '''IV:''' [[Intravenous therapy|Intravenous]]; '''NSTEMI:''' [[Non ST elevation myocardial infarction]]; '''STEMI:''' [[ST elevation myocardial infarction]]; '''TTE:''' [[Echocardiography|Transthoracic echocardiography]]; '''VT:''' [[Ventricular tachycardia]]; '''WPW:''' [[Wolff-Parkinson-White syndrome]]</span>


{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | |A01=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Identify cardinal symptoms and signs that increase the pre-test probability of palpitations'''<br>
{{familytree | | | | | | | | | | | | | B01 | | | | | | |B01=<div style="float: left; width: 15em; text-align: left; padding:1em;">'''Does the patient have any of the following findings that require urgent management?'''<br>
Symptoms:<br>
[[Syncope]] <br>(suggestive of [[VT]], complete AV block)<br>
Flip-flopping of the chest<br>
[[Hypotension]] or shock <br>(suggestive of [[VT]])<br>
❑ Rapid fluttering of the chest<br>
❑ [[Chest pain]] <br>(suggestive of [[ischemia]], complete AV block)<br>
Pounding in the neck<br>
❑ [[Shortness of breath]] <br>(suggestive of PE, cardiac tamponade, complete AV block)</div>}}
❑ Pulsation palpitations <br>
{{familytree | | | | | | | | | | |,|-|-|^|-|-|.| | |}}
Signs:<br>
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | | | | | | W01 | | | | W02 | |W01={{fontcolor|#F8F8FF|'''Yes'''}}|W02=<div style="text-align: center; background: #FFFFFF; height: 25px; line-height: 25px;">'''No'''</div>}}
❑ Increased heart rate with regular or irregular rhythm<br>
{{familytree | | | | | | | | | | |!| | | | | |!| | }}
❑ Cardiological findings suggestive of a cardiological disease<br>
{{familytree | | | | | | | | | | |!| | | | | S01 | | | | | |S01=<div style="width:15em">'''[[Palpitations resident survival guide#Complete_Diagnostic_Approach|Continue with the complete diagnostic approach below]]'''</div>}}
: ❑ [[Murmurs]]<br>
{{familytree | | | | | | | | | | DAA | | | | | | | DAA=<div style=" background: #FA8072; text-align: center; width:15em; padding:0.7em"> {{fontcolor|#F8F8FF|'''Stabilize the patient'''}}</div> <div style=" background: #FA8072; text-align: left; padding:0.7em"> {{fontcolor|#F8F8FF|❑ Consider intubation if the patient's airway is compromised, has a Glasgow coma scale (GCS < 8) or profound hemodynamic instability<br>
: ❑ [[S3]] sound<br>
Administer oxygen and maintain a saturation >90%<br>
: ❑ [[Muffled heart sounds]]<br>
Secure 2 large-bore intravenous lines (IVs) and initiate fluid resuscitation<br>
: ❑ Displaced [[apex beat]]</div>}}
Consider vasopressors only if patient remains hypotensive despite fluids<br>
{{familytree | | | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | | | B01 | | | | | | |B01=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Does the patient have any of the followign findings that require urgent management?'''<br>
Palpitations asociated with [[syncope]] (suggestive of [[VT]] of [[structural heart disease]])<br>
[[Chest discomfort]] suggestive of [[ischemia]]<br>
Decompensated [[heart failure]]<br>
----
----
❑ Consider [[Cardioversion|electrical cardioversion]]</div>}}
<center>'''Obtain the following'''</center><br>
{{familytree | | | | | | | |,|-|-|^|-|-|.| | |}}
12 lead ECG <br>
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | | | W01 | | | | W02 | | | | |W01={{fontcolor|#F8F8FF|'''Yes'''}}|W02=<div style="text-align: center; background: #FFFFFF; height: 25px; line-height: 25px;">'''No'''</div>}}
Blood for [[CBC|<span style="color:white;">CBC</span>]], electrolytes, [[Cardiac enzymes|<span style="color:white;">troponin I, CK-MB</span>]], free T3/T4, toxicology screen
{{familytree | | | | | | | |!| | | | | |!| | }}
{{familytree | | | | | | | |!| | | | | S01 | | | | | |S01='''[[Palpitations resident survival guide#Complete diagnostic approach|Continue with the complete duagnostic apporoach shown below]]'''}}
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: left;| | | | | | | Y01 | | | | | | Y01=<div style="float: left; text-align: left; width: 14em; padding:1em; color: #FFFFFF;">'''Does the patient have any of the following findings suggesting of hemodynamic instability?'''
❑ [[Hemodynamic instability|<span style="color:white;">Hemodynamic instability</span>]]<br>
[[Hypotension|<span style="color:white;">Hypotension</span>]]<br>
❑ [[Cold extremities|<span style="color:white;">Cold extremities</span>]]<br>
❑ [[Cyanosis|<span style="color:white;">Peripheral cyanosis</span>]]<br>
❑ [[Mottling|<span style="color:white;">Mottling</span>]]<br>
❑ [[Altered mental status|<span style="color:white;">Altered mental status</span>]]<br></div>}}
{{familytree | | | | | |,|-|^|-|.| | | |}}
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | C01 | | C02 | | | |C01={{fontcolor|#F8F8FF|'''Yes'''}}|C02={{fontcolor|#F8F8FF|'''No'''}}}}
{{familytree | | | | | |!| | | |!| | | | |}}
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | E01 | | |!| | | | | | | |E01=<div style="float: left; text-align: left; width: 14em; padding:1em; color: #FFFFFF;">'''Stabilize the patient'''<br>
❑ Assess circulation, secure airway and breathing<br>
❑ Secure IV line<br>
❑ Offer [[Oxygen therapy|<span style="color:white;">oxygen</span>]]<br>
Cardiac monitor to identify rhythm<br>
❑ Monitor [[Blood pressure|<span style="color:white;">blood pressure</span>]] and [[Pulse oximeter|<span style="color:white;">oximetry</span>]]</div>}}
{{familytree | | | | | |!| | | |!| | | }}
{{familytree | | | | | |`|-|v|-|'| | | }}
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | | | F01 | | | | | | | | | |F01=<div style="float: left; text-align: center; width: 14em; padding:1em; color: #FFFFFF;">'''Order an [[EKG|<span style="color:white;">EKG</span>]] immediately'''<br><br>
Does the patient has any [[EKG|<span style="color:white;">EKG</span>]] findings suggestive of an arrhythmia?</div>}}
{{familytree | | | | | |,|-|^|-|.| | | }}
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | G01 | | G02 | | | | |G01={{fontcolor|#F8F8FF|'''Yes'''}}|G02={{fontcolor|#F8F8FF|'''No'''}}}}
{{familytree | | | | | |!| | | |!| | | |}}
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | H01 | | |!| | | | |H01=<div style="float: left; text-align: left; width: 14em; padding:1em;">[[Narrow complex tachycardia#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Narrow complex tachycardia</span>]]<br> [[Wide complex tachycardia#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Wide complex tachycardia</span>]]<br> [[Bradycardia#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Bradycardia</span>]]<br> [[Wolff-Parkinson-White syndrome resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">WPW</span>]]</div>}}
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | | | | | Z02 | | | | | | | | |Z02=<div style="float: left; text-align: left; width: 24em; padding:1em; color: #FFFFFF;">'''Does the patient have any [[EKG|<span style="color:white;">EKG</span>]] findings suggestive of myocardial ischemia or pericarditis?'''<br>


[[STEMI resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">STEMI</span>]]<br>
❑ Consider CTA if patient has a Wells score >4}} </div>|boxstyle= background:  #FA8072}}
[[ST elevation|<span style="color:white;">ST elevation</span>]] 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<br>
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | | | | | | |!| | | | | | | | | | |}}
❑ [[ST depression|<span style="color:white;">ST depression</span>]] in at least two precordial leads V1-V4 (suggestive of [[posterior myocardial infarction|<span style="color:white;">posterior MI</span>]])<br>
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | | | | | | F01 | | | | | | | | | |F01=<div style="float: center; width: 14em; padding:1em; color: #FFFFFF;"><center>Does the patient have any characteristic signs and symptoms or any [[EKG|<span style="color:white;">ECG</span>]] / lab abnormalities?</center></div>}}
❑ [[ST depression|<span style="color:white;">ST depression</span>]] in several leads plus [[ST elevation|<span style="color:white;">ST elevation</span>]] in lead aVR (suggestive of occlusion of the [[left main|<span style="color:white;">left main</span>]] or proximal [[LAD|<span style="color:white;">LAD</span>]] artery)<br>
{{familytree | | | | | | |,|-|-|-|^|-|-|-|-|-|-|-|-|-|-|.|}}
❑ New [[LBBB|<span style="color:white;">LBBB</span>]]<br>
{{familytree | | | | | | C01 | | | | | | | | | | | | | C02 |C01={{fontcolor|#F8F8FF|'''Yes'''}}|C02={{fontcolor|#F8F8FF|'''No'''}}|boxstyle= background-color: #FA8072}}
{{familytree | | | | | | |!| | | | | | | | | | | | | | |!| | }}
{{familytree | | |,|-|-|-|+|-|-|-|v|-|-|-|v|-|-|-|.| | L01 | |L01=<div style="float: center; width: 14em; padding:1em; color: #FFFFFF;"><center>'''❑ Continue supportive care<br>❑ Place patient on cardiac monitor <br>❑ Re-evaluate if status worsens'''</center></div>|boxstyle= background-color: #FA8072}}
{{familytree | | H01 | | H02 | | H03 | | H04 | | H05 | | | | | |H01=<div style="float: center; padding:1em; color: #FFFFFF;"><center>'''Tachyarrhythmia'''</center></div>
----
<div style="float: left; padding:1em; color: #FFFFFF; text-align: left;">❑ Abnormal rhythm w/ a ventricular rate of ≥100/min<br><br><br></div>
|H02=<div style="float: center; padding:1em; color: #FFFFFF; width:8em;"><center>'''Ischemia'''</center></div>
----
<div style="float: left; padding:1em; color: #FFFFFF; text-align: left;">❑ ST-segment deviation<br>❑ Elevated cardiac biomarkers</div>
|H03=<div style="float: center; padding:1em; color: #FFFFFF;"><center>'''Cardiac Tamponade'''</center></div>
----
----
NSTEMI:<br>
<div style="float: left; padding:1em; color: #FFFFFF; text-align: left;">❑ Elevated JVP<br>❑ Pulsus paradoxus<br>❑ Low-voltage QRS complexes<br>❑ Electrical alternans<br>
❑ [[Non specific ST / T wave changes|<span style="color:white;">Non specific ST / T wave changes</span>]]<br>
❑ PR segment depression</div>
Flipped or inverted [[T wave|<span style="color:white;">T waves</span>]]<br>
|H04=<div style="float: center; padding:1em; color: #FFFFFF;"><center>'''Thyroid Storm'''</center></div>
❑ [[Electrocardiogram|<span style="color:white;">ST Depression</span>]]<br>
----
----
[[Pericarditis resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Pericarditis</span>]]<br>
<div style="float: left; padding:1em; color: #FFFFFF; text-align: left;">❑ Suppressed TSH<br>❑ Elevated free T3/T4<br><br><br><br></div>
[[ST segment elevation|<span style="color:white;">ST segment elevation</span>]] in leads I, II, aVL, aVF, and V3-V6<br>
|H05=<div style="float: center; padding:1em; color: #FFFFFF;"><center>'''Pulmonary Embolism'''</center></div>
❑ [[PR segment depression|<span style="color:white;">PR segment depression</span>]]<br>
----
❑ [[Low QRS voltage|<span style="color:white;">Low QRS voltage</span>]] (in large [[Pericardial effusion|<span style="color:white;">pericardial effusion</span>]] and [[Constrictive pericarditis|<span style="color:white;">constrictive pericarditis</span>]])<br>
<div style="float: left; padding:1em; color: #FFFFFF; text-align: left;">❑ Tachypnea<br>❑ Wells Score >4<br>❑ Positive chest CTA<br><br></div>
[[Cardiac tamponade|<span style="color:white;">Cardiac tamponade</span>]]: [[Electrical alternans|<span style="color:white;">electrical alternans</span>]]<br>
|boxstyle= background-color: #FA8072}}
</div>}}
{{familytree | | |!| | | |!| | | |!| | | |!| | | |!| | | | | | | |}}
{{familytree | | | | | | |,|-|-|^|-|-|.| |}}
{{familytree | | I01 | | I02 | | I03 | | I04 | | I05 | | | | | | |I01=<div style="float: left; padding:1em; color: #FFFFFF; text-align: left;">
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | | I01 | | | | I02 | | | |I01={{fontcolor|#F8F8FF|'''Yes'''}}|I02={{fontcolor|#F8F8FF|'''No'''}}}}
*[[Narrow_complex_tachycardia_resident_survival_guide#Treatment|<span style="color:white;">Supraventricular / Narrow-Complex Tachyarrhythmia Treatment Algorithm</span>]]
{{familytree | | | | |,|-|^|-|.| | | |!| | | |}}
 
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: left;| | | | J01 | | J02 | | J03 | | | | |J01=[[STEMI resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">STEMI</span>]]<br> [[Unstable angina/ NSTEMI resident survival guide#Treatment approach|<span style="color:white;">NSTEMI</span>]]<br>|J02=[[Pericarditis resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Pericarditis</span>]]|J03=<div style="float: left; text-align: left; width: 14em; padding:1em; color: #FFFFFF;">Order a [[Echocardiography|<span style="color:white;">TTE</span>]]</div>}}
 
{{familytree | | | | | | | | | | | | |!| | | | | |}}
*[[Wide_complex_tachycardia_resident_survival_guide#Treatment|<span style="color:white;">Ventricular / Wide-Complex Tachyarrhythmia Treatment Algorithm</span>]]</div>
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | | | | | | | | K01 | | |K01=<div style="float: left; text-align: center; width: 18em; padding:1em; color: #FFFFFF;">'''Does the patient have any structural heart disease?'''</div>}}
|I02=<div style="float: left; padding:1em; color: #FFFFFF; text-align: left;">
{{familytree | | | | | | | | | | |,|-|^|-|.| | | |}}
 
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | | | | | | L01 | | L02 | | |L01={{fontcolor|#F8F8FF|'''Yes'''}}|L02={{fontcolor|#F8F8FF|'''No'''}}}}
*[[Unstable_angina/_NSTEMI_resident_survival_guide|<span style="color:white;">UA / NSTEMI Treatment Algorithm</span>]]
{{familytree | | | | | | | | | | |!| | | |!| | | |}}
 
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: left;| | | | | | | | | | M01 | | M02 | | | | |M01=[[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Acute heart failure</span>]]<br> [[Aortic stenosis resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">AS</span>]]<br> [[Aortic regurgitarion resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Acute AR</span>]]<br>|M02=<div style="float: left; text-align: center; width: 22em; padding:1em; color: #FFFFFF;">'''Does the patient have history of consuming any toxic substance that can explain the palpitations and hemodynamic instability?'''</div>}}
 
{{familytree | | | | | | | | | | | | |,|-|^|-|.| | | |}}
*[[STEMI_resident_survival_guide#FIRE:_Focused_Initial_Rapid_Evaluation|<span style="color:white;">STEMI Treatment Algorithm</span>]]<br><br><br><br><br><br></div>
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | | | | | | | | N01 | | N02 | | | |N01={{fontcolor|#F8F8FF|'''Yes'''}}|N02={{fontcolor|#F8F8FF|'''No'''}}}}
|I03=<div style="float: left; padding:1em; color: #FFFFFF; text-align: left;">
{{familytree | | | | | | | | | | | | |!| | | |!| | | | |}}
 
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | | | | | | | | O01 | | O02 | | | |O01=<div style="float: left; text-align: left; width: 14em; padding:1em;">[[Alcohol|<span style="color:white;">Alcohol</span>]]<br> [[Cocaine|<span style="color:white;">Cocaine</span>]]<br> [[Heroin|<span style="color:white;">Heroin</span>]]<br> [[Amphetamines|<span style="color:white;">Amphetamines</span>]]</div>|O02=<div style="float: left; text-align: center; width: 14em; padding:1em; color: #FFFFFF;">Look for systemic diseases than can cause palpitations and hemodynamic instability</div>}}
*[[Cardiac_tamponade_resident_survival_guide#Treatment|<span style="color:white;">Cardiac Tamponade Treatment Algorithm</span>]]<br><br><br><br><br><br><br><br><br><br><br><br></div>
{{familytree | | | | | | | | | | | | | | | | |!| | | | | |}}
|I04=<div style="float: left; padding:1em; color: #FFFFFF; text-align: left;">
{{familytree |boxstyle= padding: 0; background: #FA8072; text-align: left;| | | | | | | | | | | | | | | | P01 | | | | | |P01=[[Electrolyte disturbance#ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT)|<span style="color:white;">Electrolyte disturbances</span>]]<br>[[Hyperthyroidism medical therapy|<span style="color:white;">Hyperthyroidism</span>]]<br>[[Hypoglycemia medical therapy|<span style="color:white;">Hypoglycemia</span>]]<br>[[Hypovolemia#Treatment|<span style="color:white;">Hypovolemia</span>]]<br>}}
 
*[[Hyperthroidism_resident_survival_guide#Treatment|<span style="color:white;">Thyroid Storm Treatment Algorithm</span>]]<br><br><br><br><br><br><br><br><br><br><br><br></div>
|I05=<div style="float: left; padding:1em; color: #FFFFFF; text-align: left;">
 
*[[Pulmonary_embolism_resident_survival_guide#Treatment|<span style="color:white;">Pulmonary Embolism Treatment Algorithm</span>]]<br><br><br><br><br><br><br><br><br><br><br><br></div>
|boxstyle= background-color: #FA8072}}
{{familytree/end}}
{{familytree/end}}


Line 165: Line 146:
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref><ref name="har">{{Cite web  | last =  | first =  | title = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | url = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | publisher =  | date =  | accessdate = 16 April 2014 }}</ref><ref name="Abbott-2005">{{Cite journal  | last1 = Abbott | first1 = AV. | title = Diagnostic approach to palpitations. | journal = Am Fam Physician | volume = 71 | issue = 4 | pages = 743-50 | month = Feb | year = 2005 | doi =  | PMID = 15742913 }}</ref><ref name="Thavendiranathan-2009">{{Cite journal  | last1 = Thavendiranathan | first1 = P. | last2 = Bagai | first2 = A. | last3 = Khoo | first3 = C. | last4 = Dorian | first4 = P. | last5 = Choudhry | first5 = NK. | title = Does this patient with palpitations have a cardiac arrhythmia? | journal = JAMA | volume = 302 | issue = 19 | pages = 2135-43 | month = Nov | year = 2009 | doi = 10.1001/jama.2009.1673 | PMID = 19920238 }}</ref><ref name="turner">{{Cite web  | last =  | first =  | title = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | url = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | publisher =  | date =  | accessdate = 25 April 2014 }}</ref>
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref><ref name="har">{{Cite web  | last =  | first =  | title = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | url = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | publisher =  | date =  | accessdate = 16 April 2014 }}</ref><ref name="Abbott-2005">{{Cite journal  | last1 = Abbott | first1 = AV. | title = Diagnostic approach to palpitations. | journal = Am Fam Physician | volume = 71 | issue = 4 | pages = 743-50 | month = Feb | year = 2005 | doi =  | PMID = 15742913 }}</ref><ref name="Thavendiranathan-2009">{{Cite journal  | last1 = Thavendiranathan | first1 = P. | last2 = Bagai | first2 = A. | last3 = Khoo | first3 = C. | last4 = Dorian | first4 = P. | last5 = Choudhry | first5 = NK. | title = Does this patient with palpitations have a cardiac arrhythmia? | journal = JAMA | volume = 302 | issue = 19 | pages = 2135-43 | month = Nov | year = 2009 | doi = 10.1001/jama.2009.1673 | PMID = 19920238 }}</ref><ref name="turner">{{Cite web  | last =  | first =  | title = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | url = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | publisher =  | date =  | accessdate = 25 April 2014 }}</ref>


<span style="font-size:85%"> '''Abbreviations:''' '''AF:''' [[Atrial fibrillation]]; '''AVRT:''' [[AV reentry tachycardia]]; '''AVNRT:''' [[AV nodal reentry tachycardia]]; '''BP:''' [[Blood pressure]]; '''CBC:''' [[Complete blood count]]; '''EKG:''' [[Electrocardiogram]]; '''EPS:''' [[Electrophysiology|Electrophysiological study]] '''SVT:''' [[Supraventricular tachycardia]] '''TSH:''' [[Thyroid stimulating hormone]]; '''TTE:''' [[Echocardiography|Transthorasic echocardiography]]; '''VT:''' [[Ventricular tachycardia]]; '''WPW:''' [[Wolff-Parkinson-White syndrome]] </span>
<span style="font-size:85%"> '''Abbreviations:''' '''AF:''' [[Atrial fibrillation]]; '''AVRT:''' [[AV reentry tachycardia]]; '''AVNRT:''' [[AV nodal reentry tachycardia]]; '''BP:''' [[Blood pressure]]; '''CBC:''' [[Complete blood count]]; '''EKG:''' [[Electrocardiogram]]; '''EPS:''' [[Electrophysiology|Electrophysiological study]] '''SVT:''' [[Supraventricular tachycardia]] '''TSH:''' [[Thyroid stimulating hormone]]; '''TTE:''' [[Echocardiography|Transthoracic echocardiography]]; '''VT:''' [[Ventricular tachycardia]]; '''WPW:''' [[Wolff-Parkinson-White syndrome]] </span>


{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | A01 | | | | |A01=<div style="float: left; text-align: left; width: 24em; padding:1em;">'''Characterize the symptoms:'''<br>
{{familytree | | | | | | | A01 | | | | |A01=<div style="float: left; text-align: left; width: 24em; padding:1em;">'''Characterize the symptoms:'''<br>
❑ '''Duration'''
❑ '''Character of palpitations'''<br>
: ❑ Breif: spontaneous termination<br>
: ❑ Flip-flopping of the [[chest]]<br>
: ❑ Persistent: need appropriate tratment for controlling the symptoms<br>
: ❑ Rapid fluttering of the [[chest]] <br>
❑ '''Frequency:''' (daily, weekly, monthly)<br>
: ❑ Pounding in the [[neck]] <br>
❑ '''Onset'''
: ❑ Pulsation [[palpitations]] <br>
: ❑ Sudden (suggestive of [[SVT]] or [[VT]])<br>
: ❑ Gradual (suggestive of [[anxiety]] or excerise induced [[sinus tachycardia]])<br>
❑ '''Termination:''' with [[vagal maneuvers]] (suggestive of [[SVT]])<br>
❑ '''Type of palpitations'''<br>
: ❑ Flip-flopping of the [[chest]] (suggestive of [[extrasystole]])<br>
: ❑ Rapid fluttering of the [[chest]] (suggestive of [[tachycardia]])<br>
: ❑ Pounding in the [[neck]] (suggestive of [[AVRT]] and [[AVNRT]])<br>
: ❑ Pulsation [[palpitations]] (suggestive of [[structural heart disease]])<br>
: ❑ [[Anxiety|Anxiety-related]] palpitations<br>
: ❑ [[Anxiety|Anxiety-related]] palpitations<br>
❑ '''Prodrome'''
❑ '''Onset'''<br>
: ❑ [[Chest pain]]<br>
: ❑ Sudden <br>
: ❑ [[Dizziness]]<br>
: ❑ Gradual<br>
❑ '''Duration'''<br>
: ❑ Brief<br>
: ❑ Persistent<br>
❑ '''Frequency'''<br>
: ❑ Daily
: ❑ Weekly
: ❑ Monthly<br>
❑ '''Termination'''<br>
: ❑ Successful with [[vagal maneuvers]] (suggestive of [[SVT]])<br>
❑ '''Associated with'''<br>
: ❑ Sudden changes of posture (suggestive of [[Orthostatic hypotension|intolerance to orthostasis]] or [[AVNRT]])<br>
: ❑ [[Syncope]]<br>
: ❑ [[Syncope]]<br>
: ❑ [[Dyspnea]]<br>
: ❑ [[Angina]], [[dyspnea]], [[fatigue]], [[vertigo]], [[dizziness]]<br>
: ❑ [[Vertigo]]<br>
: ❑ [[Polyuria]] (suggestive of [[AF]])<br>
: ❑ [[Fatigue]]<br>
: ❑ Rapid regular pulse in the [[neck]]<br>
❑ '''Position'''
: ❑ After standing up (suggestive of [[orthostatic hypotension]] or [[AVNRT]])
: ❑ Pounding sensation while lying in bed (suggestive of [[AVNRT]])
</div>}}
{{familytree | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | Z01 | | | | | | |Z01=<div style="float: left; text-align: left; width: 24em; padding:1em;">'''Search for associated symptoms and circumstances'''<br>
❑ Sudden changes of posture (suggestive of [[Orthostatic hypotension|intolerance to orthostasis]] or [[AVNRT]])<br>
❑ [[Syncope]] (suggestive of [[SVT]] or [[structural heart disease]])<br>
❑ [[Angina]], [[dyspnea]], [[fatigue]] (suggestive of [[structural heart disease]] or [[ischemic heart disease]])<br>
❑ [[Polyuria]] (suggestive of [[AF]])<br>
❑ Rapid regular pulse in the [[neck]] (suggestive of [[AVNRT]])<br>
</div>}}
</div>}}
{{familytree | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | B01 | | | | | |B01=<div style="float: left; text-align: left; width: 24em; padding:1em;">'''Inquire about drugs that can cause palpitations:'''<br>
{{familytree | | | | | | | B01 | | | | | |B01=<div style="float: left; text-align: left; width: 24em; padding:1em;">'''Inquire about drugs that can cause palpitations:'''<br>
❑ [[Sympathomimetic]] agent pump inhalers ([[Asthma|asthmatic patients]])<br>
❑ [[Sympathomimetic|Sympathomimetic agents]] <br>
❑ Inhaled beta-agonists <br>
❑ [[Vasodilator|Vasodilators]]<br>
❑ [[Vasodilator|Vasodilators]]<br>
❑ [[Anticholinergic|Anticholinergic agents]]<br>
❑ [[Anticholinergic|Anticholinergic agents]]<br>
Withdrawal of [[beta-blockers]]<br>
❑ [[Beta-blocker]] withdrawal<br>
❑ [[Alcohol]]<br>
❑ Recreational drugs<br>
❑ [[Cocaine]]<br>  
: ❑ [[Alcohol]]<br>
❑ [[Heroin]]<br>
: ❑ [[Cocaine]]<br>  
❑ [[Amphetamines]]<br>
: ❑ [[Heroin]]<br>
❑ [[Caffeine]]<br>
: ❑ [[Amphetamines]]<br>
❑ [[Nicotine]]<br>  
: ❑ [[Caffeine]]<br>
❑ [[Cannabis]]<br>
: ❑ [[Nicotine]]<br>  
❑ Synthetic drugs<br>
: ❑ [[Cannabis]]<br>
: ❑ Synthetic drugs<br>
❑ Weight reduction drugs<br>
❑ Weight reduction drugs<br>
</div>}}
</div>}}
Line 222: Line 197:
❑ Previous episodes of palpitations<br>
❑ Previous episodes of palpitations<br>
: ❑ First episode
: ❑ First episode
:: ❑ Childhood (suggestive of [[AVRT]] or [[AVNRT]])<br>
:: ❑ Adult patients (suggestive of [[AF]] or [[VT]])
: ❑ Number of episodes<br>
: ❑ Number of episodes<br>
: ❑ Time since last episode<br>
: ❑ Time since last episode<br>
Line 246: Line 219:
: ❑ [[Rhythm]]<br>
: ❑ [[Rhythm]]<br>
:: ❑ Regular (suggestive of [[SVT]] or [[VT]])<br>
:: ❑ Regular (suggestive of [[SVT]] or [[VT]])<br>
:: ❑ Irregular (suggestive of [[extrasystole]])<br>
:: ❑ Irregular (suggestive of [[premature ventricular beats]])<br>
:: ❑ Irregularly irregular (suggestive of [[AF]])<br>
:: ❑ Irregularly irregular (suggestive of [[AF]])<br>
: ❑ [[Rate]]<br>
: ❑ [[Rate]]<br>
:: ❑ [[Tachycardia]]<br>
:: ❑ [[Tachycardia]]<br>
::: ❑ Over 220 minus the patient's age (suggestive of [[SVT]] or [[VT]])<br>
::: ❑ Under 220 minus the patient's age (suggestive of [[anxiety]] or [[panic attack]])<br>
:: ❑ [[Bradycardia]] (suggestive of [[sinus bradycardia]], [[AV block]])
:: ❑ [[Bradycardia]] (suggestive of [[sinus bradycardia]], [[AV block]])
: ❑ [[Pulse]] deficit (suggestive of [[AF]] or [[premature ventricular beats]])
: ❑ [[Pulse]] deficit (suggestive of [[AF]] or [[premature ventricular beats]])
❑ [[Blood pressure]]<br>
❑ [[Blood pressure]]<br>
: ❑ [[Hypotension]] (suggestive of [[hypovolemia]])
: ❑ [[Hypotension]]<br>
: ❑ [[Orthostatic hypotension]] (Fall in [[Blood pressure|systolic BP]] ≥ 20 mmHg and/or in [[Blood pressure|diastolic BP]] of at least ≥ 10 mmHg between the [[supine]] and sitting [[BP]] reading)<br>
: ❑ [[Orthostatic hypotension]]<br>
: ❑ [[Hypertension]]<br>
: ❑ [[Hypertension]]<br>
❑ [[Temperature]]<br>
❑ [[Temperature]]<br>
: ❑ [[Fever]] (suggestive of [[infection]])<br>
: ❑ [[Fever]] (suggestive of [[infection]])<br>
❑ [[Respiratory rate]] (non-specific)<br>
❑ [[Tachypnea]] (non-specific)<br>
'''Face'''<br>
'''Eyes'''<br>
❑ [[Exophthalmos]] (suggestive of [[Graves disease]])<br>
❑ [[Exophthalmos]] (suggestive of [[Graves disease]])<br>
'''Neck'''<br>
'''Neck'''<br>
Line 267: Line 238:
❑ [[Jugular venous pulse]]: [[cannon A wave]] (suggestive of [[Atrioventricular dissociation|AV dissociation]])<br>
❑ [[Jugular venous pulse]]: [[cannon A wave]] (suggestive of [[Atrioventricular dissociation|AV dissociation]])<br>
'''Skin'''<br>
'''Skin'''<br>
❑ Hot and sweaty (suggestive of [[hyperthyroidism]])<br>
❑ Hot and sweaty (suggestive of [[hyperthyroidism]] or [[fever]])<br>
'''Hair'''<br>
'''Hair'''<br>
❑ Thin (suggestive of [[hyperthyroidism]])<br>
❑ Thin (suggestive of [[hyperthyroidism]])<br>
Line 274: Line 245:
❑ [[Wheezing]] (non-specific)<br>
❑ [[Wheezing]] (non-specific)<br>
'''Cardiovascular'''<br>
'''Cardiovascular'''<br>
❑ [[Muffled heart sounds]] (suggestive of [[pericarditis]])<br>
❑ [[Muffled heart sounds]]<br>
❑ [[Pericardial friction rub]] (suggestive of [[pericarditis]])<br>
❑ [[Pericardial friction rub]] (suggestive of [[pericarditis]])<br>
❑ [[Murmurs]] (suggestive of [[valve disease]])<br>  
❑ [[Murmurs]] (suggestive of [[valve disease]])<br>  
: ❑ Associated with [[Heart sounds|midsystolic click]] (suggestive of [[mitral valve prolapse]])<br>
: ❑ [[Heart murmur|Holosystolic murmur]] in the left sternal border that increases with [[valsalva menuver]] (suggestive of [[hypertrophic obstructive cardiomyopathy]])<br>
❑ Displaced [[apex beat]] (suggestive of [[cardiomegaly]]<br>
❑ Displaced [[apex beat]] (suggestive of [[cardiomegaly]]<br>
❑ [[S3]] (suggestive of [[heart failure]])<br>
❑ [[S3]] (suggestive of [[heart failure]])<br>
❑ [[S4]]<br>
'''Neurologic'''<br>
'''Neurologic'''<br>
❑ [[Tremors]] (suggestive of [[panic attacks]] or [[hyperthyroidism]])<br>
❑ [[Tremors]] (suggestive of [[panic attacks]] or [[hyperthyroidism]])<br>
Line 289: Line 259:
: ❑ Determine if the rhythm is regular or irregular
: ❑ Determine if the rhythm is regular or irregular
: ❑ Assess the [[p wave]] and [[QRS]] morphology
: ❑ Assess the [[p wave]] and [[QRS]] morphology
: ❑ Rate over 100 bpm, QRS <120 ms (suggestive of [[Narrow complex tachycardia resident survival guide|narrow complex tachycardia]])
: ❑ Rate over 100 bpm, QRS < 120 ms (suggestive of [[Narrow complex tachycardia resident survival guide|narrow complex tachycardia]])
: ❑ Search for short [[PR intervals]] and [[delta waves]] (suggestive of [[WPW]])
: ❑ Search for short [[PR intervals]] and [[delta waves]] (suggestive of [[WPW]])
: ❑ Irregular rhythm, change in [[p wave]] morphology (suggestive of [[AF]])
: ❑ Irregular rhythm, change in [[p wave]] morphology (suggestive of [[AF]])
: ❑ Regular rhythm, saw-tooth appearance (suggestive of [[atrial flutter]])
: ❑ Regular rhythm, saw-tooth appearance (suggestive of [[atrial flutter]])
: ❑ Rate over 100 bpm, [[QRS]] >120 ms (suggestive of [[Wide complex tachycardia resident survival guide|wide complex tachycardia]])
: ❑ Rate over 100 bpm, [[QRS]] > 120 ms (suggestive of [[Wide complex tachycardia resident survival guide|wide complex tachycardia]])
: ❑ Presence of prior [[myocardial infarction]] [[Q waves]] (suggestive of [[VT]])
: ❑ Search for deep septal [[Q waves]] in [[Introduction to ECG#Leads|I]], [[Introduction to ECG#Leads|V4]] to [[Introduction to ECG#Leads|V6]] and signs of [[left ventricular hypertrophy]] (suggestive of [[hypertrophic obstructive cardiomyopathy]])
: ❑ Search for deep septal [[Q waves]] in [[Introduction to ECG#Leads|I]], [[Introduction to ECG#Leads|V4]] to [[Introduction to ECG#Leads|V6]] and signs of [[left ventricular hypertrophy]] (suggestive of [[hypertrophic obstructive cardiomyopathy]])
: ❑ Normal [[EKG]] (suggestive of [[anxiety]] or [[panic attack]])
: ❑ Normal [[EKG]] (suggestive of [[anxiety]] or [[panic attack]])
❑ [[CBC]] (to rule out [[anemia]] or [[infection]])<br>
❑ [[CBC]] (to rule out [[anemia]] or [[infection]])<br>
❑ [[Electrolyte disturbances|Electrolytes]] (to rule out [[hypokalemia]] and [[hypomagnesemia]])<br>
❑ [[Electrolyte disturbances|Electrolytes]] (to rule out potassium and magnesium imbalances)<br>
❑ [[TSH]] (to rule out [[hyperthyroidism]])<br>
❑ [[TSH]] (to rule out [[hyperthyroidism]])<br>
❑ [[Blood sugar|Glucose level]] (to rule out [[hypoglycemia]])<br>
❑ [[Blood sugar|Glucose level]] (to rule out [[hypoglycemia]])<br>
Line 306: Line 275:
❑ [[TTE]] (to rule out [[structural heart disease]])<br>
❑ [[TTE]] (to rule out [[structural heart disease]])<br>
</div>}}
</div>}}
{{familytree | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | W01 | | | | | | | |W01= <div style="float: left; text-align: left; width: 24em; padding:1em;">'''Consider hospitalization'''<br>
{{familytree | | | | | | W01 | | | | | | | |W01= <div style="float: left; text-align: left; width: 24em; padding:1em;">'''Consider hospitalization'''<br>
❑ Recurrent episodes when no ambulatory [[EKG]] devices are available<br>
❑ Recurrent episodes when no ambulatory [[EKG]] devices are available<br>
❑ [[Structural heart disease|Severe structural heart disease]], family history of [[sudden cardiac death]] and/or [[Electrical conduction system of the heart|heart conduction abnormalities]]</div>}}
❑ [[Structural heart disease|Severe structural heart disease]], family history of [[sudden cardiac death]] and/or [[Electrical conduction system of the heart|heart conduction abnormalities]]</div>}}
{{familytree | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | Y01 | | | | | |Y01='''Does the patient have [[EKG]] findings or [[TTE]] findings suggestive of a cardiac cause for the palpitations?'''}}
{{familytree | | | | | | Y01 | | | | | |Y01='''Does the patient have clinical or [[EKG]] findings suggestive of a cardiac cause of the palpitations?'''}}
{{familytree | | | |,|-|-|-|^|-|-|-|.| |}}
{{familytree | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|.| |}}
{{familytree | | | F01 | | | | | | F02 | | | F01='''Yes''' | F02='''No'''}}
{{familytree | | | F01 | | | | | | | | | | | F02 | | | F01='''Yes''' | F02='''No'''}}
{{familytree | | | |!| | | | | | | |!| | | | | |}}
{{familytree | |,|-|^|-|v|-|-|-|.| | | | | | |!|}}
{{familytree | | | X01 | | | | | | X02 | | | |X01=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have [[EKG]] findings of an [[Arrhythmia resident survival guide|arrhythmia?]]'''</div>|X02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have history signs of a [[psychiatric disorder]]?'''</div>}}
{{familytree | S01 | | S02 | | S03 | | | | | S04 | | | |S01=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''Arrhythmia'''<br>
{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
❑ [[Premature ventricular beat]]<br>
{{familytree | W01 | | W02 | | W03 | | W04 | | |W01='''Yes'''|W02='''No'''|W03='''Yes'''|W04='''No'''}}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | | }}
{{familytree | G01 | | G02 | | G03 | | |!| | | | | G01=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Arrhythmia'''<br>
<span style="font-size:85%">Click in each link for the specific diagnostic approach and management</span><br>
 
❑ [[Extrasystole]]<br>
❑ [[Narrow complex tachycardia resident survival guide#Complete Diagnostic Approach|Narrow complex tachycardia]]<br>
❑ [[Narrow complex tachycardia resident survival guide#Complete Diagnostic Approach|Narrow complex tachycardia]]<br>
❑ [[Wide complex tachycardia resident survival guide#Complete Diagnostic Approach|Wide complex tachycardia]]<br>
❑ [[Wide complex tachycardia resident survival guide#Complete Diagnostic Approach|Wide complex tachycardia]]<br>
❑ [[Bradycardia resident survival guide#Complete Diagnostic Approach|Bradyarrhythmias]]<br>
❑ [[Bradycardia resident survival guide#Complete Diagnostic Approach|Bradyarrhythmias]]<br>
❑ [[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach|Wolff-Parkinson-White syndrome]]<br>
❑ [[Wolff-Parkinson-White syndrome resident survival guide#Complete Diagnostic Approach|Wolff-Parkinson-White syndrome]]<br>
</div>|G02=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Non-arrhythmic cardiac cause'''<br>
</div>|S02=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''Myocardial ischemia'''<br>
<span style="font-size:85%">Click in each link for the specific diagnostic approach and management</span><br>
❑ [[Acute coronary syndrome]]<br>
: ❑ [[STEMI resident survival guide#Diagnosis|STEMI]]<br>
: ❑ [[Unstable angina/ NSTEMI resident survival guide#Diagnostic approach|NSTEMI]]<br>
: ❑ [[Unstable angina/ NSTEMI resident survival guide#Diagnostic approach|Unstable angina]]<br>
</div>|S03=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''Other EKG findings'''</div>|S04=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''Does the patient have a history of [[psychiatric disorder]]s?'''</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
{{familytree | | | | | | R01 | | R02 | | R03 | | R04 | | |R01=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''EKG findings suggestive of pericarditis'''<br>
[[Pericarditis resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Pericarditis</span>]]<br>
❑ [[ST segment elevation]] in leads I, II, aVL, aVF, and V3-V6<br>
❑ [[PR segment depression]]<br>
❑ [[Low QRS voltage]] (in large [[Pericardial effusion]] and [[Constrictive pericarditis]])<br>
</div>|R02='''Non-specific EKG findings'''|R03='''Yes'''|R04='''No'''}}
{{familytree | | | | | | | | | | | |!| | | |!| | | |!| | }}
{{familytree | | | | | | | | | | | T01 | | T02 | | T03 | | |T01='''Order a TTE'''|T02=<div style="float: left; text-align: left; width: 12em; padding:1em;">
Consider the following if all diagnostic tests are normal:<br>


❑ [[Acute coronary syndrome]]<br>
❑ [[Anxiety]]<br>
❑ [[Panic attack]]<br>
❑ [[Depression]]<br>
❑ [[Somatization]]<br>
</div>|T03=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Is the patient taking any substances/drugs that can cause palpitations?'''</div>}}
{{familytree | | | | | | | | | | | |!| | | | |,|-|-|^|-|-|.| | |}}
{{familytree | | | | | | | | | | | Q01 | | | Z01 | | | | Z02 | | | | |Q01=<div style="float: left; text-align: left; width: 12em; padding:1em;">
❑ [[Congenital heart disease]]<br>
❑ [[Congenital heart disease]]<br>
❑ [[Cardiomyopathy]]<br>
❑ [[Cardiomyopathy]]<br>
❑ [[Heart failure resident survival guide#Complete Diagnostic Approach|Congestive heart failure]]<br>
❑ [[Heart failure resident survival guide#Complete Diagnostic Approach|Congestive heart failure]]<br>
❑ [[Mitral valve prolapse]]<br>
❑ [[Pericarditis resident survival guide#Complete Diagnostic Approach|Pericarditis]]<br>
❑ [[Pericarditis resident survival guide#Complete Diagnostic Approach|Pericarditis]]<br>
❑ [[Valvular disease]]<br>
❑ [[Valvular disease]]<br>
: ❑ [[Aortic stenosis resident survival guide#Complete Diagnostic Approach|Aortic stenosis]]<br>
: ❑ [[Aortic stenosis resident survival guide#Complete Diagnostic Approach|Aortic stenosis]]<br>
: ❑ [[Aortic regurgitation resident survival guide#Complete Diagnostic Approach|Aortic regurgitation]]<br>
: ❑ [[Mitral valve prolapse]]<br>
</div>|G03=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Psychiatric cause'''<br>
</div>|Z01='''Yes'''|Z02='''No'''}}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | |!| | | |}}
{{familytree | | | | | | | | | | | | | | | | I03 | | | | I04 | | | |I03=<div style="float: left; text-align: left; width: 12em; padding:1em;">
<span style="font-size:85%">Click in each link for the specific diagnostic approach and management</span><br>
<span style="font-size:85%">Click in each link for the specific diagnostic approach and management</span><br>
❑ [[Anxiety]]<br>
❑ [[Panic attack]]<br>
❑ [[Depression]]<br>
❑ [[Somatization]]<br>
</div>}}
{{familytree | | | | | | | | | | | | | U01 | | | U01=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''Does the patient have history of taking drugs or medications that can cause [[palpitations]]?'''</div>}}
{{familytree | | | | | | | |,|-|-|-|-|v|'| | | |}}
{{familytree | | | | | | | H01 | | | H02 | | | |H01='''Yes'''|H02='''No'''}}
{{familytree | | | | | | | |!| | | | |!| | | | |}}
{{familytree | | | | | | | I01 | | | I02 | | | |I01=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Drugs or medication intake'''<br>
<span style="font-size:85%">Click in each link for the specific diagnostic approach and management</span><br>
❑ [[Acute alcohol intoxication|Alcohol]]<br>
❑ [[Acute alcohol intoxication|Alcohol]]<br>
❑ [[Caffeine#Overuse|Caffeine]]<br>
❑ [[Caffeine#Overuse|Caffeine]]<br>
Line 360: Line 331:
: ❑ [[Vasodilator|Vasodilators]]<br>
: ❑ [[Vasodilator|Vasodilators]]<br>
: ❑ [[Anticholinergic#Effects|Anticholinergic agents]]<br>
: ❑ [[Anticholinergic#Effects|Anticholinergic agents]]<br>
: ❑ Withdrawal of [[beta-blockers]]<br>
: ❑ [[Beta-blocker]] withdrawal<br>
: ❑ [[Beta-agonists]]<br>
: ❑ [[Beta-agonists]]<br>
: ❑ [[Digoxin#Wanrings|Digitalis]]<br>
: ❑ [[Digoxin#Wanrings|Digitalis]]<br>
Line 369: Line 340:
: ❑ [[Amphetamines]]
: ❑ [[Amphetamines]]
❑ [[Nicotine]]
❑ [[Nicotine]]
</div>|I02=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Systemic disease'''<br>
</div>|I04=<div style="float: left; text-align: left; width: 12em; padding:1em;">
<span style="font-size:85%">Click in each link for the specific diagnostic approach and management</span><br>
<span style="font-size:85%">Click in each link for the specific diagnostic approach and management</span><br>
❑ [[Anemia]]<br>
❑ [[Anemia]]<br>
❑ [[Electrolyte disturbances]]<br>
❑ [[Electrolyte disturbances]]<br>
Line 384: Line 354:


==Treatment==
==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.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref><ref name="har">{{Cite web  | last =  | first =  | title = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | url = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | publisher =  | date =  | accessdate = 16 April 2014 }}</ref><ref name="Abbott-2005">{{Cite journal  | last1 = Abbott | first1 = AV. | title = Diagnostic approach to palpitations. | journal = Am Fam Physician | volume = 71 | issue = 4 | pages = 743-50 | month = Feb | year = 2005 | doi =  | PMID = 15742913 }}</ref><ref name="turner">{{Cite web  | last =  | first =  | title = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | url = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | publisher =  | date =  | accessdate = 25 April 2014 }}</ref><br>
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.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref><ref name="har">{{Cite web  | last =  | first =  | title = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | url = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | publisher =  | date =  | accessdate = 16 April 2014 }}</ref><ref name="Abbott-2005">{{Cite journal  | last1 = Abbott | first1 = AV. | title = Diagnostic approach to palpitations. | journal = Am Fam Physician | volume = 71 | issue = 4 | pages = 743-50 | month = Feb | year = 2005 | doi =  | PMID = 15742913 }}</ref><ref name="turner">{{Cite web  | last =  | first =  | title = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | url = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | publisher =  | date =  | accessdate = 25 April 2014 }}</ref><br>
<span style="font-size:85%">'''Abbreviations:''' '''NSTEMI:''' [[Non ST elevation myocardial infarction]]; '''STEMI:''' [[ST elevation myocardial infarction]]</span>
<span style="font-size:85%">'''Abbreviations:''' '''NSTEMI:''' [[Non ST elevation myocardial infarction]]; '''STEMI:''' [[ST elevation myocardial infarction]]</span>


Line 390: Line 360:
{{familytree | | | | | | | | A01 | | | | | | | | | | |A01='''Determine the cause of the palpitations'''}}
{{familytree | | | | | | | | A01 | | | | | | | | | | |A01='''Determine the cause of the palpitations'''}}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | | | | | | }}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | | | | | | }}
{{familytree | | | B01 | | | | | | | | B02 | | | | | | |B01=<div style="float: left; text-align: left; width: 08em; padding:1em;">'''Cardiac cause'''</div>|B02='''Extracardiac cause'''}}
{{familytree | | | B01 | | | | | | | | B02 | | | | | | |B01=<div style="float: left; text-align: left; width: 08em; padding:1em;">'''Cardiac cause'''</div>|B02='''Non-cardiac cause'''}}
{{familytree | |,|-|^|-|.| | | |,|-|-|-|+|-|-|-|.| | | |}}
{{familytree | |,|-|^|-|.| | | |,|-|-|-|+|-|-|-|.| | | |}}
{{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | | |C01=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Arrhythmia'''<br>
{{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | | |C01=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Arrhythmia'''<br>
Line 414: Line 384:
: [[Aortic stenosis resident survival guide#treatment|Aortic stenosis]]<br>
: [[Aortic stenosis resident survival guide#treatment|Aortic stenosis]]<br>
: [[Aortic regurgitation resident survival guide#Treatment|Aortic regurgitation]]<br>
: [[Aortic regurgitation resident survival guide#Treatment|Aortic regurgitation]]<br>
</div>|C03=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Psychiatric cause'''<br>
</div>|C03=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Psychiatric disorder'''<br>
[[Anxiety]]<br>
[[Anxiety]]<br>
[[Panic attack]]<br>
[[Panic attack]]<br>
[[Depression]]<br>
[[Depression]]<br>
[[Somatization]]<br>
[[Somatization]]<br>
</div>|C04=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Drugs or medication intake'''<br>
</div>|C04=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Substance/drug intake'''<br>
❑ [[Alcohol]]<br>
❑ [[Alcohol]]<br>
❑ [[Caffeine]]<br>
❑ [[Caffeine]]<br>
Line 426: Line 396:
: ❑ [[Vasodilators]]<br>
: ❑ [[Vasodilators]]<br>
: ❑ [[Anticholinergic|Anticholinergic agents]]<br>
: ❑ [[Anticholinergic|Anticholinergic agents]]<br>
: ❑ Withdrawal of [[beta-blockers]]<br>
: ❑ [[Beta-blocker]] withdrawal<br>
: ❑ [[Beta-agonists]]<br>
: ❑ [[Beta-agonists]]<br>
: ❑ [[Digitalis]]<br>
: ❑ [[Digitalis]]<br>
Line 458: Line 428:


==Do's==
==Do's==
* If possible, perform physical exam and [[EKG]] when the patient is symptomatic.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref>
* If possible, perform a physical exam and an [[EKG|ECG]] when the patient is symptomatic.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref>
* While asymptomatic, search for signs of [[structural heart disease]] such as [[murmurs]], displaced [[apex beat]] or [[S3]].<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref>
* If a patient is asymptomatic, search for signs of [[structural heart disease]] such as [[murmurs]], displaced [[apex beat]] or [[S3]].<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref>
* Perform an ambulatory [[EKG]] in patients with recurrent episodes of [[palpitations]] in which the cause couldn't be determined.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref>  
* Perform an ambulatory [[EKG|ECG]] in patients with recurrent episodes of [[palpitations]] of undetermined etiology.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref>  
* Perform an [[Electrophysiology|EPS]] in patients in whom the ambulatory [[EKG]] is inconclusive.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref>
* Perform an electrophysiologic study ([[Electrophysiology|EPS]]) for patients with inconclusive ambulatory [[EKG|ECG]].<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref>
* Perform an [[Electrophysiology|EPS]], with [[Catheter ablation|ablation therapy]] if necessary, in patients severe [[heart disease]], when [[palpitations]] preceded [[syncope]] and when the patient need [[cardiorespiratory resuscitation]] maneuvers.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Thavendiranathan-2009">{{Cite journal  | last1 = Thavendiranathan | first1 = P. | last2 = Bagai | first2 = A. | last3 = Khoo | first3 = C. | last4 = Dorian | first4 = P. | last5 = Choudhry | first5 = NK. | title = Does this patient with palpitations have a cardiac arrhythmia? | journal = JAMA | volume = 302 | issue = 19 | pages = 2135-43 | month = Nov | year = 2009 | doi = 10.1001/jama.2009.1673 | PMID = 19920238 }}</ref>
* Perform an [[Electrophysiology|EPS]], with [[Catheter ablation|ablation therapy]] if necessary, in patients with severe [[heart disease]], particularly when [[palpitations]] preceded [[syncope]] and when the patient required cardio-respiratory resuscitation maneuvers.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Thavendiranathan-2009">{{Cite journal  | last1 = Thavendiranathan | first1 = P. | last2 = Bagai | first2 = A. | last3 = Khoo | first3 = C. | last4 = Dorian | first4 = P. | last5 = Choudhry | first5 = NK. | title = Does this patient with palpitations have a cardiac arrhythmia? | journal = JAMA | volume = 302 | issue = 19 | pages = 2135-43 | month = Nov | year = 2009 | doi = 10.1001/jama.2009.1673 | PMID = 19920238 }}</ref>
* Estimulate life-style changes that may lower the posibility of future episodes, such as exercise, lower [[alcohol]] and [[caffeine]] intake, [[Smoking|smoke cesation]].<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref>
* Advise life-style changes that may lower the possibility of future episodes, such as exercise, lower [[alcohol]] and [[caffeine]] intake, and [[Smoking|smoking cessation]].<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref>
* Perform an [[exercise stress test]] in patients with exercise induced [[palpitations]].<ref name="turner">{{Cite web  | last =  | first =  | title = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | url = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | publisher =  | date =  | accessdate = 25 April 2014 }}</ref><br>
* Perform an [[exercise stress test]] in patients with exercise induced [[palpitations]].<ref name="turner">{{Cite web  | last =  | first =  | title = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | url = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | publisher =  | date =  | accessdate = 25 April 2014 }}</ref><br>


==Don'ts==
* Do not recomend high intesity sports as it may induce [[atrial fibrillation]].<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref>


==EKG examples==
==EKG gallery==
===Narrow complex tachycardia===
===Narrow complex tachycardia===
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
|-
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Type of [[Arrhythmia]]'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''[[EKG]]''' (lead II)||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Clues'''  
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align="center" | '''Type of [[Arrhythmia]]'''|| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align="center" | '''[[EKG]]''' (lead II) || style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align="center" | '''Clues'''  
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left| '''[[Sinus tachycardia]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:Sinus tachycardia.png|300px|link=Narrow complex tachycardia resident survival guide]]||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Onset and termination''': gradual<br> '''Rhythm''': regular<br> '''Rate''': >220 minus the age of the patient <br> '''Response to adenosine''': transient decrease of the rate
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" | '''[[Sinus tachycardia]]'''|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |[[Image:Sinus tachycardia.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''Onset and termination''': gradual<br> '''Rhythm''': regular<br> '''Rate''': >220 minus the age of the patient <br> '''Response to adenosine''': transient decrease of the rate
|-  
|-
|style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[Atrial fibrillation]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:atrial fibrillation.png|300px|link=Narrow complex tachycardia resident survival guide]]||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Onset and termination''': abrupt <br> '''Rhythm''': irregular <br> '''Rate''':100-180 bpm <br> '''Response to adenosine''': transient decrease of the ventricular rate
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''[[Atrial fibrillation]]'''|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |[[Image:atrial fibrillation.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''Onset and termination''': abrupt <br> '''Rhythm''': irregular <br> '''Rate''':100-180 bpm <br> '''Response to adenosine''': transient decrease of the ventricular rate
|-  
|-
|style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[Atrial flutter]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:atrial flutter.png|300px|link=Narrow complex tachycardia resident survival guide]]||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Onset and termination''': abrupt <br> '''Rhythm''': regular<br> '''Rate''': >150 bpm <br> '''Response to adenosine''': transient decrease of the rate <br> Presence of saw-tooth appearance
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''[[Atrial flutter]]'''|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |[[Image:atrial flutter.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''Onset and termination''': abrupt <br> '''Rhythm''': regular<br> '''Rate''': >150 bpm <br> '''Response to adenosine''': transient decrease of the rate <br> Presence of saw-tooth appearance
|-  
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[AVNRT]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:AVNRT.png|300px|link=Narrow complex tachycardia resident survival guide]]||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Onset and termination''': abrupt <br> '''Rhythm''': regular<br> '''Rate''': 150-250 bpm <br> '''Response to adenosine''': termination of the arrhythmia
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''[[AVNRT]]'''|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |[[Image:AVNRT.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''Onset and termination''': abrupt <br> '''Rhythm''': regular<br> '''Rate''': 150-250 bpm <br> '''Response to adenosine''': termination of the arrhythmia
|-  
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[AVRT]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:AVRT.png|300px|link=Narrow complex tachycardia resident survival guide]]||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left| '''Onset and termination''': abrupt <br> '''Rhythm''': regular<br> '''Rate''': 150-250 bpm <br> '''Response to adenosine''': termination of the arrhythmia
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''[[AVRT]]'''|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |[[Image:AVRT.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" | '''Onset and termination''': abrupt <br> '''Rhythm''': regular<br> '''Rate''': 150-250 bpm <br> '''Response to adenosine''': termination of the arrhythmia
|-  
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[Focal atrial tachycardia]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:focal atrial tachycardia.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Onset and termination''': abrupt <br> '''Rhythm''': regular<br> '''Rate''': 150-250 bpm  
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''[[Focal atrial tachycardia]]'''|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |[[Image:focal atrial tachycardia.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''Onset and termination''': abrupt <br> '''Rhythm''': regular<br> '''Rate''': 150-250 bpm  
|-  
|-
|style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[Junctional tachycardia|Nonparoxysmal junctional tachycardia]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:JTS.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Rhythm''': regular <br> Retrograde P wave<br> Most commonly due to ischemia or digitalis toxicity
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''[[Junctional tachycardia|Nonparoxysmal junctional tachycardia]]'''|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |[[Image:JTS.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''Rhythm''': regular <br> Retrograde P wave<br> Most commonly due to ischemia or digitalis toxicity
|-  
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[Multifocal atrial tachycardia]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:MAT.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Onset and termination''': gradual<br> '''Rhythm''': irregular<br> '''Rate''': 100-150 bpm <br> '''Response to adenosine''': no effect<br>3 different [[P wave]] morphologies
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''[[Multifocal atrial tachycardia]]'''|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |[[Image:MAT.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align="left" |'''Onset and termination''': gradual<br> '''Rhythm''': irregular<br> '''Rate''': 100-150 bpm <br> '''Response to adenosine''': no effect<br>3 different [[P wave]] morphologies
|-  
|-
|}
|}
† [[ECG]] strips are courtesy of ECGpedia.


===Wide complex tachycardia===
===Wide complex tachycardia===
Line 505: Line 472:
!p-wave
!p-wave
!Effect of adenosine
!Effect of adenosine
|-  
|-
| colspan="8" style="text-align:left;background-color:#cfefcf;" | '''Wide complex (QRS > 0.12)'''
| colspan="8" style="text-align:left;background-color:#cfefcf;" | '''Wide complex (QRS > 0.12)'''
|-
|-
Line 561: Line 528:
| [[AV-dissociation]]
| [[AV-dissociation]]
| no rate reduction
| no rate reduction
|-  
|-
|colspan="8"|* Bundle-branch re-entrant tachycardia is extremely rare
| colspan="8" |* Bundle-branch re-entrant tachycardia is extremely rare
|}
|}


Line 569: Line 536:


[[Image:STEMI evolution.png|center|800px]]
[[Image:STEMI evolution.png|center|800px]]
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:AMI_evolutie.png


===[[Unstable angina/non ST elevation myocardial infarction electrocardiogram|NSTEMI]]===
===[[Unstable angina/non ST elevation myocardial infarction electrocardiogram|NSTEMI]]===
Shown below is an EKG showing an [[ST depression]] in [[Electrocardiogram#Precordial|V2]], [[Electrocardiogram#Precordial|V3]], [[Electrocardiogram#Precordial|V4]] and [[Electrocardiogram#Precordial|V6]].
Shown below is an EKG showing an [[ST depression]] in [[Electrocardiogram#Precordial|V2]], [[Electrocardiogram#Precordial|V3]], [[Electrocardiogram#Precordial|V4]] and [[Electrocardiogram#Precordial|V6]].


[[Image:unstable-angina.jpg|center|500px]]
[[Image:unstable-angina.jpg|center|800px]]
''Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page''
----
Shown below is an [[EKG]] showing an inversion in the T wave at leads [[Electrocardiogram#Precordial|V4]], [[Electrocardiogram#Precordial|V5]] and [[Electrocardiogram#Precordial|V6]].
[[Image:T wave inversion in V4, V5 and V6.png|center|800px]]


===Pericarditis===
===Pericarditis===
Shown below is an [[EKG]] with [[ST elevation]] in lead I, II, V2, V3, V4, V5 and V6.
Shown below is an [[EKG]] with [[ST elevation]] in lead [[Electrocardiogram#Augmented limb Leads|I]], [[Electrocardiogram#Augmented limb Leads|II]], [[Electrocardiogram#Precordial|V2]], [[Electrocardiogram#Precordial|V3]], [[Electrocardiogram#Precordial|V4]], [[Electrocardiogram#Precordial|V5]] and [[Electrocardiogram#Precordial|V6]].


[[Image:Acute-pericarditis.jpg|center|500px|thumb|ST elevation in leads I, II, V2, V3, V4, V5, and V6 depicting acute pericarditis]]
[[Image:Acute-pericarditis.jpg|center|800px|thumb|ST elevation in leads I, II, V2, V3, V4, V5, and V6 depicting acute pericarditis]]


==References==
==References==
Line 588: Line 556:
[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date]]
[[Category:Emergency]]
[[Category:Emergency medicine]]


{{WikiDoc Help Menu}}
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
{{WikiDoc Sources}}
</div>
</div>

Latest revision as of 16:20, 4 May 2015

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 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

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.

NSTEMI

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


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

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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