Palpitations/Tachycardia

Differential Overview

❑ Sinus tachycardia

❑ Paroxysmal supraventricular tachycardia

❑ Atrial fibrillation

❑ Atrial flutter

❑ AV nodal re-entrant tachycardia

❑ Ventricular premature beats

❑ Anxiety

❑ Drugs

❑ Anemia

❑ Multifocal atrial tachycardia

❑ Ventricular tachycardia

Diagnostic Approach

A disquieting awareness of the heartbeat described as pounding, skipping, racing, flopping, or fluttering is usually due to an arrhythmia, or a change in rhythm, rate, or contractility.

Arrhythmia should be approached both from the standpoint of determining the specific rhythm disturbance and recognizing it as a marker for other potentially serious disorders. Signs of underlying heart disease such as ischemia (exertional chest pain), cardiomyopathy (rales, S₃ gallop, diffuse PMI), or syncope must be searched for because they alter the prognostic implications of the rhythm disorder.

A sensation of pounding in the neck is associated with jugular cannon a waves. Presence of a cannon a wave implies atrial contraction and can rule out atrial fibrillation. Intermittent cannon a waves result from atrioventricular dissociation.

Carotid massage will suddenly halve the rate with atrial flutter, but there is a gradual slowing of the pulse with sinus tachycardia. Supraventricular tachycardia either continues or terminates abruptly with carotid massage.

Clinical Findings

Sinus tachycardia  There is a gradual onset and resolution of the tachycardia, and the rate fluctuates with physiological stimuli. A primary cause such as fever, intravascular volume depletion, anxiety, hyperthyroidism, hypoglycemia, or congestive heart failure is usually evident.

Paroxysmal supraventricular tachycardia  The onset and termination are sudden (an “alarm clock heart”), the rhythm is regular, and symptoms last minutes to hours. The patient may be dizzy, feel anxious, and have chest pressure. Termination with vagal stimulation (vomiting, Valsalva, or carotid massage) is an important clue. PSVT usually occurs in an otherwise healthy heart.

Atrial fibrillation  The pulse will be rapid and irregular in rhythm and volume. Jugular a waves will be absent. The peripheral pulse may vary in intensity due to variable ventricular filling with varying cycle lengths. There will often be a precipitating cause, such as underlying mitral regurgitation, new-onset congestive heart failure, pulmonary embolism, hyperthyroidism, or myocardial ischemia.

Atrial flutter  A regular tachycardia at a rate of 150/minute suggests flutter. A precipitating cause, such as pericarditis, ischemia, hyperthyroidism, or mitral stenosis, usually exists.

AV nodal re-entrant tachycardia  There is a sudden-onset regular tachycardia at a rate of 120 to 250/minute. There may be hypotension due to the loss of atrial filling, acute pulmonary edema caused by a sudden increase in atrial pressure, or cannon a waves with A-V dyssynchrony.

Ventricular premature beats  A compensatory pause is often felt as a cessation of the heartbeat, and the following heartbeat is strong due to increased stroke volume from increased filling time. VPBs will usually decrease in frequency with exertion unless they are caused by ischemia.

Anxiety  Awareness of palpitations will be increased at rest and suppressed with exertion. Symptoms occur despite the heart’s regular rate and rhythm.

Drugs  Symptomatic tachycardia/palpitations may be caused by insulin, cocaine, caffeine, sympathomimetics, withdrawal from beta blockers, theophylline, MAO inhibitors, alcohol, and tricyclics.

Anemia  When anemia is mild, palpitation is present on exertion. When it is severe, it is present at rest.

Multifocal atrial tachycardia  There is an irregular rhythm caused by varying A-V conduction, but there will not be cannon a waves. It is usually secondary to severe cardiac or pulmonary disease, digitalis or theophylline intoxication, or hypokalemia.

Ventricular tachycardia  When there is A-V dissociation, cannon a waves may occur at irregular intervals, a helpful clue in deciding between ventricular tachycardia (VT) and supraventricular tachycardia (SVT) with aberrant conduction. There is usually subtle beat-beat variability, and S₁ varies in intensity and quality. It usually accompanies ischemic heart disease, cardiomyopathy, or metabolic disorders and is more likely to be associated with hypotension.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Atrial fibrillation

Read excerpts from these other book chapters related to Atrial fibrillation:

Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

More About Causes of Atrial fibrillation

• Back to symptom: Atrial fibrillation: Introduction (review 77 causes)
• Next Book Extract About Atrial fibrillation: Diastolic Murmur (Field Guide to Bedside Diagnosis)
• All Book Extracts: All Online Book Extracts for Atrial fibrillation

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

 » Next page: Diastolic Murmur (Field Guide to Bedside Diagnosis)

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Diastolic Murmur (Field Guide to Bedside Diagnosis)
• Systolic Murmur (Field Guide to Bedside Diagnosis)
• Continuous Murmur (Field Guide to Bedside Diagnosis)
• Bradycardia (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
• Murmurs (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Tools & Services:

• Bookmark this page
• Related medical articles for Atrial Fibrillation:
• Take a survey relating to Atrial fibrillation
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

Common Health Mistakes

Symptom
Checker

Search Specialists by State and City