Palpitations

Palpitations: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter

David M. Schneider

Palpitations (PPTs), defined as an uncomfortable or abnormal awareness of the heart beat, are common in primary care patients. In one study, recurrent symptoms occurred in 75% of patients and 33% reported lower quality of life, but the 1-year mortality rate was 1.6% (1).

Approach

The initial task is to detect a life-threatening cause of the PPTs. Studies have shown a 7% to 40% incidence of potentially serious arrhythmias in these patients, although the cause in up to 31% is psychiatric (1–3). Because the heart is electrically paced, the mnemonic E-PACED [Electrolytes, Psychiatric, Anemia, Cardiac, Endocrine (hyperthyroidism, hypoglycemia, menopause, pheochromocytoma), Drugs] may bring to mind the major causes of PPTs. Not all patients with arrhythmias experience PPTs, and individual patients vary greatly in sensitivity to PPTs.

History

 The history alone may suggest the underlying diagnosis.

A. Characteristics of the PPTs. Are the PPTs regular or irregular? Fast or slow? What descriptors does the patient use? Are the PPTs only in the chest? Ask patients to tap out the rhythm of their PPTs, and to check their pulse during an episode (3).

1. Rapid, irregular PPTs imply atrial fibrillation, multifocal atrial tachycardia, or atrial flutter with variable conduction.

2. Rapid, regular PPTs occur with supraventricular tachycardias (SVTs), including sinus tachycardia and ventricular tachycardia (VT).

3. A “stop-start,” “flip-flop,” or “turning over” sensation in the chest (postectopic pause and subsequent accentuated beat) is usually caused by premature ventricular contractions (PVCs) or premature atrial contractions (PACs).

 4. PPTs felt in the neck represent atria contracting against closed atrioventricular (AV) valves, with blood refluxing into the superior vena cava. The most common cause is AV nodal reentrant tachycardia (AVNRT), which generally causes rapid, regular, sustained pounding; it can also occur with PVCs (slower, less regular, less sustained) (3).

 B. Situations in which PPTs occur. PPTs can be associated with anxiety or somatization disorders. Although overlap is seen among patients with PPTs and those with psychiatric disorders, true arrhythmias do occur in such patients. Arrhythmias (SVT, VT, torsades de pointes) can occur with catecholamine release (exercise, emotional stress); PPTs occurring at rest may indicate benign conditions. PPTs associated with position may result from SVT or PVCs.

C. Onset and termination. Although abrupt onset and termination of PPTs suggests PSVT, this finding is neither sensitive nor specific. Anxiety can lead to sinus tachycardia following an arrhythmia, precluding the patient from sensing an abrupt cessation.

D. Associated symptoms. When syncope, presyncope, or dizziness occurs with PPTs, sustained or nonsustained VT must be ruled out (Chapters 2.2 and 2.12).

 E. Other information. Patients with structural heart disease are more likely to have arrhythmias. Age of onset in childhood or adolescence suggests SVT, especially preexcitation syndromes or long QT syndrome. Various substances can be associated with SVT (nicotine, caffeine, adrenergic or anticholinergic drugs, cocaine, amphetamines) or atrial fibrillation (alcohol). Findings consistent with hyperthyroidism or less common disorders causing PPTs (diabetes, Lyme disease, sarcoidosis, amyloidosis) should be pursued. Ask if the patient has found relief with beta-blockers (PVCs) or vagal maneuvers (SVT). Family history (arrhythmias, sudden death, other cardiovascular disease, syncope) can be helpful.

Physical examination (PE)

If the patient is not seen during an episode, aim the PE at detecting abnormalities that are associated with PPTs. Midsystolic click and murmur (mitral valve prolapse), harsh holosystolic murmur (hypertrophic cardiomyopathy), diastolic murmur (aortic regurgitation), or signs of congestive heart failure may aid in diagnosis. Look for stigmata of hyperthyroidism and other conditions noted above (II.E) (Chapter 14.8).

Testing

 A. 12-lead electrocardiogram (ECG). All patients with PPTs should have an ECG. The presence of an arrhythmia may be diagnostic. Findings between episodes can include short PR interval and delta waves (preexcitation),
Q waves (VT, PVCs), long QT interval (drugs, long QT syndrome), left ventricular hypertrophy with left atrial abnormality (AF), and complete heart block (PVCs, torsades de pointes) (3).

 B. Laboratory testing. Initial laboratory testing consists of serum potassium, hemoglobin and hematocrit, and thyroid-stimulating hormone; serum glucose can be added with a suspicion of hypoglycemia.

C. Ambulatory ECG recording (AECG). For patients in whom a diagnosis has not been made with the initial evaluation, AECG monitoring is indicated. A Holter monitor (24- or 48-hour continuous ECG) should be the initial study for patients with daily symptoms. In those with less frequent episodes, a continuous-loop event recorder worn for a duration of 2 weeks is more cost-effective (4,5).

Diagnostic assessment

The history, PE, and ECG are important steps in the evaluation of PPTs, although many patients will require ambulatory ECG testing to reach a diagnosis. If symptoms correlate with arrhythmias on AECG monitoring, a diagnosis can be made and treatment begun, if appropriate. If no arrhythmia occurs and the patient has typical PPTs, a benign cause is likely. When no symptoms and no arrhythmias are found, the AECG is nondiagnostic and repeat testing or referral may be necessary, especially with underlying heart disease or poorly tolerated PPTs.

References

1. Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. Am J Med 1996;100:138–148.

2. Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. The clinical course of palpitations in medical outpatients. Arch Intern Med 1995;155:1782–1788.

3. Zimetbaum P, Josephson ME. Evaluation of patients with palpitations. N Engl
J Med 1998;338:1369–1373.

4. Kinlay S, Leitch JW, Neil A, Chapman BL, Hardy DB, Fletcher PJ. Cardiac event recorders yield more diagnoses and are more cost-effective than 48-hour Holter monitoring in patients with palpitations. Ann Intern Med 1996;124:16–20.

5. Zimetbaum PJ, Kim KY, Josephson ME, Goldberger AL, Cohen DJ. Diagnostic yield and optimal duration of continuous-loop event monitoring for the diagnosis of palpitations. Ann Intern Med 1998;128:890–895.

Book Source Details

• Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
• Author(s): Robert B. Taylor (editor)
• Year of Publication: 2000
• Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.

More About Tachycardia

• Back to disease: Tachycardia: Introduction
• Next Book Extract About Tachycardia: Tachycardia (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
• More Book Extracts: All Online Books for Tachycardia

More Medical Textbooks Online about Tachycardia

Review other book chapters online related to Tachycardia:

Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X

 » Next page: Tachycardia (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

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:

• Tachycardia (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
• Heart Murmur, Diastolic (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
• Heart Murmur, Systolic (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
• Palpitations/Tachycardia (Field Guide to Bedside Diagnosis)
• Diastolic Murmur (Field Guide to Bedside Diagnosis)

Tools & Services:

• Bookmark this page
• 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