Management of the Patient Presenting with

Palpitation

Samir Saba, MD

Director, Cardiac Electrophysiology

University of Pittsburgh

Definition

Perceptible unpleasant forcible pulsation of the heart, usually with an increase in frequency or force, with or without irregularity in rhythm.

Presentation

• Most common outpatient complaint in patients presenting to PCP and cardiologists

• 16% in one study of 500 patients

• Terminology used:– Rapid fluttering in the chest– Flop-flopping in the chest– Pounding in the neck

Etiology

• Cardiac:– Arrhythmias– Cardiac and extracardiac

shunts– Valvular heart disease– Pacemaker– Atrial myxoma– Cardiomyopathy

• Psychiatric:– Panic disorders– Anxiety disorders– Somatization– Depression

Etiology• Medication:

– Sympathomimetic– Vasodilators– Anticholinergic -blocker withdrawal

• Catecholamine Stress:– Exercise– Stress

• Habits:– Cocaine– Amphetamines– Caffeine– Nicotine

Etiology

• Metabolic disorders:– Hypoglycemia– Thyrotoxicosis– Pheochromocytoma– Mastocytosis– Scombroid Food

Poisoning

• High output states:– Anemia– Pregnancy– Fever– Paget’s disease

Arrhythmic Etiologies

• PAC/PVC

• Sinus arrhythmias

• SVT (AF, Aflutter, ORT, AVNRT, AT)

• Idiopathic ventricular arrhythmias (RVOT, LVOT, fascicular VT)

• Life-threatening ventricular arrhythmias (MMVT, PMVT, TdP, VFlutter, VF)

Approach to the Patient

1. Is the cause of palpitations possibly a life-threatening condition? (Usually cardiac etiology)

• Majority of outpatients have benign etiologies

2. How can we make the patient feel better?

Predictors of Cardiac Etiology

• Male gender

• Reporting irregular heart beats

• History of heart disease

• Event duration > 5 minutes

History

• Circumstances:– Association with anxiety or panic (20% of palpitations

are due to panic attacks and 67% of patients with SVT where diagnosed at some point with panic disorder)

– Association with stress (arrhythmias benign and fatal)– Association with position (AVNRT pr PAC/PVC)– Association with syncope or near-syncope (high level

of suspicion for VA)

Evaluation• Detailed History:

– Age – Onset– Duration– Circumstances – Symptoms– Termination – Maneuvers (CSM, valsalva)– Regularity (tap out the rhythm)– Medications– Habits– Psychiatric disorders

Evaluation

• Physical Exam:– Rarely during

palpitations– Auscultation (MVP,

HCM, chronic AF)– Evidence of CMP,

valvular disease, congenital abnormalities

Evaluation

• 12-Lead ECG:– PAC/PCV/SVT/VT– WPW– LVH/LAE/RAE– Long QT, Brugada,

ARVD– Old MI– Conduction

abnormalities predisposing to TdP

ECG 1

ECG 2

ECG 3

ECG 4

ECG 5

ECG 6

ECG 7

Evaluation: Further Diagnostic Testing

• The diagnostic yield of history, P/E, and ECG is 1/3.

• Further diagnostic testing is needed in 3 groups of patients:

1. Those in whom the initial dx suggests arrhythmias

2. Those at high risk of arrhythmias

3. Those who remain anxious about arrhythmias

Diagnostic Testing

• Rule out structural abnormalities of the heart– Echo– Stress test– Cardiac Cath– MRI

Diagnostic Testing

• Document arrhythmia in the setting of symptoms– Ambulatory monitors

(HM (yield is 33-35%),, Event recorder, Loop monitor (yield is 66-88%), continuous ambulatory monitors)

– ILR, EP testing

Testing

Diagnostic Yield of Loop Monitor

Yield =100%

Yield = 78%

ILR 1: Palpitations

ILR 2: Palpitations and Syncope

EP Study 1

EP Study 2

EP Study 3

Therapy

• No therapy-Blockers, CCB

• Anti-arrhythmic drugs (IC, III)

• Ablation

• Devices

Inappropriate Sinus Tachycardia

• Diagnosis of exclusion after ruling out:– Thyrotoxicosis, anemia, fever, dehydration,

arrhythmias, etc…

• Formulas:– HR max = 220 - age– HR max = 205.8 − (0.685 X age)

• Therapy: -blockers or CCB– Sinus node modification (high recurrence rate, need a

PM, paralysis of phrenic nerve)

Take Home Points

1. Palpitations are very common

2. Differentiating between cardiac and non cardiac causes is essential

3. History, PE, ECG are essential with a yield of 1/3

4. Continuous event monitors are a good adjunct tool with a good diagnostic yield (up to 88%)

5. Therapy can be directed to cause but also empiric (-blockers)

Questions?