PALPITATIONPALPITATION

A. A. DefinitionDefinition..

Abnormal subjective awareness of the heart Abnormal subjective awareness of the heart beat.beat.

Thumping, pounding, fluttering, jumping, Thumping, pounding, fluttering, jumping, racing, skipping)racing, skipping)

But patient may describe palpitation as a But patient may describe palpitation as a feeling of breathlessness, excitement, fright feeling of breathlessness, excitement, fright etc.etc.

Palpitation Palpitation ≠ arrythmias≠ arrythmias

B. Causes.B. Causes.

Palpitation may be due to Rapid heart beat orPalpitation may be due to Rapid heart beat or

Slow heart beat or Slow heart beat or

Irregular heart beat.Irregular heart beat. Palpitation may be due to Palpitation may be due to

Primary cardiac disease (Acute or Chronic) Primary cardiac disease (Acute or Chronic) oror

Secondary effect on the heart (Systemic Secondary effect on the heart (Systemic disease disease or Drugs)or Drugs)

Common causes areCommon causes are

(1) Anxiety, Exercise, hyperthyroidism(1) Anxiety, Exercise, hyperthyroidism(2) Drugs (2) Drugs (Sympathomimetics, Atropine)(Sympathomimetics, Atropine)(3) Diet (3) Diet (Tea, coffee, cola)(Tea, coffee, cola)(4) Nicotine(4) Nicotine (Smoking)(Smoking)(5) Abnormal rate(5) Abnormal rate

Sinus tachycardia(100-160)Sinus tachycardia(100-160)SupraventricularSupraventricular

tachycardia(160-220)tachycardia(160-220)Ventricular tachycardiaVentricular tachycardiaSinus BradycardiaSinus Bradycardia

(6) Abnormal rhythms(6) Abnormal rhythms

Atrial fibrillationAtrial fibrillation

Ventricular fibrillationVentricular fibrillation

(7) Extrasystole(7) Extrasystole

Atrial extrasystole.Atrial extrasystole.

Ventricular extrasystoleVentricular extrasystole

(8) Wolff-Parkinson-White (WPW)(8) Wolff-Parkinson-White (WPW)

(9) Forceful heart beat(9) Forceful heart beat

Aortic regurgitation.Aortic regurgitation.

Sinus TachycardiaSinus Tachycardia. .

Heart rate = 100 bpm-160bpmHeart rate = 100 bpm-160bpm

CausesCauses FeverFever ThyrotoxicosisThyrotoxicosis

AnaemiaAnaemia PhaeochromocytomaPhaeochromocytoma

AnxietyAnxiety Carcinoid tumorCarcinoid tumor

ExerciseExercise Heart failureHeart failure

PregnancyPregnancy DrugsDrugs

Sinus bradycardiaSinus bradycardiaHeart rate = < 60 bpmHeart rate = < 60 bpm

CausesCauses Myocardial infarctionMyocardial infarction

Sick sinus syndromeSick sinus syndrome

HypothermiaHypothermia

HypothyroidismHypothyroidism

Cholestatic jaundiceCholestatic jaundice

Raised intracranial pressureRaised intracranial pressure

Drugs (Digoxin, Beta blockers.)Drugs (Digoxin, Beta blockers.)

TreatmentTreatment AtropineAtropine

Supraventricular Tachycardia (SVT)Supraventricular Tachycardia (SVT)Ventricular Tachycardia (VT)Ventricular Tachycardia (VT)

Heart rate (140-220)Heart rate (140-220)CausesCauses Coronary artery disease.Coronary artery disease.Valvular heart disease.Valvular heart disease.Myocarditis.Myocarditis.Cardiomyopathy.Cardiomyopathy.Drugs.Drugs.SVT usually benign.SVT usually benign.VT always malignant and need urgent VT always malignant and need urgent treatment.treatment.DC cardiovertionDC cardiovertionLignocaine, Mexilatine, Flecainide, K, MgLignocaine, Mexilatine, Flecainide, K, Mg

Paroxysmal atrial tachycardia (PAT).Paroxysmal atrial tachycardia (PAT).

Heart rate is usually about 140-220 during Heart rate is usually about 140-220 during attack.attack.

Clinical featureClinical featureAsymptomatic.Asymptomatic.Symptomatic Symptomatic Palpitation Palpitation DyspnoeaDyspnoea

Cheat pain Cheat pain FaintingFaintingSudden onset and sudden disappear.Sudden onset and sudden disappear.Polyuria (due to Atrial Natriuretic Polyuria (due to Atrial Natriuretic

peptide)peptide)

ECGECG Normal or WPW syndrome during intervals.Normal or WPW syndrome during intervals. SVT during attackSVT during attack

TreatmentTreatment Carotid sinus massage.Carotid sinus massage. Increases vagal tone by induced vomiting, Increases vagal tone by induced vomiting,

Valsalva manoeuvre.Valsalva manoeuvre. Inj IV Adenosine or IV VerapamilInj IV Adenosine or IV Verapamil Alternative drugsAlternative drugs Beta-blockers.Beta-blockers.

Disopyramide.Disopyramide.Digoxin.Digoxin.DC cardioversion.DC cardioversion.

PreventionPrevention Above drugsAbove drugs Radio frequency ablation.Radio frequency ablation.

Atrial Fibrillation.Atrial Fibrillation.

Causes.Causes.

Coronary artery diseaseCoronary artery disease AlcoholAlcohol

Valvular heart diseaseValvular heart disease HypertensionHypertension

CardiomyopathyCardiomyopathy Pulmonary embolismPulmonary embolism

PericarditisPericarditis Congenital heart Congenital heart diseasedisease

ThyrotoxicosisThyrotoxicosis PneumoniaPneumonia

IdiopathicIdiopathic Bronchial carcinomaBronchial carcinoma

ECGECG No P wave.No P wave.

Fibrillatory wave.Fibrillatory wave.

Normal but amplitude of QRS Normal but amplitude of QRS complex.complex.

TreatmentTreatment DigoxinDigoxin

AmioderoneAmioderone

CardioversionCardioversion

ββ blockerblocker

VerapamilVerapamil

AntiplateletsAntiplatelets

ExtrasystolesExtrasystolesPremature beats or premature contractions.Premature beats or premature contractions.

a. Atrial extrasystole.a. Atrial extrasystole.b. Ventricular extrasystole.b. Ventricular extrasystole.

Clinical featuresClinical featuresAsymptomatic.Asymptomatic.Symptomatic.Symptomatic. PalpitationPalpitation

Irregular beatsIrregular beatsMissed beat or Strong beat.Missed beat or Strong beat.heart sound have missed orheart sound have missed or

extra beats.extra beats.

ECGECG

AEAE Normal QRS complex with preceding Normal QRS complex with preceding abnormal P wave.abnormal P wave.

VEVE Broad and bizarre QRS without preceding Broad and bizarre QRS without preceding

P wave.P wave.

CoupletCouplet 2 successive ectopic beat.2 successive ectopic beat.

TripletTriplet 3 successive ectopic beat.3 successive ectopic beat.

BigeminyBigeminy Alternate sinus and ectopic Alternate sinus and ectopic beat.beat.

AEAE No treatedNo treated

VEVE Treatment of underlying diseasesTreatment of underlying diseases

VEVE HealthyHealthy

more prominent at restmore prominent at rest

tend to disappear with exercisetend to disappear with exercise

treatment is unnecessarytreatment is unnecessary

low dose low dose ββ blocker blocker may reduce anxiety and may reduce anxiety and palpitationpalpitation

Heart diseaseHeart disease During AMIDuring AMI

Heart failureHeart failure

Digoxin toxicityDigoxin toxicity

Mitral valve prolapse (MVP)Mitral valve prolapse (MVP)

Wolff-Parkinson-White (WPW) syndromeWolff-Parkinson-White (WPW) syndromePre-excitation syndromePre-excitation syndrome

Presence of extra conducting tissue Presence of extra conducting tissue (bundle of (bundle of Kent)Kent)..

ECGECG 1. Short PR interval (< 0.1 sec.)1. Short PR interval (< 0.1 sec.)

2. Delta wave.2. Delta wave.

3. Wide QRS complex (> 0.1 sec.)3. Wide QRS complex (> 0.1 sec.) Complications Paroxysmal atrial tachycardiaComplications Paroxysmal atrial tachycardia(PAT).(PAT).

Atrial fibrillation Atrial fibrillation (Af).(Af). Trans-venous radiofrequency catheter ablationTrans-venous radiofrequency catheter ablation Amiodarone, Disopyramide, Flecainide Amiodarone, Disopyramide, Flecainide Contrindication – Digoxin, verapamilContrindication – Digoxin, verapamil

C. DiagnosisC. Diagnosis

Careful and thorough history is important.Careful and thorough history is important.

Definitive diagnosis may be obtained by Definitive diagnosis may be obtained by doing ECG during attacks or ambulatory doing ECG during attacks or ambulatory ECG monitoring.ECG monitoring.

The evaluation of patient with palpitation.The evaluation of patient with palpitation.

Continuous or intermittent?Continuous or intermittent? Regular or irregular heartbeat?Regular or irregular heartbeat? Approximate heart rate?Approximate heart rate? Discrete attacks or not? If yes, is the onset Discrete attacks or not? If yes, is the onset

abrupt? Or how do attacks terminate?abrupt? Or how do attacks terminate? Any associated symptoms? Eg. Chest pain, Any associated symptoms? Eg. Chest pain,

lightheadedness, polyuria.lightheadedness, polyuria. Any precipitating factors? Eg. Exercise, Any precipitating factors? Eg. Exercise,

alcohol.alcohol. Evidence of structural heart disease? Eg. Evidence of structural heart disease? Eg.

Coronary heart disease, valvular heart Coronary heart disease, valvular heart disease.disease.

Regular heart beat

NOYes

Ectopics

Atrial fibrillation Discrete attacks

NOYes

SVT Sinus tachycardiaHigh stroke volume

AnaemiaAnxietyAR