Palpitation refers to "an unpleasant awareness of the heart beating in the chest". This is when sudden awareness of the heart beating interrupts unrelated thoughts. Patients often describe the feeling as "thumping", "pounding", "fluttering" or "racing". Palpitations are commonly experienced on an occasional basis by people in all age groups. They are usually harmless; however frequent palpitations or palpitations with associated symptoms such as pre syncope or syncope can be an indication of an underlying condition.
Three general pathophysiological mechanisms cause palpitations. These are:
Patients will usually not be experiencing palpitations at the time that they are seen by a doctor. Taking a good history is therefore an important first step towards forming a diagnosis. There are several key areas to explore in the history aimed at distinguishing the nature of the pathophysiological mechanism involved.
Next, the history of the presenting complaint should be taken including a systematic description of the episodes from start to finish.
- What was the patient doing when the episode came on? (e.g. exercising, drinking alcohol
or coffee, taking medical or other drugs, experiencing emotional or physical stress, was the
patient standing or sitting?)
- Was the onset sudden or gradual?
- Did the patient experience any other symptoms directly preceding the event? e.g.Chest
pain, dizziness, lightheadedness,
shortness of breath, or syncope
- Assess the character of the rhythm. Was the rhythm regular or irregular, rapid or slow? It
can be helpful to ask the patient to tap out the rhythm for you.
- Did the patient experience any other symptoms during the episode? e.g.Chest pain,
dizziness, lightheadedness, shortness of
breath, or syncope
- How long did the episode last?
- Did the symptoms subside suddenly or gradually?
- Did the patient do anything to stop the symptoms?
- Has the patient experienced these symptoms before? How many times, or how often?
- When was the first time that they experienced them?
The remainder of the history is the same as for other medical histories, including a systems review, past medical history, drug and allergies history, family history and social history. There are however some key areas to focus on.
- Previous cardiovascular disease, particularly coronary heart disease or valvular heart disease.
- Previous psychosomatic, thyroid or systemic disease.
- Cardiovascular disease (tachycardia) or sudden cardiac death.
- A thorough drug history is important as many drugs can cause palpitations as a side
- Drug and alcohol abuse.
More often than not, a physical examination will take place at a time when the patient is not experiencing symptoms. Signs may still be present however that could reveal the underlying cause of the palpitations and help to establish a diagnosis.
The examination follows standard procedures: Observe, inspect, palpate and auscultate. It is important to do a thorough cardiovascular exam, checking for signs of disease (hypertension, murmur, oedema, etc) and also to examine for other systemic diseases.
If a patient does experience palpitations during a consultation, the rate and rhythm of the pulse should be examined, followed by an assessment of the patient's cardiovascular state during the episode.
When examining a patient, important ALARM signs to look out for are:
-Reduced consciousness level
-Systolic BP <90 mmHg
For all patients an ECG should be performed whether or not they are experiencing symptoms, as signs of an underlying condition can still be present on the ECG and the results will influence the need for further investigation.
The findings of the history and examination will indicate the aetiology of the palpitations in about half of patients, and can rule out, with some certainty, a sinister cause.
Some characteristic descriptions of types of palpitations are listed below:
Palpitations are usually benign, and common arrhythmias such as extra systole or sinus tachycardia have a very good outcome if no structural heart disease is present. Therefore patients with a low probability of an arrhythmic cause and no history of cardiovascular disease often do not require further investigation. In other cases, specialist assessment should be considered. Investigations
See the diagram below for the diagnostic approach.
Management is aimed at treating the underlying cause of the palpitations. The main treatment strategies are outlined below.
Most causes of palpitations are benign, and mortality is low. They are not without morbidity however as recurrent episodes can cause anxiety and reduce quality of life. When managing palpitations it is important to consider the effect on the patient's quality of life as well as managing the underlying condition.
D-Definition, A-Aetiology, P-Pathophysiology, H+E-History and Examination, C-Characteristic Presentations, I-Investigations, T-Treatment, P-Prognosis
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