Palpitations: An Overview | ScienceDirect Topics (2023)

diagnostic tests

A 12-lead ECG should be performed on all patients. A limited laboratory evaluation with complete blood count (CBC), thyroid-stimulating hormone (TSH), and comprehensive metabolic panel (CMP or Chem-14) is appropriate to identify anemia, thyroid disease, and electrolyte abnormalities that predispose to arrhythmias. 🇧🇷 Etiology can be determined in 40% of patients from this limited evaluation (seeMesas 5y6).

Traditionally, ambulatory cardiac monitoring is done using a Holter monitor. Patients keep a diary of the time and characteristics of their symptoms. This method is suitable for patients withpalpitations🇧🇷 The monitor is used from 24 to 48hours. If symptoms are not present during the time the monitor is being used, the test will not be revealing. In addition, Holter monitoring may uncover arrhythmias (most commonly benign ectopia) that are unrelated to the patient's symptoms.

If a patient is suspected of arrhythmia, but 24 to 48 hours is insufficient time to record an event, it is recommended that the patient be evaluated with a continuous loop event recorder for 2 weeks. These ambulatory monitors record continuously but save data only at the specified interval when the monitor is activated by the patient (for example, 2 minutes before and after an episode of palpitations). These monitors usually send information over the phone rather than keeping the data stored on the device itself. In patients with infrequent palpitations but known severe heart disease, an implantable loop recorder is an option. These monitors are implanted subcutaneously, usually in the left pectoral region, and generally remain in place for 1 year. Like other looping event recorders, they save data when activated by the patient and can send information over the phone.

Panic or anxiety disorder is a diagnosis of exclusion. A patient with anxiety or another psychiatric illness may have a significant underlying arrhythmia. The increase in catecholamines in patients with psychiatric disorders during times of stress or intense emotional experience may be proarrhythmogenic. These patients should be evaluated for arrhythmia, especially in the presence of risk factors, before all of their symptoms are attributed to their psychiatric illness.

Patients who present with palpitations associated with dizziness, presyncope, or syncope where the diagnosis is not obvious should be referred for evaluation by a cardiologist. This type of palpitation is more likely to be associated with ventricular tachycardia or another serious arrhythmia.

Palpitations may occur more frequently during pregnancy, which is a high output state. Postpartum cardiomyopathy is a structural disease unique to this population. As pregnant women are also at increased risk for new arrhythmias, including atrial fibrillation, persistent palpitations should be carefully evaluated.

Causes

Palpitation is one of the most common cardiac symptoms encountered in medical practice, but it corresponds little to demonstrable abnormalities. A lot ofpalpitationsare not serious, but palpitation may indicate the possible presence of serious cardiac arrhythmias.

Box 32-1list the causes of palpitation. A high percentage of patients with palpitations do not have an etiology that can be established. Occasionally, a psychogenic or psychiatric cause of your symptoms may be suspected. Certain medications and substances can be identified as a cause of palpitations. Caffeine, a common stimulant, is found in many foods and beverages, including coffee, tea, hot chocolate, soft drinks, chocolate, and some medications. Most energy drinks (like Venom, Whoop Ass, Red Bull, Adrenaline Rush), which are all the rage popular in youth culture, contain large doses of caffeine and other legal stimulants like ephedrine, guarana, taurine and ginseng. Some medical conditions, such as hyperthyroidism, anemia, and hypoglycemia, can be the cause of palpitations. Although relatively rare, cardiac arrhythmias and structural heart diseases should be investigated as a cause of palpitations. However, most palpitations are not accompanied by arrhythmias, and most arrhythmias are not noticed or reported as palpitations. Some adult patients with palpitations have panic disorder or panic attack. Panic attacks and arrhythmias can be difficult to distinguish clinically because both can appear as palpitations, shortness of breath and dizziness.

palpitations

palpitationsare the perception of heartbeats that may be caused by rapid heartbeats, heart rhythm irregularities, or increased force of heart contraction, as occurs with post-extrasystolic heartbeats; however, this perception can also exist in the context of a completely normal heart rhythm. Patients who complain of palpitations describe the unpleasant sensation of a strong, irregular, or rapid heartbeat. Many patients are aware of any cardiac irregularities, while others are unaware of prolonged episodes of rapid ventricular tachycardia or atrial fibrillation (AF) with rapid ventricular rates. The latter is particularly noteworthy because, if left untreated, it can be associated with stroke or lead to tachycardia-induced cardiomyopathy. Patients may use terms such as a "thumping" or "turning" sensation in the chest; fullness or throbbing in the throat, neck, or chest; or a pause in the heartbeat, or "missed a beat". Jumping usually results from pausing after a premature ventricular complex (PVC) or restoring sinus rhythm after a premature atrial complex (PAC). Usually, the premature beat, especially if it is a ventricular extrasystole, occurs too early to allow the ventricle to fill enough to cause a sensation as the ventricle contracts. The ventricular systole that ends the compensatory pause is usually responsible for the actual palpitation, resulting from stronger contraction due to prolonged ventricular filling or increased movement of the heart in the chest. Anxiety with such symptoms is usually the complaint that brings the patient to the doctor's office.

Premature atrial or ventricular complexes are the most common causes of palpitations. If premature complexes are frequent, or particularly if there is sustained tachycardia, patients are more likely to experience additional symptoms such as dizziness, syncope or near-syncope, chest discomfort, fatigue, or shortness of breath. The context and symptoms associated with palpitations can be informative for diagnosis and prognosis. Low-risk features include isolated non-exercise-induced palpitations, no structural heart disease or symptoms such as syncope or chest pain, no family history of sudden cardiac death (SCD), and a normal 12-lead ECG. Associated symptoms such as syncope or chest pain, presence of structural heart disease or documented arrhythmia, and family history of SCD may be related to a more sinister cause of palpitations.¹In the context of structural heart disease, the differential diagnosis is broad. The patient's age and the presence of associated CV problems influence the nature of the symptoms. For example, a supraventricular tachycardia (SVT) at a rate of 180 beats/min may cause chest pain in a patient with coronary artery disease (CAD) or syncope in a patient with aortic stenosis, but may cause mild dyspnea in a healthy patient. young person.

Definition

Palpitation is an unpleasant subjective awareness of one's own heartbeat. This usually occurs as a feeling in the chest of a fast, irregular, or unusually strong heartbeat. The patient describes it as palpitations, jumping, racing, irregular heartbeat, a "flip flop" or "quick flutter" in the chest, or palpitations in the neck. Palpitations can be felt in the chest, throat or neck. The heartbeat may become faster or rarely slower than normal. The endpalpitationit is used so freely that specific questions must be asked to determine the exact nature of the symptom.

palpitations

palpitations(chapter 56) describe a subjective sensation of an irregular or abnormal heartbeat. Palpitations can be caused by any arrhythmia (chapters 58y59) with or without significant underlying structural heart disease. Palpitations should be defined in terms of duration and frequency of episodes; precipitating and related factors; and any associated symptoms of chest pain, dyspnoea, dizziness or syncope. It is crucial to use the history to determine whether the palpitations are caused by an irregular or regular heartbeat. The sensation associated with a premature atrial or ventricular contraction, often described as a "missed beat" or a "change in heart rhythm", must be distinguished from the irregular irregular rhythm of atrial fibrillation and the rapid but regular rhythm of supraventricular tachycardia . 🇧🇷 🇧🇷 Associated symptoms of chest pain, dyspnoea, dizziness, lightheadedness or diaphoresis suggest a significant effect on cardiac output and warrant further evaluation. Evaluation usually begins with an ambulatory electrocardiogram (ECG) (Table 45-4), which is indicated in patients with palpitations in the presence of structural heart disease or substantial comorbid symptoms.^3bDepending on the series, 9% to 43% of patients have significant underlying heart disease. In these patients, further evaluation is required (seeFigure 56-1).

stunosyncope(chapter 56) can be caused by any condition that decreases cardiac output (eg, bradyarrhythmia, tachyarrhythmia,left ventricular or right ventricular inlet or outlet obstruction, cardiac tamponade, aortic dissection, or severe pump failure) due to reflex-mediated vasomotor instability (eg,Table 56-1🇧🇷 Neurological conditions (eg, migraines, transient ischemic attacks, or seizures) can also cause transient loss of consciousness. History, physical examination, and ECG are often diagnostic of the cause of syncope (seeTable 56-2🇧🇷 Syncope caused by a cardiac arrhythmia usually occurs without warning. Syncope on exertion or shortly after cessation of exertion is typical of aortic stenosis and obstructive hypertrophic cardiomyopathy. In many patients, additional tests are needed to document central nervous system disease, the cause of reduced cardiac output or carotid sinus syncope. When history, physicsexamination and ECG do not provide useful diagnostic information pointing to a specific cause of syncope, it is imperative that patients with cardiac disease or abnormal ECG be evaluated with continuous ambulatory ECG monitoring to diagnose possible arrhythmia; in selected patients, formal electrophysiologic testing may be indicated (chapter 56🇧🇷 In patients without obvious heart disease, the tilt test (chapter 56) can help detect reflex-mediated vasomotor instability.

palpitations

palpitationsThey are among the most common complaints associated with arrhythmias; the differential diagnosis is extensive. Palpitations can be intermittent or sustained, regular or irregular, and even unrelated to an arrhythmia. Excess catecholamines alone can cause a feeling of palpitations without arrhythmia.¹⁷

Some causes of palpitations include the following: anxiety; severe viral syndrome; alcohol; stimulants (cocaine, methamphetamine); stimulant medications, including pseudoephedrine; beverages containing caffeine, theobromine or theophylline; poor sleep (or irregular sleepcycle); and various supplements (includingGinkgo biloba,ephedrine, ginseng, guarana, zealous goat weed, yohimbe and others). Hormonal changes and excess thyroid hormone can also trigger palpitations.

Palpitations may represent the somatization of a psychiatric disorder. Of the 125 outpatients referred for ambulatory electrocardiographic monitoring to assess palpitations, 34% had arrhythmia, while 19% had a psychiatric disorder, mainly major depression or panic disorder.¹⁸Those with psychiatric disorders were younger, more disabled and more hypochondriacal about their health. Their palpitations were more likely to last longer than 15 minutes, were accompanied by other symptoms, were more severe, and were associated with more emergency room visits. Several reports have confirmed the high incidence of psychiatric conditions in association with palpitations.^19,20However, careful evaluation of the palpitations should rule out organic disease.

Palpitations are rarely the result of a life-threatening process, although they may be associated with or represent manifestations of underlying ventricular dysfunction or other structural heart disease. Palpitations in a patient with heart disease, especially coronary artery disease, should raise suspicion that the palpitations are the result of an arrhythmia.^21,22

palpitations

palpitations, defined here as awareness of the heartbeat, is a symptom commonly encountered in clinical practice. Although possibly a manifestation of arrhythmias, palpitations are often caused by non-cardiac factors. When arrhythmias are the cause of palpitations, the most common rhythms recorded during symptoms are premature atrial contractions, premature ventricular contractions, SVT, and AF. In a prospective cohort study, 190 patients who presented to an academic medical center with palpitations were evaluated and followed for 1 year. The diagnosis of the etiology of their palpitations was established in 84%. Among these patients, 40% had palpitations from cardiac arrhythmias and 33% from anxiety and panic disorder, with the remainder of patients having non-arrhythmic causes.¹Patients with palpitations associated with structural heart disease (including complex congenital heart disease), presyncope, or syncope are at increased risk of cardiac arrhythmia, which can even be fatal.

Interpretation of studies evaluating the diagnostic performance of ambulatory ECG monitors in the study of palpitations requires careful evaluation of whether the monitor provided a correlation between symptoms and rhythm. Although it does not provide the diagnosis of arrhythmia, the finding of sinus rhythm or sinus tachycardia during palpitations remains important in the diagnosis, as it provides useful clinical information and can reassure the patient. Assessment of palpitations is difficult due to several inherent limitations: (1) non-cardiac factors are the cause of palpitations in a significant number of patients; (2) arrhythmias in some patients may be associated with palpitations, while in others they may be asymptomatic; and (3) for a given patient, palpitations may arise from multiple arrhythmic causes as well as non-arrhythmic causes (the patient may not be able to discern differences between causes).

A limitation of some studies evaluating the diagnostic effectiveness of 24- to 48-hour continuous monitors for diagnosing palpitations is that some of these studies report the number of times these monitors provide a diagnosis of arrhythmia, but not the number of times palpitations are associated. with sinus rhythm. This underestimates the diagnostic performance of the 24-hour Holter monitor because multiple recordings of sinus rhythm associated with palpitations can help rule out cardiac arrhythmia as the cause of the palpitations.Tables 69-1, 69-2 and 69-3).

palpitations

palpitationsThey are among the most common complaints associated with arrhythmias; the differential diagnosis is extensive. Palpitations can be intermittent or sustained, regular or irregular, and even unrelated to an arrhythmia. Excess catecholamines alone can cause a feeling of palpitations without arrhythmia.^sixteen

Some causes of palpitations include anxiety, severe viral syndrome, alcohol, stimulants (cocaine, methamphetamine), stimulant medications including pseudoephedrine, beverages containing caffeine, theobromine or theophylline, poor sleep (or irregular sleep cycle), and various supplements (includingGinkgo biloba, ephedrine, ginseng, guarana, zealous goat weed, yohimbe and others). Hormonal changes can trigger palpitations and excess thyroid hormone.

Palpitations may be a somatization of a psychiatric disorder. Of the 125 outpatients referred for outpatient electrocardiographic (ECG) monitoring to assess palpitations, 34% had arrhythmia, while 19% had a psychiatric disorder, primarily major depression or panic disorder.¹⁷Those with psychiatric disorders were younger, more disabled and had more hypochondriacal concerns about their health. Their palpitations were more likely to last longer than 15 minutes, were accompanied by other symptoms, were more severe, and were associated with more emergency room visits. Several reports have confirmed the high incidence of psychiatric conditions in association with palpitations.^18,19However, careful assessment of palpitations is important to rule out organic disease.

Palpitations may occur in patients with arrhythmias but may not be related to a rhythm disorder. In a study of 1,454 elderly patients (60 to 94 years old), 8.3% had palpitations. Arrhythmias, predominantly conduction disorders and sinus bradycardia, were found in 12.6%.²⁰The prevalence of palpitations was similar in those with and without arrhythmias. In another study of 518 patients who had 24-hour ECG recordings, 34% had their typical symptoms at a time when the ECG was normal.²¹

Palpitations are rarely the result of a life-threatening process, although they may be associated with or represent manifestations of underlying ventricular dysfunction or other structural heart disease. Palpitations in a patient with heart disease, especially coronary artery disease, should raise the suspicion that the palpitations are due to an arrhythmia.

palpitations

palpitationsthey represent the subjective sensation that one's heart is beating in an unusual or abnormal way. All children old enough to understand this phenomenon should be asked about palpitations, although the way in which the question is asked should be tailored to the child's age and developmental abilities. Because many adults, let alone children, don't understand what palpitations are, it's important to ask about them in a way that's easy to understand. You can ask the children if the heart sometimes beats strangely in the chest, for example if it skips a beat or seems to jump or do a somersault. Older children can be asked if they have noticed their heart suddenly start beating at any time. When this condition is present, one should look for the initial and final mode of these palpitations.

Palpitations derived from arrhythmias usually appear suddenly and resolve in the same way, although this phenomenon is not absolute. Palpitations associated with fainting or dizziness are significant and should be investigated further. The same goes for palpitations caused by startle or exercise. These palpitations are sometimes caused by ventricular arrhythmias and can cause sudden death, so take them seriously! Sometimes palpitations are perceived as chest pain. Children with SVT may complain of an unusual sensation in the throat rather than identifying their experience as palpitations. Young people with palpitations should also be asked about medication and recreational drug use, including use of energy drinks and other caffeine-containing products.