Definition
A.Palpitations are a feeling or an unpleasant awareness of the heartbeat in the chest. It may be described as feeling a sensation of the heart flip-flopping
or feeling a rapid flutter
of the heart.
Incidence
A.The incidence of palpitations may range from 1% to 8% of patients in a general practice setting.
Pathogenesis
Palpitations may be caused by the following:
A.Increase in stroke volume or contractility.
B.Sudden change in heart rate or rhythm.
C.Unusual cardiac movement within thorax.
D.Hyperkinetic states, which cause constant pounding.
E.Valvular heart disease that produces large stroke volumes.
F.Catecholamine release during anxiety or panic attacks.
Predisposing Factors
A.Cardiac defects.
B.Severe anemia.
C.Hyperthyroidism.
D.Pregnancy.
E.Fever.
F.Anxiety.
G.Stimulants, such as caffeine and certain drugs.
H.Emotions, such as fear.
I.Exertion.
J.Diabetes mellitus and insulin reaction.
Common Complaints
A.Palpitations are often described as a turning over or flopping sensation in the chest, but symptoms vary enormously.
B.Most patients are free of palpitations at the time of the exam.
Other Signs and Symptoms
A.Fluttering in the chest.
B.Shortness of breath (SOB).
C.Pounding in the chest and neck.
D.Diaphoresis.
E.Lightheadedness.
F.Anxiety or fear.
Subjective Data
A.Ask the patient when symptoms first presented, including age, and how they have changed.
B.Have the patient describe the characteristics of the palpitations, such as rapid, regular, irregular, or slow.
C.Ask the patient what precipitates the palpitations. Does anything terminate them, or do they go away on their own?
D.Inquire whether symptoms occur or change with position (standing, bending over, lying down, left lateral decubitus position) and/or exercise.
E.Ask the patient about other symptoms associated with the palpitations such as dizziness or syncope.
F.Ask how often the episodes occur and how long each lasts.
G.Discuss any previous treatments for this condition and the results.
H.Ask the patient about risk factors for coronary heart disease (CHD) and prior cardiac history.
I.Obtain a complete list of medications the patient is currently taking, including over-the-counter (OTC) and herbal products:
1.Specifically question the patient’s use of OTC decongestants and diet pills.
2.Are there any new medications or changes in routine medications?
Physical Examination
A.Check pulse (count the pulse for 1 full minute), respirations, and blood pressure (BP):
B.Inspect:
1.Inspect overall appearance.
2.Inspect the skin for diaphoresis and pallor.
3.Inspect the neck for thyromegaly or jugular vein distension.
4.Inspect the legs for edema.
C.Palpate:
1.Palpate the skin for temperature and dryness.
2.Palpate the lower extremities for edema and calf tenderness.
3.Palpate the neck for thyroid enlargement.
D.Auscultate:
1.Auscultate the heart for abnormal rhythms. Auscultate heart sitting, standing, and left lateral decubitus position. Ask patient to walk quickly down the hallway and back and then auscultate heart in all positions again.
2.Auscultate the lungs.
3.Auscultate the neck and carotid arteries for bruits.
E.Mental status: Does the patient appear lightheaded, anxious, or fearful?
Diagnostic Tests
A.Diagnostic testing is highly recommended for patients with an arrhythmia or at risk for an arrhythmia, and patients who are anxious and want to explore causes for their symptoms. The following testing is recommended:
1.Hgb to rule out anemia, if suggestive on exam.
2.Thyroid-stimulating hormone (TSH) to rule out hyperthyroidism, if suggestive on exam.
3.ECG during episode, if possible.
4.Ambulatory monitoring if symptoms continue, either 24-hour Holter monitor or patient-activated transtelephonic monitoring.
5.Treadmill test if palpitations are provoked by exercise.
Differential Diagnoses
A.Palpitations are secondary to the underlying problem, such as anxiety, medications, or cardiac or pulmonary origin.
Plan
A.General interventions: Provide reassurance if the palpitations result from a neurotic concern.
B.Patient teaching:
1.Caution the patient to avoid any factors that trigger episodes. Factors may include stress, exercise, foods, and medications.
2.Teach the patient the vagal maneuver, which is effective in halting palpitations.
C.Medical and surgical management:
1.Correct any underlying problem (e.g., cardiac or pulmonary).
2.Treat medical conditions accordingly.
3.Management of arrhythmias should be monitored by a cardiologist.
D.Pharmaceutical therapy: Discontinue all nonessential medications that could cause palpitations.
Follow-Up
A.Depending on the etiology of palpitations and the existence of comorbid conditions, the prognosis in patients with no underlying cardiac disease is generally favorable.
Consultation/Referral
A.Consult a physician if the patient has a history of palpitations leading to syncope or near syncope, angina-like chest pain, or dyspnea. These patients are candidates for referral to a cardiologist and/or inpatient evaluation. Refer any patient with an arrhythmia to a cardiologist.
B.Hemodynamically compromised patients need prompt hospital admission.
Individual Considerations
A.Geriatrics:
1.Elderly patients are at increased risk for adverse effects from antiarrhythmic medications.
2.If drug treatment is necessary, lower doses should be used. Use the rule of thumb of start low and go slow.
3.Polypharmacy (variously defined as the use of more than five to nine medications) may be involved in heartrelated symptoms.
4.Use caution when prescribing aspirin therapy in older adults. Refer to section Atrial Fibrillation
of this chapter under pharmaceutical therapy for details found in the Beers Criteria.