PALPITATION HISTORY TAKING Learning Document Last updated: Mar 2018 By Estee Soh (DEM3, Class of 2020) 1 Palpitation: An unexpected awareness of heartbeat. DIFFERENT TYPES OF PALPITATION Types Ectopic Beat Supraventricular tachycardia (SVT) Ventricular Tachycardia (VT) Atrial fibrillation Anxiety Characteristic Heart misses and thumps Regular, Fast Regular, Fast Fast, Irregular Forceful/ pounding, Regular, Not fast Other features Worse at rest Instantaneous onset, Relieved by vagal maneuvers Associated with severe dizziness/ syncope, Pre-existing heart failure CAUSES FOR PALPITATION Cardiac Endocrine Metabolic Others Atrial fibrillation Ectopic beat SVT VT HOCM Pheochromocytoma Hyperthyroidism Hypoglycemia Menopause Hypokalemia Hyperkalemia Anaemia Anxiety Diet (Caffeine, Alcohol) Medication (Salbutamol) Recreational drugs (Cocaine) Cardiac causes - Atrial Fibrillation (A-fib) o Definition § A chaotic, irregular atrial rhythm at 300 – 600 beats per minute o Types of A-fib § Paroxysmal (< 7 days) § Long-standing (> 7 days) § Persistent long-standing (> 12 months) § Permanent (decision to not treat a-fib) o Clinical Features § Irregularly irregular pulse, a-fib-like palpitations, fatigue, pre-syncope/ syncope, generalized weakness § Risk factors: • Elderly (> 75 years old) o Causes § Cardiac: ischemic heart disease, hypertension, congestive heart failure, mitral valve disease § Respiratory: Pneumonia, PE, COPD § Endocrine: Thyrotoxicosis § Other: Caffeine, alcohol, post-op
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PALPITATIONHISTORYTAKINGLearningDocument
Lastupdated:Mar2018
ByEsteeSoh(DEM3,Classof2020)
1
Palpitation:Anunexpectedawarenessofheartbeat.
DIFFERENTTYPESOFPALPITATIONTypes EctopicBeat Supraventricular
tachycardia(SVT)Ventricular
Tachycardia(VT)Atrial
fibrillationAnxiety
Characteristic Heartmissesandthumps
Regular,Fast
Regular,Fast
Fast,Irregular
Forceful/pounding,Regular,Notfast
Otherfeatures
Worseatrest Instantaneousonset,Relievedbyvagalmaneuvers
Associatedwithseveredizziness/syncope,Pre-existingheartfailure
CAUSESFORPALPITATIONCardiac Endocrine Metabolic Others
AtrialfibrillationEctopicbeatSVTVTHOCM
PheochromocytomaHyperthyroidismHypoglycemiaMenopause
HypokalemiaHyperkalemia
AnaemiaAnxietyDiet(Caffeine,Alcohol)Medication(Salbutamol)Recreationaldrugs(Cocaine)
Cardiaccauses
- AtrialFibrillation(A-fib)o Definition
§ Achaotic,irregularatrialrhythmat300–600beatsperminute
o TypesofA-fib§ Paroxysmal(<7days)§ Long-standing(>7days)§ Persistentlong-standing(>12months)§ Permanent(decisiontonottreata-fib)
o ClinicalFeatures
§ Irregularlyirregularpulse,a-fib-likepalpitations,fatigue,pre-syncope/syncope,generalizedweakness
§ Riskfactors:• Elderly(>75yearsold)
o Causes
§ Cardiac:ischemicheartdisease,hypertension,congestiveheartfailure,mitralvalvedisease
§ Respiratory:Pneumonia,PE,COPD§ Endocrine:Thyrotoxicosis§ Other:Caffeine,alcohol,post-op
PALPITATIONHISTORYTAKINGLearningDocument
Lastupdated:Mar2018
ByEsteeSoh(DEM3,Classof2020)
2
o Investigation§ 12leadECG–lookforirregularlyirregularQRScomplexes,absenceofpwaves§ Echocardiography–lookforleftatrialenlargement,mitralvalvedisease,poorLV
function§ Bloodtest–TFTs,cardiacenzymes,U&E
o Management
§ Acute(<48hours)• Emergency:O2,cardioversion(ifunavailable,giveIVamiodarone5mg/kg
over1hour,then900mgover24hoursviacentralline)• Treatunderlyingcausee.g.MI,pneumonia• Ratecontrol:Bisoprolol2.5-5.0mg/dPO(Verapamil40-120mg/8hPOfor
situationswherebisoprololiscontraindicatedsuchasasthmatics)• Anti-coagulation:(unsureaboutembolirisk)Heparin,(highembolirisk)
warfarin–targetINR2.5§ Chronic
• Ratecontrol:beta-blocker,Ca2+blocker• Rhythmcontrol:Sotaloloramiodarone(foryoungerandfitpatients)• Anti-coagulation:Warfarin–targetINR2-3orAspirin300mg/dPO(2nd
line)
- HypertrophicObstructiveCardiomyopathy(HOCM)o Definition
§ Presenceofleftventricularoutflowtractobstructionfromasymmetricseptalhypertrophy
§ Leadingcauseofsuddencardiacdeathintheyoung
o Clinicalfeatures§ Dyspnoea,palpitation,syncope§ Jerkypulse,double-apexbeat,systolicthrillatlowerleftsternaledge§ PMHofangina,congestiveheartfailure§ Riskfactors:
• Wolff-Parkinson-Whitesyndrome,Mutationinbeta-myosin,alpha-tropomyosinandtroponinTgenes
o Investigation
§ ECG–ProgressiveTwaveinversion(indicatesLVH),deepQwaves@inferior+lateralleads
§ ECHO–Asymmetricalseptalhypertrophy,smallLVcavity§ Exercisetest+Holtermonitor
o Management
§ Symptomaticrelief:BisoprololorVerapamil§ Preventiveforemboli:Anti-coagulate§ Implantabledefibrillator§ Septalmyomectomy
PALPITATIONHISTORYTAKINGLearningDocument
Lastupdated:Mar2018
ByEsteeSoh(DEM3,Classof2020)
3
- Supraventriculartachycardia(SVT)
o Definition§ Tachyarrhythmiaabovetheventricularmuscle(e.g.SAnode,AVnode)
o Classification(Basedonsiteoforigin)
§ Sinoatrialnode:Sinoatrialnodere-entranttachycardia(SNRT)§ Atrialnode:Atrialfibrillation,Atrialflutter§ Atrioventricularnode:AVnodere-entranttachycardia(AVNRT),Wolff-Parkinson
Whitesyndrome
o Clinicalfeatures§ Heartrate>100bpm§ Riskfactor:Underlyinghyperthyroidism,electrolyteabnormalities
o Investigations
§ ECG–NarrowQRScomplexes(<120ms)
o Management§ Acute:Vagalmanoeuvre,IVadenosineorverapamil(ifnotonbeta-blocker)§ Emergency:Cardioversion§ Maintenance:Beta-blockerorverapamil
Endocrinecauses
- Phaeochromocytomao Definition
§ Adrenalglandtumourwhichproducesexcesscatecholamine.§ Ruleof10%:10%malignant,10%extra-adrenal,10%bilateral,10%familial
(Thyroid,MEN-2a,MEN-2b,neurofibromatosis,vonHippel-Lindausyndrome)
o Clinicalfeatures§ Classictriadof:Episodicheadache,SweatingandTachycardia§ Hypertension
o Investigation
§ Fullbloodcount–raisedWCC§ Urinesample–3x24hoursurinesampletotestforfreemetadrenalineand
normetadrenaline§ Clonidinesuppressiontest–onlyifborderline§ AbdominalCT/MRIscan–lookforextra-adrenaltumour
o Management
§ Alpha-antagonist:Phenoxybenzamine§ Beta-blockeriftachycardicorheartdisease§ Surgery
PALPITATIONHISTORYTAKINGLearningDocument
Lastupdated:Mar2018
ByEsteeSoh(DEM3,Classof2020)
4
- Hypoglycaemiao Definition
§ Whenplasmaglucoseis<3mmol/L
o Causes(EXPLAIN)§ Exogenousdrugs(alcohol,aspirinoverdose,insulinoverdose)§ Pituitaryinsufficiency§ Liverfailure§ Addison’sdisease§ Isletcelltumours(insulinoma),Immunehypoglycaemia(anti-insulinreceptor
antibodiesinHodgkin’sdisease)§ Non-pancreaticneoplasms(Fibrosarcoma,Hemangiopericytoma)
o Clinicalfeatures
§ Autonomic:Sweating,Anxiety,Hunger,Tremor,Palpitation,Dizziness§ Neuroglycopenic:Confusion,Drowsiness,Visualtroubles,Seizures,Coma
o Investigation
§ Bloodtest–HbA1C,plasmaketones,c-peptide,insulin
o Resultsinterpretation§ Highinsulin(=Hypoglycemichyperinsulinaemia)–Insulinoma,Exogenousdrugs§ Lowinsulin,low/noketones–Non-pancreaticneoplasm,immunehypoglycaemia§ Lowinsulin,highketones–Alcohol,pituitaryinsufficiency,Addison’sdisease
o Management
§ Giveglucose(seeLOCofpatient):Oralsugarandlongactingstarchor25-50ml50%glucoseIVwith0.9%salineviacentrallineorglucagon1mgIM
§ Rationalizeinsulintherapy(fordiabetics)
- Hyperthyroidismo Definition
§ Excessthyroidhormone,usuallyfromglandhyperfunction
o Causes§ Graves’disease:CirculatingIgGautoantibodiesbindingtoandactivatingG-protein-
coupledthyrotropinreceptors§ Toxicmultinodulargoitre:elderlyandiodine-deficientareas§ Toxicadenoma:SolitarynoduleproducingT3andT4§ Ectopicthyroidtissue:Metatasticfollicularthyroidcancer,strumaovarii§ Exogenous:Excessiodine,excesslevothyroxine,amiodarone§ SubacutedeQuervain’sthyroiditis:Self-limitingpost-viralwithpainlessgoitre
o Clinicalfeatures
§ Diarrhoea,lossweight,increaseappetite,sweating,heatintolerance,palpitation,tremor,irritability,labileemotions,oligomenorrhea,infertility
PALPITATIONHISTORYTAKINGLearningDocument
Lastupdated:Mar2018
ByEsteeSoh(DEM3,Classof2020)
5
§ Irregularandfastpulse,palmarerythema,thinhair,lidretraction,lidlag§ Graves’disease:Goitre,exophthalmos,Pretibialmyxoedema,thyroidacropachy
(clubbing,painfulfingerandtoeswelling,periostealreactioninlimbbones)
o Investigations§ Fullbloodcount–lowTSH,highT4andT3,TPOantibodies(onlyforGraves)§ Serumbioprofile–ESR,LFT,Ca2+
o Management
§ Drugs:• Symptomaticrelief:Propanolol40mg/6h• Anti-thyroid:Carbimazole20-40mg/dPO(titratedown4weekstoevery1-
2months)§ Radioiodine(131I)§ Thyroidectomy
Metaboliccauses
- Hypokalemiao Definition
§ Whenthepotassiumlevelinthebloodislessthan3.5mmol/L§ [K+]<2.5mmol/L=life-threatening
o Clinicalfeatures
§ Muscleweakness,hypotonia,hyporeflexia,cramps,tetany,palpitations,light-headedness
o Investigation
§ Bloodtest§ ECG–SmallorinvertedTwaves,prominentUwaves,longPRinterval,depressedST
segment
o Management§ Mild(>2.5mmol/L):OralK+supplements(>80mmol/24hours)§ Severe(<2.5mmol/L):IVpotassium(max20mmol/h,40mmol/L)§ Ifonthiazide,changemedicationtoK+sparingdiuretics
- Hyperkalemia
o Definition§ Whenbodypotassiumlevelismorethan5mmol/L.§ When[K+]>6.5mmol/L
o Causes
§ Acuterenalfailure,Addison’sdisease,Rhabdomyolysis,Metabolicacidosis,K+sparingdiuretics,ACE-I,Suxamethonium,Burns
PALPITATIONHISTORYTAKINGLearningDocument
Lastupdated:Mar2018
ByEsteeSoh(DEM3,Classof2020)
6
o Clinicalfeatures§ Fastirregularpulse,chestpain,weakness,palpitations,light-headedness
o Investigation
§ ECG–tallTwaves,smallbroadPwaves/absentPwaves,wideQRScomplex
o Management§ 10ml10%calciumgluconate–stabilizecardiacmembrane§ 10unitsofactrapid(insulin)in50ml20%glucose–driveK+intocells§ 0.5mgslowIVsalbutamolor10mgnebulizedsalbutamol–stimulatesNa+-K+ATP
pump§ 50gpolysytrenesulfonateresinin100-200ml30%sorbitolor10%glucose§ Treatunderlyingcause
Others
- Anxietyo Definition
§ Theabruptonsetofintensefearordiscomfort
o Clinicalfeatures§ Palpitation,sweating,tremor,chills,dyspnoea,chestpain,nausea,dizziness,
parasthesia,fearofdying,depersonalization
o Investigations§ Asthisisadiagnosisofexclusion,beawareofhowthepatientmayrespondtothis
diagnosis.
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