3. Palpitations, syncope, sudden death

What are palpitations?

Palpitations are sensations of a rapid, fluttering, or pounding heart. They can be caused by stress, anxiety, caffeine, or heart conditions.

Why can palpitations be alarming?

While palpitations are often benign, they can occasionally signal a more serious condition

What is the key challenge in diagnosing palpitations?

. The key challenge in diagnosing palpitations lies in their transient nature, as they often resolve before medical evaluation.

Common Causes of palpitations

• Tachyarrhythmias

• Bradyarrhythmias

why does tacharrythmias cause palpitations

• This is the most common direct cardiac cause of palpitations. These are conditions where the heart beats abnormally fast due to issues in the electrical impulses that regulate the heartbeat.

why does bradyarrythmias cause palpitations

• While less common, slow heart rates can sometimes cause palpitations, especially when they lead to significant reductions in cardiac output, manifesting as fatigue or syncope.

Risk Factors of Palpitations

• Stimulant Medication

• Emotional Stress:

• Sepsis

• Anemia

• Endocrine disorder

• Underlying Cardiac Disorders

What can trigger palpitations related to stimulant medication?

Use of drugs such as caffeine, nicotine, or certain medications like decongestants and some psychiatric drugs.

Decongestants & Palpitations:

Decongestants can cause palpitations due to their stimulant effect on the heart, leading to increased heart rate and irregular heartbeats.

How can emotional stress provoke palpitations?

Anxiety, stress, and emotional disorders can provoke palpitations through sympathetic nervous system activation.

How can sepsis affect heart rate and rhythm?

Sepsis, a severe infection, can affect heart rate and rhythm, leading to palpitations among other systemic symptoms.

How can anemia cause palpitations?

Low hemoglobin levels can cause the heart to work harder to deliver oxygen to tissues, sometimes resulting in palpitations.

What effect do endocrine disorders like hyperthyroidism have on palpitations?

Conditions like hyperthyroidism significantly increase metabolism and cardiac output, often leading to palpitations.

What are some underlying cardiac disorders that can cause palpitations?

Structural abnormalities such as valve defects, congenital heart disease, or the presence of additional conductive pathways (e.g., Wolff-Parkinson-White syndrome) can be underlying causes.

Wolff-Parkinson-White syndrome is a heart condition where an extra electrical pathway in the heart causes a rapid heartbeat. It can lead to palpitations, dizziness, and fainting.

Diagnostic Approach for Palpitations

• Patient History

• Physical Examination

• Electrocardiogram (ECG)

• Holter Monitor

• Event Monitors

• Blood Tests

• Echocardiogram

What information is gathered during the patient history for palpitations?

Detailed discussion about the nature of the palpitations, their onset, duration, associated symptoms, and potential triggers.

Why is a physical examination conducted in patients with palpitations?

To identify any signs of cardiac or systemic disease.

What is the purpose of an Electrocardiogram (ECG) in patients with palpitations?

Although often normal if the patient is not experiencing palpitations during the test, it can reveal underlying rhythm abnormalities.

What is a Holter Monitor used for?

• A portable device worn for 24-48 hours to record the heart's electrical activity over a longer period.

How long can an Event Monitor be used for intermittent palpitations?

• For intermittent palpitations, an event monitor can be used for weeks to capture arrhythmias.

Why are Blood Tests conducted in patients with palpitations?

• To check for anemia, thyroid dysfunction, and other possible metabolic causes.

When is an Echocardiogram recommended for patients with palpitations?

• To evaluate heart structure and function, particularly if structural heart disease is suspected.

Causes of Palpitations

1. Sinus Tachycardia

2. Tachyarrhythmias

3. Bradyarrhythmias

4. Premature Beats

What is sinus tachycardia?

Sinus tachycardia is a normal increase in heart rate that occurs in response to certain situations or conditions, which may cause palpitations

Sinus tachycardia is a type of fast heart rate that originates from the sinus node in the heart. It is defined as a heart rate greater than 100 beats per minute.

Causes of Sinus Tachycardia

• Stimulant Intoxication

• Withdrawal from Substances

• Hypoglycemia

• Hyperthyroidism

• Pheochromocytoma

• Anxiety

• Autonomic Dysregulation

How can stimulant intoxication affect heart rate?

• Substances like cocaine, caffeine, and certain medications increase heart rate through sympathetic nervous system stimulation.

How can Withdrawal from Substances: affect heart rate?

• Alcohol, benzodiazepines, and beta-blockers can lead to increased heart rate during withdrawal as the body reacts to the absence of the previously inhibiting substance.

What role does hypoglycemia play in heart rate?

• Low blood sugar can trigger a release of adrenaline, increasing heart rate.

How does hyperthyroidism impact heart rate?

• Excess thyroid hormone increases overall metabolism and cardiac output, often leading to higher heart rates and increasing the risk of atrial fibrillation.

What is Pheochromocytoma?

A rare tumor that can secrete excess catecholamines, thus increasing heart rate.

What is Anxiety?

A very common cause where the perception of a fast-beating heart can be both a symptom and cause of further anxiety.

What is Autonomic Dysregulation?

Conditions like POTS and inappropriate sinus tachycardia can cause increased heart rate upon standing or without significant physical exertion, particularly affecting young females.

Autonomic Dysregulation is a condition where the autonomic nervous system doesn't function properly, leading to issues with involuntary bodily functions like heart rate, blood pressure, and digestion.

What are tachyarrhythmias?

These are conditions where the heart rhythm is abnormally fast

Causes of Tachyarrythmias

• Atrial Fibrillation

• Atrial Flutter

• Supraventricular Tachycardia

• Ventricular Tachycardia

What is Atrial Fibrillation

: Irregular and often rapid heart rate originating from abnormal electrical impulses in the atria.

What is Atrial Flutter?

• Similar to atrial fibrillation but with more organized electrical abnormalities.

Atrial Flutter: A rapid heart rhythm that occurs in the atria, causing them to beat quickly and regularly. It is characterized by a sawtooth pattern on an ECG.

What is Supraventricular Tachycardia?

Includes AVNRT and AVRT, which involve re-entry circuits typically in or near the AV node.

Supraventricular Tachycardia is a condition where the heart beats abnormally fast due to electrical signals originating above the heart's ventricles. It can cause symptoms like palpitations, dizziness, and shortness of breath. Treatment may involve medications or procedures to regulate the heart rate.

AVNRT and AVRT Supraventricular Tachycardia:

AVNRT (Atrioventricular Nodal Reentrant Tachycardia) and AVRT (Atrioventricular Reentrant Tachycardia) are types of supraventricular tachycardia characterized by abnormal electrical pathways in the heart leading to rapid heart rates.

What is Ventricular Tachycardia

?

• A potentially life-threatening condition where the lower chambers of the heart beat very quickly, can occur due to myocardial infarction, ischemia, cardiomyopathy, or genetic conditions like long QT syndrome.

What are Bradyarrhythmias?

Although less common, slow heart rhythms can still cause palpitations, especially when the reduced heart rate leads to insufficient blood flow

Causes of Bradyarrhythmias

• Slow Atrial Fibrillation with High-Degree AV Block

• Complete Heart Block:

Describe Slow Atrial Fibrillation with High-Degree AV Block.

• unique scenario where the atria beat irregularly and quickly but few impulses pass to the ventricles.

What is Complete Heart Block?

• There is a complete disconnect between the atrial and ventricular contractions, causing ineffective and unsynchronized heartbeats.

What are premature beats?

These are extra beats that disrupt the regular rhythm of the heart and can be felt as a skipped beat followed by a stronger-than-normal contraction:

Premature beat types

• Premature Atrial Contractions (PACs

• Premature Ventricular Contractions (PVCs):

What are Premature Atrial Contractions (PACs)?

• Occur in the atria and are typically less symptomatic.

Premature Atrial Contractions (PACs) are early, extra heartbeats originating in the atria. They are usually harmless but can be associated with certain heart conditions.

What are Premature Ventricular Contractions (PVCs)?

• Occur in the ventricles and can be more noticeable due to the compensatory pause that follows, leading to a stronger subsequent contraction.

Premature Ventricular Contractions (PVCs) are extra, abnormal heartbeats that begin in the ventricles of the heart. They can feel like a fluttering or a skipped beat in the chest.

ASSESMENT OF PALPITATIONS

1. History

2. Physical Exam

3. Blood Tests

4. Urine Test

5. Electrocardiogram (ECG)

6. Echocardiogram

What is crucial in the evaluation of palpitations?

Taking a detailed medical history is crucial in the evaluation of palpitations and can often provide key insights into the potential causes

History of palpitations - steps

• Duration and Timing

• Specific Triggers

• Medication and Substance Use

• Quality of Palpitations

• Associated Symptoms

• Other Health Conditions and Stressors

How can duration and timing help in evaluating palpitations?

Helps distinguish between transient, sporadic episodes and persistent conditions.

Why is identifying specific triggers important in evaluating palpitations?

It can indicate specific causes such as anxiety, dietary factors, or exercise-induced arrhythmias.

What role do medication and substance use play in the evaluation of palpitations?

Certain medications, caffeine, alcohol, and illicit drugs can all be relevant.

What helps differentiate the type of arrhythmia when describing palpitations?

Describing them as too fast, strong, or irregular.

What can the presence of symptoms like dyspnea, syncope, or chest pain suggest?

More serious cardiac conditions.

What can be contributing factors to palpitations besides underlying diseases?

Emotional stressors.

What information can a detailed medical history provide in the evaluation of palpitations?

Duration and Timing, Specific Triggers, Medication and Substance Use, quality of palpitations, associated symptoms, other health conditions and stressors

2. Physical Exam

• Vitals

• Cardiac Exam

• Auscultation

• Thyroid Exam

What are some components of the physical exam related to palpitations?

Vitals, Cardiac Exam, Auscultation, Thyroid Exam

what is vitals for physical exam related to palpitations?

• Checking for any abnormalities in blood pressure, heart rate, and respiratory rate.

what is Cardiac Exam for physical exam related to palpitations?

• : Includes palpating the chest for heaves or thrills, auscultating for any abnormal heart sounds or murmurs, and assessing jugular venous pressure to evaluate for signs of heart failure.

what is Auscultation for physical exam related to palpitations?

• Auscultation: Critical for detecting irregular heartbeats, murmurs which might indicate valve disorders, or other abnormalities.

what is Thyroid Exam: for physical exam related to palpitations?

• Thyroid Exam: An enlarged thyroid or signs of hyperthyroidism can be linked to palpitations.

3. Blood Tests

• Thyroid Function Tests

• Drug Levels:

What is a common endocrine cause of palpitations?

Hyperthyroidism

Why are drug levels especially relevant in blood tests for palpitations?

To check for medications known to affect heart rhythm or suspicion of substance abuse.

4. Urine Test

• Drug Screening

What is a urine test useful for identifying?

• Useful for identifying the presence of stimulants or other illicit substances that can cause palpitations.

5. Electrocardiogram (ECG)

• Routine ECG:

• Extended Monitoring:

What does a routine ECG capture?

A snapshot of the heart's electrical activity.

How can an ECG help identify arrhythmias?

It can identify arrhythmias, even if the patient is not currently experiencing palpitations.

What is the purpose of extended monitoring with a Holter monitor or event recorder?

To track the heart’s rhythm over 24 hours or longer, useful for detecting intermittent arrhythmias.

6. Echocardiogram

• Structural Assessment

What does an echocardiogram assess for?

Checks for heart disease that could cause palpitations, such as valve abnormalities, heart muscle issues, or other structural changes.

Advanced Diagnostic Tools

• Stress Test

• Electrophysiological Study:

What is a Stress Test used for in diagnosing palpitations?

A Stress Test is used to observe the heart's activity under physical stress when initial tests are inconclusive.

What is an Electrophysiological Study and when is it considered?

An Electrophysiological Study is an invasive test to map the heart's electrical system, helpful for complex arrhythmias not diagnosed by other means.

Typical Cases of Palpitations

1. Extrasystolic

2. Tachycardiac

3. Anxiety-Induced

4. Pulsation

What is the characteristic of extrasystolic palpitations?

Characterized by the feeling of a skipped beat followed by a stronger-than-normal subsequent beat.

What typically causes extrasystolic palpitations?

Premature atrial or ventricular contractions.

How do patients usually describe the sensation of extrasystolic palpitations?

The sensation of a skipped beat can be startling but is usually benign.

What is tachycardia?

• This involves a significantly accelerated heart rate that can be regular or irregular.

What are common triggers for tachycardia?

• Often triggered by physical exertion, emotional stress, or could be idiopathic

What are some associated symptoms of tachycardia?

• May include syncope, dyspnea, fatigue, and chest pain, indicating more severe underlying conditions like arrhythmias that may need urgent evaluation.

What are the characteristics of anxiety-induced palpitations?

Can be accompanied by non-cardiac symptoms like tingling in the hands, a lump in the throat, frequent sighing, and shortness of breath.

How do anxiety-induced palpitations generally manifest in terms of heart rate and onset?

Generally a slight acceleration of heart rate, often with a gradual onset linked to stress or anxiety disorders.

How do anxiety-induced palpitations typically respond to interventions?

These palpitations are typically more related to psychological factors and respond well to stress management and anxiety-reducing techniques.

What does the term "pulsation" refer to?

Describes a sensation of a pounding heart that maintains a normal rhythm.

When does pulsation typically occur?

Usually occurs during or after physical effort or in emotional situations.

What are the characteristics of pulsation?

Although the heartbeat remains regular, the enhanced awareness of heartbeat can cause discomfort or concern.

Complications of Palpitations

1. Fainting (Syncope)

2. Cardiac Arrest

3. Stroke

4. Heart Failure

What is a potential complication of palpitations that can occur due to rapid heartbeat?

Fainting (Syncope)

What happens during fainting (syncope) in relation to palpitations?

It occurs when the rapid heartbeat leads to insufficient blood flow and oxygen to the brain.

What can cause transient loss of consciousness in individuals experiencing palpitations?

Rapid arrhythmias dropping blood pressure can cause transient loss of consciousness.

What life-threatening condition can certain arrhythmias associated with palpitations lead to?

Cardiac Arrest

How can life-threatening arrhythmias like ventricular fibrillation or sustained ventricular tachycardia progress in individuals with palpitations?

They may degenerate into cardiac arrest.

What can conditions like atrial fibrillation cause, leading to the formation of blood clots that can result in a stroke?

Conditions like atrial fibrillation can cause the heart to beat irregularly and inefficiently, leading to the formation of blood clots that can travel to the brain, causing a stroke.

Atrial Fibrillation

Atrial fibrillation is a heart condition where the heart beats irregularly and can lead to blood clot formation, potentially causing a stroke.

How can persistent or chronic tachycardia impact the heart, eventually leading to heart failure?

Persistent or chronic tachycardia can overwork the heart, leading to heart muscle fatigue and eventual heart failure where the heart can't pump blood effectively.

Causes of Syncope:

1. Cardiac Syncope

2. Reflex Syncope

3. Orthostatic syncope

What is Cardiac Syncope?

A form of syncope that occurs when the heart is unable to meet the body's oxygen demand, leading to critically low cerebral perfusion.

Why is Cardiac Syncope particularly concerning?

It is associated with high mortality rates.

Cardiac Syncope subtypes

• Arrhythmogenic Subtype

• Cardiovascular Subtype