Overview / Goals•Define•Statistics / Epidemiology•History•Exam•Differential Dx•Tests•Put It All Together•Sample Cases

Definition

•sensations of a rapid or irregular heartbeat

•

Differential Diagnosis of Palpitations

•Arrhythmias•Psychiatric causes•Drugs and medications•Nonarrhythmic cardiac causes•Extracardiac causes

Differential Diagnosis of Palpitations/ Drugs and medications

•Alcohol, Caffeine•beta agonists, phenothiazine, theophylline,

isotretinoin, digoxin•Cocaine •Tobacco

Dietary Supplement Causing Palpitation

•Chocolate•Ephedra/Diet pills•Ginseng•Bitter Orange•Valerian•Hawthorn

Differential Diagnosis of Palpitations/ Arrhythmias

•Atrial fibrillation/flutter•Bradycardia caused by advanced AV block or sinus node

dysfunction•Bradycardia-tachycardia syndrome(sick sinus syndrome)•Multifocal atrial tachycardia•Premature supraventricular or ventricular contractions•Sinus tachycardia•Supraventricular tachycardia•Ventricular tachycardia•Wolff-Parkinson-White syndrome

Differential Diagnosis of Palpitations/ Nonarrhythmic cardiac causes

•Atrial or ventricular septal defect•Cardiomyopathy•Congenital heart disease•Congestive heart failure•Mitral valve prolapse•Pacemaker-mediated tachycardia•Pericarditis•Valvular disease (e.g., aortic

insufficiency,stenosis)

Differential Diagnosis of Palpitations /Extracardiac causes

•Anemia ,•Electrolyte imbalance•Fever•Hyperthyroidism•Hypoglycemia•Hypovolemia•Pheochromocytoma•Vasovagal syndrome

History/PE of Palpitation

•Description : Fluttering, pounding, or uncomfortable sensation in the chest or neck,

or simply an increased awareness of the heartbeat

•Knowing the circumstances, precipitating factors, and associated symptoms

Exam•General Appearance?•Vitals: Pulse, BP, febrile or afebrile?, tachypneic?•Neck: JVP?, bruits?, carotid exam?, thyroid

palpable and normal?•Pulmonary: Clear, rales or wheezing?•Cardiovascular: Apical pulse – regular, irregular,

mostly regular with some ectopy?, normal heart sounds?, murmurs?, gallups?, rub?, PMI

location?•Abdomen: Masses?, bruits?•Extremities: Edema – pitting or nonpitting?•…

Differential Diagnoses•Arrhythmia (tachy / brady / SV / ventricular)•Heart Blocks (higher grade)•PVC’s / PAC’s•Sinus Tachycardia•Valvular Disease (usually arrythmias)•Structural Heart Disease (Ex.) HCM)

•Anxiety•Depression

•Hypoglycemia•Thyrotixicosis•Fever•Illicit Drugs•Prescribed Medications•Pheochromocytoma•…

Diagnostic Implications•Overall:

-84% of cases received a diagnosis43% - Cardiac31% - Psychiatric10%“ - Other” (Medications, drugs, etc…)

-16% No diagnosis found

•ER or ambulatory setting? (differences p < 0.002)ER (87% diagnosis) Ambulatory (72% diagnosis)

47% - Cardiac 21% - Cardiac

27% - Psychiatric 45% - Psychiatric

13% - “Other” 6% - “Other”

13% - No diagnosis 28% - No diagnosis