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 diagnosis 43% - Cardiac 31% - Psychiatric 10% - “Other” (Medications, drugs, etc…) -16%  No diagnosis found ER or ambulatory setting? (differences p < 0.002) ER (87% diagnosis)Ambulatory (72% diagnosis) 47% - Cardiac21% - Cardiac 27% - Psychiatric45% - Psychiatric 13% - “Other”6% - “Other” 13% - No diagnosis28% - No diagnosis