1. Palpitations Jeff Ascenzo, PGY-3 2/11/2008

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

10. “Code Blue”

11. Palpitations “A sensation of rapid or irregular beating of the heart” – Taber’s

12. Chief Complaints “fluttering” “pounding” “thudding” “throbbing” “quivering” “skipping beats” “my chest is going to explode” “can’t catch my breath” …

13. Chief Complaint Clues “skipped beats” or “flopping”: PAC’s / PVC’s -PAC’s/PVC’s  compensatory pause -pause   ’d LV volume -post-extrasystolic potentiation   ’d contractility “sustained bursts”: ventricular or SV tachyarrhythmias “irregular”: Atrial Fibrillation “abrupt”: Sustained ventricular or SV tachyarrhythmias “gradual”: Sinus tachycardia

14. Statistics Represent ~16% of all medical encounters (ER & outpatient ambulatory  has diagnostic consequences) 1-Year Mortality: 1.6% (3/190) 1-Year CVA Rate: 1.1% (2/190) 75% recurrence rate within 1 year

15. Next Step Focus the chief complaint -Is this life-threatening? -Hemodynamic consequences (syncope, pre-syncope or dyspnea) -Risk factors (CAD, HFailure or other heart disease) -Is it not? “Patients do not read Harrison’s” – Dr. Hafner Zebras are not always zebras, they may be the zebra presentation of the horse

16. History Conditions of symptom onset (rest, exertional, stressors, recent illnesses…) Associated symptoms Duration Conditions of symptom termination PMH Medications (especially at the VA) Social History: -Job -Coffee / tea / caffeine -Smoking -Alcohol -…

17. History - Importance Study – Predictors of a “cardiac” etiology to palpitations (p < 0.05): 1) > 5-minute duration 2) Known history of “heart disease” 3) “Irregular beats” 4) Male

18. 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? …

21. 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 …

22. 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

23. Diagnoses

24. Tests / Procedures Carotid Massage Valsalva DA Method EKG Fingerstick Echo Basic chemistries Thyroid functions Urine metanephrines Holter monitor (most common test after EKG) -Only 24 hrs.  best for daily symptoms Loop recorder / Event monitor Stress testing Patient education (pulse) ?Psychiatry referral

25. Putting It All Together “This is what you get paid the big bucks for” – Dr. Doug Phelps I think it’s this because A,B & C ~65% of cases – diagnosis can be determined from the history, exam & EKG alone (123/190)

26. Can’t Put It All Together? 16% of cases  no diagnosis! -13% in ER presentations -28% in Ambulatory presentations Beta-blockers are useful

27. Questions ?

28. Case #1 A 75 y.o. man with long-standing hypertension diagnosed 30 years ago, comes to your office complaining of fatigue and a sense of his “heart pounding” for the past day. He has never had this feeling before. His pulse is rapid and irregularly, irregular EKG…

29. Case #1 Diagnosis: Atrial Fibrillation with RVR

30. Case #2 A 28 y.o. resident comes to your clinic describing an incident of “fluttering” in her chest that began this morning after an overnight call. She has no relevant past medical history and takes no medications. Her pulse is 136 and regular. She drank a full 2-liter bottle of Mountain Dew this AM before rounds to “wake up.” EKG…

31. Case #2 Diagnosis: Atrial Flutter (2:1)

32. Case #3 A 36 y.o. successful businessman comes to the ER because of a one-week history of his “heart pounding out of his chest.” He has noticed these symptoms mostly at rest but also with exertion. He has no real significant past medical history, takes no medications, denies any use of illicit drugs, but does mention that he was recently promoted to a new job. His exam is normal. EKG…

33. Case #3 A Holter is also unremarkable Diagnosis?

34. Case #4 A 66 y.o. man presents to the ER with a 6- hour history of being unable to catch his breath. He also feels as if his “heart is racing.” He is a type 2 diabetic and has had multiple NSTEMI’s in the past but without any bypass targets seen at cardiac catheterization. EKG…

35. Case #4 Diagnosis: Ventricular Tachycardia

36. Case #5 A 79 y.o. woman presents to your clinic complaining of fatigue and sensations that began earlier today that her “heart is skipping.” She takes Digoxin for a history of atrial fibrillation, Lopressor for a history of an MI sustained several years ago, Cardizem for hypertension. She has a known old LBBB. EKG…

37. Case #5 Diagnosis: Complete Heart Block

38. References Weber BE, Kapoor WN. Evaluation and Outcomes of Patients With Palpitations. Amer Jour Med. 1996: 100 (2): 138-148. Surawicz B & Knilans TK. Chou’s Electrocardiography in Clinical Practice. W.B. Saunders Company. Philadelphia, PA. 2001. Harvard Medical School Online ECG Web Maven: http://ecg.bidmc.harvard.edu/maven/mavenmain.asp http://ecg.bidmc.harvard.edu/maven/mavenmain.asp Dubin D. Rapid Interpretation of EKG’s: 6 th Edition. COVER Publishing Company. Tampa, FL. 2000. Braunwald et al. Harrison’s Principles of Internal Medicine: 15 th Edition. McGraw-Hill. New York, NY. 2001. Guyton & Hall. Textbook Of Medical Physiology - 10th Edition. Saunders. Philadelphia, PA. 2000. Zipes, Libby, Bonow & Braunwald. Braunwald’s Heart Disease: A Textbook Of Cardiovascular Medicine – 7 th Edition. Elsevier Saunders. Philadelphia, PA. 2005. Topol EJ et al. Textbook of Cardiovascular Medicine. Lippincott Williams & Wilkins. Philadelphia, PA. 1998. Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med. 1990: 150 (8):1685-1689. Zimetbaum P, Josephson ME. Evaluation of Patients with Palpitations. NEJM. 1998: 338 (19): 1369-1373.

39. Questions / Comments / Concerns?