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Dr. Rajendran Rajendran
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PALPITATION



DEFINITION

Palpitation is an unpleasant awareness of the beating of the heart.

CAUSES

Palpitation may be caused by any change in rate, rhythm, or force of contraction of the heart. Palpitation is a common complaint and is usually not due to heart disease. Patients with chronic heart disease may adapt to the changes in rate, rhythm, or force of contraction. Therefore, they may not complain of palpitation.

Common

1. Anxiety
2. Emotional stress (e.g., fear)
3. Strenuous exercise
4. Extra-systoles

Less common causes

1. Atrial fibrillation
2. Supraventricular tachycardia
3. Drug induced tachycardia (e.g., salbutamol, atropine)
4. Thyrotoxicosis
5. Valvular heart disease (MS, AR, MR)
6. Complete heart block
7. Hypoglycemia
8. Pheochromocytoma


Palpitation is most commonly due to anxiety or emotional stress


CLINICAL APPROACH

As usual, history and physical examination give the most useful information. An ECG is commonly indicated. Sometimes continuous ECG (Holter) monitoring may be necessary.


1 Is there an occasional `thump' (or single skipped beat)?

An occasional `thump’ suggests extra-systole. Extra-systoles commonly occur in healthy persons.

2 How was the onset? How did it end?

Sudden onset and sudden cessation of palpitation suggests paroxysmal atrial tachycardia or paroxysmal atrial fibrillation. Persistent atrial fibrillation or tachycardia may or may not be associated with any palpitation.
Gradual onset and cessation suggests sinus tachycardia or anxiety.

3 What are the associated complaints?

Palpitation along with a variety of complaints like insomnia, fatigue, precordial chest pain, paresthesias, or anorexia suggests anxiety neurosis. Associated PND, orthopnoea, syncope, or central chest pain suggests organic heart disease. Palpitation, followed by syncope, suggests Stokes-Adams syndrome, or a tachyarrhythmia.

4 What is the heart rate at the time of palpitation?

Palpitation with a regular heart rate between 100 and 140 suggests sinus tachycardia. Atrial fibrillation is the most common cause of an irregular fast heart.

5 What precipitates the attacks?

Palpitation precipitated by mild physical activity suggests cardiac failure, anemia, thyrotoxicosis, atrial fibrillation, or physical deconditioning.

6 What terminates the attacks?

Palpitation terminated by vagal stimulation (e.g., pressure on the carotid sinus, stooping, breath holding, or induced vomiting) suggests paroxysmal atrial tachycardia.
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