Transcript Palpitations Powerpoint

Palpitations
Jeff Ascenzo, PGY-3
2/11/2008
Overview / Goals
•
•
•
•
•
•
•
•
Define
Statistics / Epidemiology
History
Exam
Differential Dx
Tests
Put It All Together
Sample Cases
“Code Blue”
Palpitations
• “A sensation of rapid or irregular beating
of the heart” – Taber’s
Chief Complaints
•
•
•
•
•
•
•
•
•
“fluttering”
“pounding”
“thudding”
“throbbing”
“quivering”
“skipping beats”
“my chest is going to explode”
“can’t catch my breath”
…
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
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
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
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
-…
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
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% - Cardiac
21% - Cardiac
27% - Psychiatric
45% - Psychiatric
13% - “Other”
6% - “Other”
13% - No diagnosis
28% - No diagnosis
Diagnoses
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
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)
Can’t Put It All Together?
• 16% of cases  no diagnosis!
-13% in ER presentations
-28% in Ambulatory presentations
• Beta-blockers are useful
Questions
?
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…
Case #1
• Diagnosis: Atrial Fibrillation with RVR
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…
Case #2
• Diagnosis: Atrial Flutter (2:1)
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…
Case #3
• A Holter is also unremarkable
• Diagnosis?
Case #4
• A 66 y.o. man presents to the ER with a 6hour 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…
Case #4
• Diagnosis: Ventricular Tachycardia
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…
Case #5
• Diagnosis: Complete Heart Block
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
Dubin D. Rapid Interpretation of EKG’s: 6th Edition. COVER Publishing Company. Tampa,
FL. 2000.
Braunwald et al. Harrison’s Principles of Internal Medicine: 15th 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 – 7th 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.
Questions / Comments / Concerns?