Palpitation

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Overview
A palpitation is an awareness of the beating of the heart, whether it is too slow, too fast, irregular, or at its normal frequency. Palpitations may be brought on by overexertion, adrenaline, alcohol, disease (such as hyperthyroidism) or drugs, or as a symptom of panic disorder. It can also be associated with valve disorders such as mitral stenosis.

Nearly everyone experiences an occasional awareness of their heart beating, but when it occurs frequently, it can indicate an underlying cardiac abnormality. Palpitations may be associated with heart problems, but also with systemic disorders such as anemias and thyroid abnormalities.

Attacks can last for a few seconds or hours, and may occur very infrequently, or more than daily. Palpitations, if they occur in conjunction with other symptoms such as sweating, faintness, chest pain or dizziness, may be a sign of underlying cardiac disease and may warrant further evaluation.

Palpitations may also be associated with anxiety and panic attacks, in which case reassurance or psychological assessment may be of value, and blood loss, excessive pain, or lack of oxygen.

Common Causes of Palpitations
Palpitations can be attributed to one of three main causes:

1- Hyperdynamic circulation (Diseases of the Valvular Structures, Thyrotoxicosis, Hypercapnia, Pyrexia, Anemia, Pregnancy)

2- Sympathetic overdrive (Panic disorders, Hypoglycemia, Hypoxia, Anemia, Heart Failure)

3- Arrhythmias (atrial fibrillation, supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, or Heart Block...)

Differential Diagnosis of Conditions Associated with Palpitations
In alphabetical order.


 * Adrenal tumor
 * Alcohol
 * Aminophylline
 * Anemia
 * Antiarrythmics
 * Antiasthmatics
 * Antidepressants
 * Anemia
 * Anxiety
 * Aortic aneurysm
 * Aortic regurgitation
 * Aortic stenosis
 * Arteriovenous fistula
 * Atrial fibrillation
 * Atrial flutter
 * Atrial septal defect
 * Atrioventricular heart blocks
 * Atropine
 * AV nodal re-entry tachycardia
 * Beta blockers
 * Bradyarrhythmias
 * Caffeine
 * Cardiac glycosides
 * Cardiomegaly
 * Cocaine
 * Drugs leading to tachyarrhythmia
 * Exercise
 * Extrasystoles
 * Fever
 * Heart failure
 * Hyperkinetic heart syndrome
 * Hyperventilation
 * Hyperthyroidism
 * Hypoglycemia
 * Hypoxemia
 * Junctional tachycardia
 * Menopause
 * Metabolic acidosis
 * Migraine
 * Mitral valve prolapse
 * Myocardial ischemia
 * Myocarditis
 * Neuroleptics
 * Nicotine
 * Nitrates
 * Pacemaker
 * Paroxysmal atrial tachycardia
 * Patent ductus arteriosus
 * Pheochromocytoma
 * Premature atrial contractions
 * Premature ventricular contractions
 * Prosthetic heart valve
 * Psychiatric disorders
 * Respiratory acidosis
 * Sinus tachycardia
 * Sympathomimetics
 * Tachyarrhythmia
 * Theophylline
 * Thyroxine
 * Tricuspid insufficiency
 * Ventricular septal defect
 * Ventricular tachycardia

Types of Palpitations
People describe their palpitations in many different ways, but there are some common patterns:

The heart "stops"
Those who experience palpitations may have the feeling that their heart stops beating for a moment, and then starts again with a "thump" or a "bang". Usually this feeling is actually caused by an extra beat (premature beat or extrasystole) that happens earlier than the next normal beat, and results in a pause until the next normal beat comes through. People are not usually aware of the early, extra beat, but may be aware of the pause, which follows it (the heart seems to stop). The beat after the pause is more forceful than normal, giving the "thumping" sensation.

The heart is "fluttering" in the chest
Any rapid heartbeat (or tachycardia) can give rise to this feeling. A rapid, regular fluttering in the chest may be associated with sensation of pounding in the neck as well, due to simultaneous contraction of the upper, priming chambers of the heart (the atria) and the lower, main pumping chambers (the ventricles). If the fluttering in the chest feels very irregular, then it is likely that the underlying rhythm is atrial fibrillation. During this type of rhythm abnormality, the atria beat so rapidly and irregularly that they seem to be quivering, rather than contracting. The ventricles are activated more rapidly than normal (tachycardia) and in a very irregular pattern.

Feelings of Anxiety or Panic
Palpitations may be associated with feelings of anxiety or panic. It is normal to feel the heart thumping when feeling terrified or scared, but it may be difficult to know whether the palpitations or the panicked feeling came first. Unfortunately, since it can take some time before a clear diagnosis is made in a patient complaining of palpitations, people are sometimes told initially that the problem is anxiety.

Stressful situations cause an increase in the level of stress hormones, such as adrenaline, circulating in the blood, and there are some types of abnormal heart rhythm that can be stimulated by adrenaline excess, or by exercise. It may be possible to diagnose these sorts of palpitations by performing simple tests, such as an exercise test, while monitoring the ECG.

Changes in Posture
Some types of abnormal heart rhythm seem to be affected by posture. For many people, standing up straight after bending over can provoke a rapid heart rate. Often these attacks can be abolished again by lying down. Many people, if not all, are more aware of the heartbeat when lying quietly in bed at night. This is partly because at that time, the attention is not focused on other things, but also because the slower heart beat at rest can allow more premature beats to occur.

Symptoms
Many times, the person experiencing palpitations may not be aware of anything apart from the abnormal heart rhythm itself. But palpitations can be associated with other things such as tightness in the chest, shortness of breath, dizziness or lightheadedness. Depending on the type of rhythm problem, these symptoms may be just momentary or more prolonged. Actual blackouts or near blackouts, associated with palpitations, should be taken seriously because they often indicate the presence of important underlying heart disease.

Diagnosis
The most important initial clue to the diagnosis is one's description of the palpitations. The approximate age of the person when first noticed and the circumstances under which they occur are important, as is information about caffeine intake. It is also very helpful to know how they start and stop (abruptly or not), whether or not they are regular, and approximately how fast the pulse rate is during an attack. If the person has discovered a way of stopping the palpitations, that is also helpful information.

The diagnosis is usually not made by a routine medical examination and electrical tracing of the heart's activity (ECG), because most people cannot arrange to have their symptoms while visiting the doctor. Nevertheless, findings such as a heart murmur or an abnormality of the ECG, which could point to the probable diagnosis, may be discovered. In particular, ECG changes that can be associated with specific disturbances of the heart rhythm may be picked up; so routine physical examination and ECG remain important in the assessment of palpitations.

Blood tests, particularly tests of thyroid gland function are also important baseline investigations (an overactive thyroid gland is a potential cause for palpitations; the treatment in that case is to treat the thyroid gland over-activity).

The next level of diagnostic testing is usually 24 hour (or longer) ECG monitoring, using a form of tape recorder (a bit like a Walkman), which can record the ECG continuously during a 24-hour period. If symptoms occur during monitoring it is a simple matter to examine the ECG recording and see what the cardiac rhythm was at the time. For this type of monitoring to be helpful, the symptoms must be occurring at least once a day. If they are less frequent then the chances of detecting anything with continuous 24, or even 48-hour monitoring, are quite remote.

Other forms of monitoring are available, and these can be useful when symptoms are infrequent. A continuous-loop event recorder monitors the ECG continuously, but only saves the data when the wearer activates it. Once activated, it will save the ECG data for a period of time before the activation and for a period of time afterwards - the cardiologist who is investigating the palpitations can program the length of these periods. A new type of continuous-loop recorder has been developed recently that may be helpful in people with very infrequent, but disabling symptoms. This recorder is implanted under the skin on the front of the chest, like a pacemaker. It can be programmed and the data examined using an external device that communicates with it by means of a radio signal.

Investigation of heart structure can also be important. The heart in most people with palpitations is completely normal in its physical structure, but occasionally abnormalities such as valve problems may be present. Usually, but not always, the cardiologist will be able to detect a murmur in such cases, and an echo scan of the heart (echocardiogram) will often be performed to document the heart's structure. This is a painless test performed using sound waves and is virtually identical to the scanning done in pregnancy to look at the fetus.

A family history of sudden cardiac death, QT prolongation and cardiomyopathy should be obtained.

Laboratory Findings
Depending upon the clinical suspicion of the underlying disorder, initial laboratory studies may include:
 * CBC to rule out anemia
 * Glucose to rule out hypoglycemia
 * TSH to rule out hyperthyroidism
 * Digoxin level
 * Drug or tox screen to rule out cocaine and other causes of palpitations

Treatment
Treating heart palpitations depends greatly on the nature of the problem. In many patients, excessive caffeine intake triggers heart palpitations. In this case, treatment simply requires caffeine intake reduction. If it's been determined that caffeine is not the cause, another dietary consideration is too little magnesium, particularly in pre-menopausal women. A supplement of equal dosages of magnesium and calcium may be helpful in eliminating palpitations. For severe cases, medication is often prescribed.

A variety of medications manipulate heart rhythm, which can be used to try to prevent palpitations. If severe palpitations occur, a beta-blocking drug is commonly prescribed. These block the effect of adrenaline on the heart, and are also used for the treatment of angina and high blood pressure. However, they can cause drowsiness, sleep disturbance, depression, impotence, and can aggravate asthma. Other anti-arrhythmic drugs can be employed if beta blockers are not appropriate.

If heart palpitations become severe, antiarrhythmic medication can be injected intravenously. If this treatment fails, cardioversion may be required. Cardioversion is usually performed under a short general anaesthesia, and involves delivering an electric shock to the chest, which stops the abnormal rhythm and allows the normal rhythm to continue.

For some patients, often those with specific underlying problems found in ECG tests, an electrophysiological study may be advised. This procedure involves inserting a series of wires into a vein in the groin, or the side of the neck, and positioning them inside the heart. Once in position, the wires can be used to record the ECG from different sites within the heart, and can also start and stop abnormal rhythms to further accurate diagnosis. If appropriate, i.e. if an electrical "short respons circuit" is shown to beythm, thible for the abnormal rhen a special wire can be used to cut the "short circuit" by placing a small burn at the site. This is known as "radiofrequency ablation" and is curative in the majority of patients with this condition.

Atrial fibrillation has been discussed in a separate article. Differential Diagnosis of Palpitation

Treatment may include medication to control heart rate, or cardioversion to support normal heart rhythm. Patients may require medication after a cardioversion to maintain a normal rhythm. In some patients, if attacks of atrial fibrillation occur frequently despite medication, ablation of the connection between the atria and the ventricles (with implantation of a pacemaker) may be advised. A very important risk of atrial fibrillation is the increased risk of stroke. Management of atrial fibrillation usuaf blood lly includes some form oVery rarthinning treatment.

ely, palpitations are associated with an increased risk of blackouts, and even premature death. Generally speaking, serious arrhythmias occur in patients who are known to have heart disease, or carry a genetic predisposition for heart disease or related abnormalities and complications.

Palpitations, in the setting of the above problems, or occurrences such as blackouts or near blackouts, should be taken seriously. Even if ultimately nothing is found, a doctor should be contacted immediately to arrange the appropriate investigations, especially if palpitations occur with blackouts or if any of the above conditions are noticed.