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Palpitations and Tachycardia
Palpitations are a common and frequently perplexing presenting complaint in emergency medicine. Patients ultimately may have a life-threatening disease, a benign rhythm disturbance, or simply "anxiety." Definitive diagnosis on initial presentation to the ED is uncommon. The ED physician must distinguish highrisk patients needing treatment or hospitalization from low-risk patients who can be evaluated in an outpatient setting. The sensation of a beating heart is normal in many situations. The normal contraction and movement of the heart is generally not felt at rest. A normal sinus tachycardia may be noted during exercise, high-stress situations, or after drug ingestion.
Causes
- Arrhythmias: Almost any arrhythmia can cause palpitations; however, most arrhythmias are clinically silent. Sinus pause or extrasystole may be felt as a pounding in the chest. Paradoxically, patients with serious heart disease frequently have the most arrhythmias and the least sensation of palpitation.
- High-output states: Patients with high-output states such as anemia, fever, hypoglycemia, or thyrotoxicosis may feel the compensatory sinus tachycardia associated with the underlying condition.
- Drug ingestion: Many legal and illegal drugs can cause palpitations.
- Caffeine: Coffee, various teas, and even sodas high in caffeine
- Illicit drugs: Cocaine, amphetamines
- Prescribed drugs: Epinephrine, aminophylline, and thyroid replacements
- Anxiety (ultimately diagnosed in 30% of unselected cases): A common cause of palpitations but a risky diagnosis to make in the ED, since only after serious diseases have been excluded should this diagnosis be made.
Symptoms
Although it remains good practice to determine the onset, timing, rate , and rhythm of the palpitations, the usefulness of many of these features is in doubt.
- Palpitations associated with the following suggest potentially serious cardiac disease and generally require hospital admission:
a: Syncope or near-syncope. This suggests a hypoperfusion state caused by an arrhythmia, which usually is an indication for admission and monitoring, although results of inpatient workup are frequently negative.
b. History of underlying ischemic heart disease. A history of prior myocardial infarction (MI) or congestive heart failure (CHF) is a serious risk factor for ventricular arrhythmias. All patients with this history and with palpitations should be admitted to the hospital to rule out ventricular tachycardia.
c. Chest pain. A history of ischemic-sounding chest pain in association with palpitations is cause for concern. Tachycardia can be thought of as a cardiac stress test. Symptoms of cardiac ischemia suggest the patient has failed the stress test.
d. Shortness of breath. This suggests possible transient pulmonary congestion of heart failure. Congestive heart failure in association with palpitations may suggest a serious arrhythmia or underlying heart disease.
2: Palpitations associated with the following suggest a potentially serious cardiac condition but may not require hospital admission:
a. Sustained palpitations. Patients who have palpitations
that last more than 5 minutes frequently have a cardiac cause of their symptoms.
b. Irregular palpitations. Palpitations clearly described as irregular are strongly predictive of an underlying cardiac cause. Rapid irregular palpitations are usually episodes of atrial fibrillation.
Signs
- The physical examination is rarely helpful in patients with palpitations, as they have generally resolved. If palpitations occur during the examination, a rhythm strip should be obtained. A normal physical examination does not rule out a serious cause for the palpitation.
- Underlying signs of cardiac disease should be sought (e.g.,cardiomegaly, signs of heart failure, and murmurs).
- Conditions that could cause a high-output state should be investigated (e.g., goiter from thyroid disease, anemia from GI bleed, and so forth).
Treatment
- In which the drug treatments, your doctor may prescribe some medicines known as anti-arrhythmics. Anti-arrhythmics such as include digoxin and flecainide. These drugs will slow down a fast heartbeat and also help it return to normal.
- Another treatment for Palpitations and Tachycardia is Cardioversion procedure, In which a controlled electrical current is applied to the chest wall and which is synchronised with the heartbeat pattern seen on the ECG. This helps your heart to return to its natural rhythm. This treatment is performed under a general anaesthetic, which means that you will be asleep throughout the procedure and will feel no pain during procedure.
- In which Catheter ablation therapy, we will idenified and destroyed the abnormal areas in your heart that are creating the arrhythmia. Catheter ablation therapy is performed using the same catheters as are used for electrophysiological testing. Radio frequency energy emitted from the tip of the catheter is used to destroy the areas of the heart that are causing an arrhythmia.
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