cardiovascular disorders
Palpitations
Evaluation of Palpitations
A complete history and physical examination are essential. Observations by other medical personnel or reliable observers should be sought. History of present illnessshould cover the frequency and duration of palpitations and provoking or exacerbating factors (eg, emotional distress, activity, change in position, intake ofcaffeineor other drugs). Important associated symptoms include syncope, light-headedness, tunnel vision, dyspnea, and chest pain. Asking the patient to tap out the rate and cadence of palpitations is better than a verbal description and often suggests a diagnosis, as in the “missed beat” of atrial or ventricular extrasystoles or the rapid total irregularity of atrial fibrillation. should cover symptoms of causative disorders, including heat intolerance, weight loss, and tremor ( Hyperthyroidism ); chest pain and dyspnea on exertion ( Past medical historyshould identify known potential causes, including documented arrhythmias and heart or thyroid disorders. Family history should note occurrences of syncope (sometimes mistakenly described as seizures) or sudden death at an early age. The drug profile should be reviewed for offending prescription drugs (eg, antiarrhythmics,digoxin, beta-agonists,theophylline, and rate-limiting drugs); over-the-counter drugs (eg, cold and sinus drugs, dietary supplements containing stimulants), including alternative medicines; and illicit drugs (eg,cocaine, methamphetamines).Caffeine(eg, coffee, tea, numerous soft drinks and energy drinks), alcohol, and tobacco use should be determined. Thegeneral examinationshould note whether an anxious demeanor or psychomotor agitation is present. Vital signs are reviewed for fever, hypertension, hypotension, tachycardia, bradycardia, tachypnea, and low oxygen saturation. Orthostatic changes in blood pressure (BP) and heart rate should be measured. Examination of the head and neckshould note any abnormality or dyssynchrony of the jugular pulse waves compared with the carotid pulse or auscultated heart rhythm and findings of hyperthyroidism, such as thyroid enlargement or tenderness and exophthalmos. The conjunctivae, palmar creases, and buccal mucosa should be inspected for pallor. Cardiac auscultationshould note the rate and regularity of the rhythm as well as any murmurs or extra heart sounds that might indicate underlying valvular or structural heart disease. Neurologic examinationshould note whether resting tremors or brisk reflexes are present (suggesting excess sympathetic stimulation). An abnormal neurologic finding suggests that seizures rather than a cardiac disorder may be the cause if syncope is one of the symptoms. Certain findings suggest a more serious etiology: Light-headedness or Syncope (particularly if injury occurs from syncope) Chest Pain None Dyspnea New onset of irregularly irregular heart rhythm Heart rate>120 beats/minute or<45 beats/minute while at rest Significant underlying heart disease Family history of recurrent syncope or sudden death Exercise-induced palpitations or, particularly, syncope History (see table Suggestive Historical Findings in Patients With Palpitations ) and, to a lesser extent, physical examination provide clues to the diagnosis. Palpation of the arterial pulse and cardiac auscultation may reveal a rhythm disturbance. However, the examination is not always diagnostic of a specific rhythm, except when it identifies the unique irregular irregularity of some cases of rapid atrial fibrillation, the regular irregularity of coupled atrial or ventricular extrasystoles, the regular tachycardia at 150 beats/minute of PSVT, and the regular bradycardia of<35 beats/minute of complete atrioventricular block. Careful examination of the jugular venous pulse waves simultaneously with cardiac auscultation and palpation of the carotid artery allows evaluation of atrial rhythm through jugular waves while the auscultated sounds or the pulse in the carotids are the product of ventricular contraction. Thyroid enlargement or tenderness with exophthalmos suggests thyrotoxicosis. Marked hypertension and regular tachycardia are consistent with pheochromocytoma. Testing typically is done: ECG, sometimes with ambulatory monitoring Laboratory testing Sometimes imaging studies, stress testing, or both ECGis done, but unless the recording is done while symptoms are occurring, it may not provide a diagnosis. Many cardiac arrhythmias are intermittent and show no fixed ECG abnormalities; exceptions include Atrial Fibrillation and Wolff-Parkinson-White Syndrome (WPW) None Torsades de Pointes Ventricular Tachycardia None Arrhythmogenic right ventricular dysplasia cardiomyopathy Brugada syndrome and its variants If no diagnosis is apparent and symptoms are frequent, Holter monitor for 24 to 48 hours is useful; for intermittent symptoms, an event recorder worn for longer periods and activated by the patient when symptoms are felt is better. These tests are used mainly when a sustained arrhythmia is suspected, rather than when symptoms suggest only occasional skipped beats. Patients with very infrequent symptoms that clinicians suspect represent a serious arrhythmia may have a device implanted beneath the skin of the upper chest. This device, often called a loop recorder, continuously records the rhythm and can be interrogated by an external machine that allows the cardiac rhythm to be printed. Finally, a variety of commercially available products that patients may be using may provide additional useful information. These products include fitness trackers, which monitor heart rate, and mobile ECG monitors that are available for phones and watches. Laboratory testingis needed in all patients. All patients should have a complete blood count and measurement of serum electrolytes, including magnesium and calcium. Further testing should be aimed at suspected causes. The cardiac marker troponin should be measured in patients with ongoing arrhythmias, chest discomfort, or other symptoms suggesting active or recent coronary ischemia, myocarditis, or pericarditis. Thyroid function tests are indicated when atrial fibrillation is newly diagnosed or there are symptoms of Hyperthyroidism . Patients with paroxysms of high BP should be evaluated for pheochromocytoma. Sometimes Tilt Table Testing is done in patients with postural syncope. is sometimes needed. Patients with newly diagnosed arrhythmia, findings suggesting cardiac dysfunction or findings suggesting structural heart disease require Echocardiography and sometimes 