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ESSENTIAL INQUIRIES
Forceful, rapid, or irregular beating of the heart.
Rate, duration, and degree of regularity of heartbeat; age at first episode.
Factors that precipitate or terminate episodes.
Light-headedness or syncope; neck pounding.
Chest pain; history of MI or structural heart disease.
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GENERAL CONSIDERATIONS
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Palpitations are defined as an unpleasant awareness of the forceful, rapid, or irregular beating of the heart. They are the primary symptom for approximately 16% of patients presenting to an outpatient clinic with a cardiac complaint. In an observational cohort study of palpitations at an outpatient cardiac unit, cardiac arrhythmias were the cause of palpitations in 81% of cases; 77% were caused by atrial arrhythmias, 15%, by junctional tachycardia, and 8%, by ventricular arrhythmias. Prehospital ECG and ECG at admission had the best positivity rates. Palpitations represent 5.8 of every 1000 emergency department visits, with an admission rate of 24.6%. While palpitations are usually benign, they are occasionally the symptom of a life-threatening arrhythmia. To avoid missing a dangerous cause of the patient’s symptom, clinicians sometimes pursue expensive and invasive testing when a conservative diagnostic evaluation is often sufficient. The converse is also true; in one study, 54% of patients with supraventricular tachycardia were initially wrongly diagnosed with panic, stress, or anxiety disorder. A disproportionate number of these misdiagnosed patients are women. Table 2–3 lists history, physical examination, and ECG findings suggesting a cardiovascular cause for the palpitations.
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When assessing a patient with palpitations in an urgent care setting, the clinician must ascertain whether the symptoms represent (1) a significant CVD, (2) a cardiac manifestation of a systemic disease such as thyrotoxicosis, (3) an arrhythmia that is minor and transient, or (4) a benign somatic symptom that is amplified by the patient’s underlying psychological state.
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Patients with palpitations who seek medical attention in an emergency department instead of a medical clinic are more likely to have a cardiac cause (47% versus 21%), whereas psychogenic causes are more common among those who seek attention in office practices (45% versus 27%). In a study of patients who went to a university medical clinic with the chief complaint of palpitations, causes were cardiac in 43%, psychogenic in 31%, and miscellaneous in 10%.
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Cardiac arrhythmias that can result in symptoms of palpitations include sinus bradycardia; atrial fibrillation or flutter; sinus, supraventricular, and ...