Presentations
Approach to palpitations
The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.
Immediate threats
- Sustained VT or rapid pre-excited AF
- Palpitations with syncope or chest pain
- A known structural or inherited heart disease background
History that discriminates
- Ask the patient to tap the rhythm: fast-regular, fast-irregular, or skipped beats
- Onset and offset: abrupt (SVT) versus gradual (sinus)
- Terminated by vagal maneuvers (points at the AV node)
- Caffeine, alcohol, stimulants, thyroid symptoms, anxiety context
Examination
- Rate and rhythm now; irregularly irregular pulse is a bedside diagnosis
- Thyroid and volume status
- Murmurs and signs of structural disease
Problem representation
Abrupt-onset regular palpitations at 180 terminating with Valsalva in a healthy 25-year-old (AVNRT) versus irregular palpitations with dyspnea in a 74-year-old with hypertension (new AF).
Differential, by mechanism
Arrhythmic
- AF and flutter
- SVT
- VT
- Ectopy (the commonest)
High-output
- Fever
- Anemia
- Thyrotoxicosis
- Pregnancy
Other
- Anxiety and panic
- Stimulants and withdrawal
- Medication effect
Investigations
- Twelve-lead ECG, even between episodes: pre-excitation, long QT, and ectopy leave footprints
- TSH, hemoglobin, electrolytes including magnesium
- Ambulatory monitoring matched to symptom frequency
- Echo when structure is in question
Interpretation
- Symptom-rhythm correlation is the entire point of monitoring: a diary without a strip proves nothing
- Ectopy on a normal heart is managed with reassurance more often than drugs
Next steps
- Teach vagal maneuvers to the SVT patient; script the emergency plan
- New AF starts the same three questions as ever: rate, rhythm, anticoagulation
Connected
Take it further
Copy this page as study notes, then paste them into QSpace for practice questions or AnkiGen for flashcards.