Palpitations or pounding is the sensation of a fast or irregular heartbeat which is often described by patients as an uncomfortable heartbeat or movement of organs around the heart. Normal heart activity is not felt at rest, but shortly after strenuous activity or during emotional stress we can feel heart rate activity. This situation is a physiological condition of palpitations. Outside of these conditions, palpitations are considered something that is not normal.
Palpitations are one of the most common complaints patients come to general practitioners, and are also the most common reason general practitioners refer patients to cardiologists. These complaints sometimes represent a form of heart rhythm disorder ( arrhythmia ) with various causes and complaints submitted by patients. The mechanisms underlying complaints of palpitations vary, heart contractions that are too fast, slow or irregular including sinus tachycardia due to mental disorders, systemic diseases or effects of drugs; strong heart contractions and heart movement abnormalities such as in structural heart disease; anomaly of subjective perception of heart rate as in some psychosomatic illnesses.
Palpitations are sometimes accompanied by complaints of fainting, dizziness, or chest pain. If this complaint accompanies palpitations, a more serious cause of illness should be considered. Therefore, in-depth investigations including anamnesis, physical examination and reading of the heart record ( ECG ) are needed to establish a diagnosis of patients with complaints of palpitations.
REASON
The causes of palpitations are very diverse, both due to cardiac ( cardiac ) and non-cardiac factors. The causes of palpitations due to cardiac causes are 43%, 30% psychiatric and the remaining 27% are unknown.
Palpitations can result from a variety of arrhythmias ( bradycardia, tachycardia, atrial and ventricular premature, sick sinus syndrome, AV block and ventricular tachycardia ) . The feeling of fluctuating beats (flip-flop) is usually due to atrial or ventricular prematurity. The feeling of cardiac arrest is caused by a pause (compensatory or noncompensatory). The sensation of being hit results from a strong postextrasystolic pulse. Patients with a feeling of palpitations in the neck area may be caused by atrioventricular nodal tachycardia which results in simultaneous atrial and ventricular beats resulting in reflux of blood into the superior vena cava
Palpitations caused by panic disorder as much as 15-31 %. This situation is often found in women of childbearing age. In these disorders, increased catecholamine may induce a supraventricular or ventricular tachycardia. Increased vagal tone after exertion can also precipitate atrial fibrillation. When we encounter a patient complaining of palpitations, examination for systemic disease is also necessary because palpitations are often encountered due to fever, dehydration, hypoglycemia, anemia or thyroid disease. Palpitations can also be triggered by some drugs and foods that contain caffeine, alcohol, cocaine, theophylline, digitalis and beta agonists.
INITIAL ASSESSMENT OF PALPITATION
History and physical examination hold the key to the initial assessment of a patient with palpitations. Anamnesis includes:
- The character of the palpitations that are felt, such as the feeling of a fluctuating pulse (flip-flop), the sensation of a stopped heartbeat, the sensation of being hit can reflect a certain type of arrhythmia.
- The type of start and end of the palpitations, whether sudden or gradual. Palpitations that come and end suddenly indicate an atrial or ventricular tachyarrhythmia, whereas those that develop slowly are usually a benign condition, such as sinus tachycardia due to emotional stress or after exercise.
- Precipitating factors, such as activity or drug use. Palpitations that occur during light physical activity indicate the presence of a pathology, such as CHF, myocardial ischemia, atrial fibrillation, anemia or thyrotoxicosis. Patients with Long QT syndrome, a state of abnormal myocardial repolarization, usually develop palpitations on exercise that manifest as VT. Patients with long QT syndrome have a high risk of sudden cardiac death.
- Associated symptoms such as syncope, presyncope, vertigo or angina.
Physical examination is sometimes difficult to do while the patient is still in a state of palpitations. Examination during palpitations is aimed at evaluating hemodynamics (blood pressure and signs of heart failure) and assessing the regularity of the heartbeat by listening or palpating the pulse.
Basic laboratory tests such as routine blood, electrolytes, thyroid hormone are useful for assessing whether there is involvement of a systemic disease that underlies palpitations. If possible checks for cardiac enzymes, BNP, routine urine can also be done.
ELECTROCARDIOGRAPHY
Electrocardiography (EKG) plays an important role in diagnosing patients with complaints of palpitations. If the patient can be examined during complaints of palpitations, the ECG is a very helpful modality in diagnosing the patient. For this reason, patients must be notified to check as soon as possible if there are complaints of palpitations. By looking at the ECG picture, the doctor can analyze the P and QRS waves and their relationship, assess the frequency and regularity of the heartbeat, so that finally they can accurately diagnose the relationship between palpitations and the presence or absence of arrhythmias. In addition, EKG images also provide information on other cardiac conditions such as the presence or absence of previous myocardial infarction, ventricular or atrial hypertrophy, and AV block, and the presence or absence of additional pathways such as delta waves in Wolf-Parkinson-White syndrome (WPW ).
ADVANCED EXAMINATION
If the history, physical examination, laboratory and ECG do not lead to a diagnosis, then additional examinations are necessary, including (1) Holter monitoring, which is continuous ECG monitoring for 24-48 hours. Patients carry out daily activities as usual and are asked to record any complaints and activities that are being carried out, so that a correlation between complaints and arrhythmias can be obtained based on the ECG strip recording. (2) The treadmill test is very useful for assessing suspicion of palpitations precipitated by activity and in patients with ischemic heart disease risk factors. (3) Echocardiography; Echocardiographic examination in patients with palpitations is aimed at assessing cardiac morphology, left ventricular function and the presence or absence of valvular disease. Often echocardiography is useful in assessing for mitral valve prolapse in young adults with unexplained palpitations. (4) Electrophysiological studies, is the last invasive measure in the diagnosis of palpitations. This electrophysiological study can accurately assess the type of arrhythmia that underlies the complaint of palpitations, as well as being able to proceed with ablation to stop the arrhythmia.
OUTPATIENT OR INPATIENT?
Most patients with palpitations can be diagnosed in an outpatient setting, or simply treated in the emergency department and continued on an outpatient basis, as is the case for most patients with SVT. However, in cases of palpitations with a very disturbing complaint or if the initial assessment suggests a serious risk of arrhythmias, treatment, monitoring and consultation of a cardiologist are urgently needed.
CONCLUSION
Palpitations are non-specific symptoms with various underlying etiologies, both cardiac and non-cardiac. If an arrhythmia is responsible for the palpitations, then a thorough investigation should be carried out because palpitations are very likely a sign of a cardiac or metabolic problem. Evaluation of palpitations includes detection of underlying arrhythmias, assessing the severity of symptoms and assessing the presence or absence of structural cardiac abnormalities and other causes of precipitation.
Palpitations accompanied by syncope, hemodynamic instability or uncontrolled arrhythmias require treatment, monitoring and consultation of a cardiologist for rapid cardiac evaluation and, if possible, electrophysiological studies and ablation.
This article was written by dr. Heri Hernawan, Sp. JP FIHA (Cardiologist at EMC Tangerang Hospital). He practices every Monday - Friday at 09.00 - 14.00 and Saturday at 09.00 - 13.00.