Palpitations are the perception of heart activity. They are often perceived as palpitations, tachycardia or hopping. They are frequently; they find some patients uncomfortable and frightening. Palpitations can occur in the absence of heart disease or result from life-threatening heart disease. It is crucial for diagnosis and treatment, the rhythm in the ECG “capture” and make careful observations during the palpitations. Pathophysiology The mechanisms that are responsible for the feeling of palpitations are unknown. Normally the sinus rhythm of a normal rate is not perceived, reflecting palpitations usually changes in heart rate or heart rhythm resist. In all cases it is the abnormal heart movement in the breast that can be felt. In the case of isolated premature beats, the patient can actually perceive the increased postextrasystolischen Beat as a “skipped” beat rather than a premature beat, probably because the premature blocks the next sinus beat and a longer ventricular filling and thus a higher stroke volume allows. The clinical perception cardiac phenomena is very variable. Some patients are aware of virtually any premature ventricular beat, but others are not even complex atrial or ventricular tachyarrhythmias aware. The awareness is increased in sedentary, anxious or depressed patients and reduced for active, happy patients. In some cases, palpitations are perceived in the absence of abnormal heart activity. Etiology Some patients simply have a heightened awareness of the normal heart activity, especially under load, febrile diseases or anxiety that increase the heart rate. In most cases, the palpitations of arrhythmias result. Arrhythmias can range from harmless to life threatening. The most common arrhythmias include premature atrial contractions (PACs) Premature ventricular arrhythmia (VES) These two arrhythmias are usually harmless. Other common arrhythmias include paroxysmal supraventricular tachycardia (PSVT) AV nodal reentrant tachycardia or atrial fibrillation Vorhoflattern Ventricular Tachycardia bradyarrhythmias rarely cause a complaint of palpitations, although some patients the slow rate are aware. Causes of Arrhythmias Some arrhythmias (z. B. PACs, PVCs, PSVT) often occur spontaneously in patients without serious underlying disease, but others are often caused by a serious cardiac disorder. Among the serious cardiac causes include myocardial ischemia or other myocardial diseases, congenital heart defects (eg. As Brugada syndrome, arrhythmogenic right ventricular cardiomyopathy, congenital long QT syndrome), valvular heart disease and conduction system disorders (z. B. disorders bradycardia or AV block cause). Patients with orthostatic hypotension often feel palpitations caused standing by sinus tachycardia. Non-cardiac conditions that increase myocardial contractility (z. B. thyrotoxicosis, pheochromocytoma, anxiety) may cause palpitations. Some substances, including digitalis, caffeine, alcohol, nicotine and sympathomimetic cause (z. B. Albutamol, amphetamines, cocaine, dobutamine, epinephrine, ephedrine, isoproterenol, norepinephrine and theophylline) or frequently reinforce palpitations. Metabolic disorders, including anemia, hypoxia, hypovolemia and electrolyte disorders (eg. As diuretic-induced hypokalemia) can cause palpitations or verst√§rken.Folgen Many arrhythmias that cause palpitations have, but no adverse physiological effects (d. E., Regardless of the underlying disease). However, can bradyarrhythmias, tachyarrhythmias and “heart block” to be unpredictable and negatively affect cardiac output and lead to hypotension or death. Ventricular tachycardia degenerates sometimes to fibrillation. Assessment A complete history and physical examination are essential. An observation by other medical personnel or reliable observers should be included. History The history of the present illness should cover the frequency and duration of palpitations and provocative or reinforcing factors (eg. As emotional stress, activity, change in position, intake of caffeine or other substances). Important associated symptoms include syncope, dizziness, tunnel vision, dyspnea and chest pain. to ask the patient, tap out the rate and cadence of palpitations, is better than a verbal description and often allows a definitive diagnosis, as with the “missed beat” of atrial or ventricular premature beats or the rapid absolute irregularity of atrial fibrillation. The system check should cover the symptoms-causing diseases, including heat intolerance, weight loss and tremor (hyperthyroidism); Chest pain and exertional (myocardial ischemia); and fatigue, weakness, heavy vaginal bleeding and dark tar-like stools (anemia) The medical history should identify known potential causes, including documented arrhythmias and heart or thyroid disease. The family history was the occurrence of syncope (sometimes mistakenly called cramps described) or sudden death note at a young age. The medication should be based on inducing prescription drugs (eg. As antiarrhythmics, digitalis, beta-agonists, theophylline, and “rate-limiting drugs”), non-prescription drugs (eg. As cold and sinus medications, dietary supplements with stimulants), including alternative substances and illegal drugs (eg. as cocaine, methamphetamine) are reviewed. The intake of caffeine (eg. As coffee, tea, many soft soft drinks and energy drinks), alcohol and tobacco should be determined werden.K√∂rperliche study the general investigation should determine whether an anxious attitude or psychomotor agitation present. The vital signs are checked for fever, hypertension, hypotension, tachycardia, bradycardia, tachypnea and low oxygen saturation. Orthostatic changes in blood pressure and heart rate should be measured. The study of head and neck should any anomaly or missing synchrony of the jugular pulse waves compared to the carotid or auscultated heart rhythm and finds of hyperthyroidism, such as enlargement, tenderness and exophthalmus thyroid record. The conjunctiva, palmar creases and buccal mucosa should be inspected for pallor. The cardiac auscultation should the frequency and regularity of the rhythm and any noise or extra heart sounds that might indicate underlying valvular or structural heart disease noted. The neurological examination should note whether resting tremor or rapid reflexes are present (indicating excess sympathetic stimulation). An abnormal neurological findings suggests that strokes can be the cause rather than cardiac disease if syncope one of the symptoms ist.Warnzeichen Certain findings indicate a more serious etiology out: dizziness or syncope (especially if injury from syncope occur) chest pain dyspnea New inserting an irregularly occurring irregular heart rhythm heart rate> 120 beats / min or <45 beats / min underlying at rest significant heart disease family history of recurrent syncope or sudden death exercise-induced palpitations, or in particular syncope interpretation of the findings the history (see Table: Suggestive anamnestic findings in patients with palpitations) and to a lesser extent the physical examination give clues au f the diagnosis. Palpation of the arterial pulse and cardiac auscultation be able to recognize a rhythm disorder. However, the investigation is not always diagnostic for a particular rhythm, except when the particular irregular irregularity some cases rapid atrial fibrillation, the regular irregularity coupled atrial or ventricular premature beats, regular tachycardia at 150 beats / min of PSVT and regular bradycardia <35 beats / identified min of complete heart block. Careful examination of the jugular vein pulse waves with simultaneous cardiac auscultation and -palpation the carotid artery allows the diagnosis of most arrhythmias when no ECG is available because the jugular waves indicate the atrial rhythm, while the auscultated sounds or the pulse in the carotid arteries, the product of ventricular contraction are. A thyroid enlargement or tenderness with exophthalmus speak for hyperthyroidism. A very high blood pressure and regular tachycardia indicate a pheochromocytoma. Suggestive anamnestic findings in patients with palpitations finding Possible cause occasional skipped beats PACs, PVCs fast, regular palpitations with sudden onset and end Often history of recurrence PSVT, atrial flutter with 2: 1 atrioventricular block, ventricular tachycardia syncope subsequent to palpitations sinus node dysfunction, accessory pathways (such as Wolff-Parkinson-White syndrome), congenital long QT's syndrome m palpitations during exercise and emotional episodes sinus tachycardia (especially in healthy people) Ventricular arrhythmia of exercise-induced ischemia (especially in individuals with congenital cardiac arrhythmia or CAD) palpitations after episodic * Drug Abuse drug-induced cause feeling of impending doom, anxiety or panic Indicates a psychological cause (but not confirmed) Postoperative patient sinus tachycardia (Z. As a result of infection, bleeding, pulmonary embolism, pain) Repeated episodes since childhood supraventricular arrhythmia (z. B. AV nodal reentrant tachycardia, Wolff-Parkinson-White syndrome) congenital long QT syndrome (usually manifests itself in adolescence) family history of syncope or sudden death Brugada syndrome, congenital long QT syndrome, congenital dilated or hypertrophic cardiomyopathy * the role of a regular intake of drugs (particularly therapeutic drugs) or substances (eg. as daily caffeine) can be difficulthave to be determined; sometimes a withdrawal study is diagnostic. All medications with cardiovascular effects that may cause most psychotropic drugs and medicines that hypokalemia or hypomagnesemia must be suspected. CAD = coronary artery disease; PACs = premature atrial contractions; PSVT = paroxysmal supraventricular tachycardia; VES = ventricular arrhythmias. Tests Typically, tests are performed. ECG, sometimes with ambulatory monitoring laboratory tests Sometimes imaging tests, stress tests, or both An EKG is performed, but only if the recording takes place while symptoms occur, they can provide a diagnosis. Many cardiac arrhythmias are intermittent and show no fixed ECG abnormalities. Exceptions include Wolff-Parkinson-White syndrome Long QT syndrome Arrhythmogenic right ventricular dysplasia cardiomyopathy Brugada syndrome and its variants If no diagnosis has been made and the symptoms are often a Holter monitoring for 24-48 hours can be useful. In intermittent symptoms, is an event memory which is worn longer and activated by the patient when symptoms occur, the better. These tests are primarily used when a sustained arrhythmia is suspected, rather than when the symptoms indicate only occasional skipped heartbeats. Patients with very rare symptoms, of which clinicians suggest that they indicate a serious arrhythmia, a device can be implanted under the skin of the upper chest area. This device continuously records the rhythm and can be interrogated by an external computer which can print out the heart rhythm. Laboratory tests are required in all patients. All patients should receive a measurement of the complete blood count and serum electrolytes, including magnesium and calcium. The cardiac markers troponin should be measured in patients with persistent arrhythmias, chest pain or other symptoms that may indicate an active or recent coronary ischemia, myocarditis or pericarditis. Thyroid function tests are indicated if atrial fibrillation is newly diagnosed or present symptoms of hyperthyroidism. Patients with paroxysms of high blood pressure should be investigated for pheochromocytoma. Sometimes a tilt-table testing in patients is done with orthostatic syncope. Imaging is often required. Patients with findings that indicate cardiac dysfunction or structural heart disease requiring an echocardiogram and sometimes cardiac MRI. Patients with symptoms on exertion require stress tests, sometimes with stress echocardiography, nuclear scan, or PET. Treatment triggering drugs and substances should be discontinued. If dangerous or debilitating arrhythmia caused by a necessary therapeutic drug, a different medication should be tried. For isolated PACs and PVCs in patients without structural heart disease a simple reassurance is appropriate. In otherwise healthy patients in whom these phenomena are disabling, a beta blocker can be given, unless efforts are made to avoid the perception of anxious patients is enhanced, they had a serious illness. Identified arrhythmias and underlying diseases are examined and treated (see Table: Some treatments for arrhythmias). Some treatments for arrhythmias disease treatment * Narrow complex tachycardia multifocal atrial premature reassurance or ?-blocker atrial fibrillation aspirin, warfarin, enoxaparin, UFH, DC cardioversion, flecainide, beta-blockers, digoxin, verapamil, diltiazem, ibutilide, amiodarone, radioablation or Maze procedure depending according to clinical circumstances atrial flutter Radiofrequency ablation (often the best treatment) Sometimes DC cardioversion, digoxin, beta blockers, verapamil and / or anticoagulation supraventricular tachycardia radiofrequency ablation (often the best treatment) Sometimes vagotonic maneuvers, adenosine, DC cardioversion, beta blockers, verapamil, flecainide, amiodarone or digoxin AV nodal reentrant tachycardia radiofrequency ablation (often the best treatment) Sometimes beta blockers or verapamil wide complex tachycardia Ventricular tachycardia DC cardio version, amiodarone, sotalol, lidocaine, mexiletine, flecainide, radiofrequency ablation or implanted defibrillator torsades de pointes magnesium, potassium, DC cardioversion, beta blockers, overdrive pacemaker or an implanted defibrillator fibrillation DC cardioversion, amiodarone, lidocaine or an implanted defibrillator Brugada syndrome DC cardioversion or an implanted defibrillator * causes and reinforcing factors (eg. As electrolyte abnormalities, hypoxia, agents) must always be recognized and corrected. DC = DC Central geriatric aspects Older patients are at particular risk of side effects by antiarrhythmic drugs. The reasons include lower GFR and the concomitant use of other drugs. If drug treatment is required, lower doses should be used initially. Subclinical reconciliation abnormalities may be present (detected in the ECG or in other studies) that may worsen with the use of antiarrhythmic drugs. Such patients may need a pacemaker to allow the use of antiarrhythmic drugs. Summary palpitations are a common but relatively non-specific symptom. Palpitations are not a reliable indicator of a significant arrhythmia, palpitations but in a patient with structural heart disease or abnormal ECG a sign of a serious problem and may justify an investigation. It is essential to carry out an ECG or other receptacle during the symptoms. A normal EKG in a symptom-free interval does not exclude a significant disease. Most antiarrhythmic drugs can cause arrhythmia itself. If in doubt about a rapid tachyarrhythmia exist in a patient in hemodynamic distress, a cardioverter is first applied before questions are asked.


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