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Flashcards in Palpitations Deck (22):
1

non-cardiac risk factors associated with palpitations

exercise
caffeine
diet pills
cocaine
tobacco
alcohol
decongestant
diuretics: electrolyte abnormalities
digoxin
B agonist
theophylline
phenothiazine
stress
anemia (+ fatigue, lighthedness, GI blood loss, menorrhagia)
hyperthyroidism, hypothyroidism (+ both: fatigue, depression, menstrual irregularites)
hypoglycemia
hypovolemia
fever
pheochromocytoma (24 hr urine collection for catecholamines and metanephrines)
pulmonary disease
vasovagal syncope
labs: CBC, BMP, TSH

2

structural cardiac causes of palpitations (dysrhythmias)

hypertrophic CM (AD): most common cause of sudden cardiac death in teens, +/- chest pain, syncope, systolic murmur accentuated by Valsalva maneuver, echo with thickened IV septum
MVP syndrome: midsystolic click +/- late systolic murmur (usually asymptomatic or + fatigue, chest discomfort, dyspnea, panic attacks, manic-depressive syndrome)
MR: progression of MVP, left heart enlargement, afib, LV dysfunction → heart failure, pulmonary HTN, infective endocarditis
ASD or VSD
congenital heart disease
pericarditis
aortic stenosis, aortic insufficiency
congestive heart failure

3

subjective sensation of strong, slow, rapid, or irregular heartbeats that may be related to cardiac arrhythmias
lasts sec, min, hrs, days
d/t change in heart's electrical system

palpitations

4

etiology of palpitations

#1 primary arrhythmia
2 anxiety, panic d/o
3 unknown
4 meds
5 structural heart problem: valve, CM

5

tachycardia not originating from ventricle: narrow QRS
includes sinus tachycardia (gradual onset)
may be caused by stress, fever, hyperthyroidism
tx: B blocker (if short-lived episode, can use short-acting PRN) or CCB, digoxin to slow down rapid ventricular response to afib or aflutter

SVT

6

type of SVT with sudden onset and regular rhythm
feel heart rate go from 60-200 after quick movement (pick something off of floor)
most often a AV nodal reentrant tachycardia or WPW (may not be evident on resting EKG)
tx: vagal CN X stimulation techniques: carotid sinus massage, valsalva maneuver, cold applications to face (diver reflex)
if unsuccessful: IV adenosine (if works = reentry SVT, if doesn't work → use B blocker or CCB)

paroxysmal SVT

7

accessory track between atria and ventricles that conducts impulses in addition to AV node
upstroke of QRS wave: delta wave
can lead to sudden cardiac death

WPW (type of paroxysmal SVT)

8

Asian male
R BBB, elevation at J point > 2mm, slowly descending ST segment with flat or negative T waves in precordial: V1-V3
can lead to sudden cardiac death

Brugada syndrome

9

SA node dysfunction
bradycardia type: bradycardia, fatigue, syncope
bradycardia-tachycardia type: SVT, palpitations, angina pectoris

sick sinus syndrome

10

AD
most common in females
palpitations and/or syncope
family hx: syncope, sudden death
risk for ventricular arrhythmias and sudden death

prolonged QT syndrome
QT >470 msec men, >480 msec female

11

meds that prolong QT

quinidine
procainamide
sotalol
amiodarone
TCA

12

benign rhythm disorders - don't need to refer to cardiologist

premature atrial contractions
sinus tachycardia
sinus bradycardia appropriate for activity/stress level
sinus pauses less than 3 seconds
isolated PVC: occasional extra beat, if occur at rest and disappear with exercise (benign) vs in presence of cardiac sx or syncope or seizures (↑ risk vtack, vfib) - refer to cardio

13

childbearing age female
brief, overwhelming panic, impending doom
tachycardia, dyspnea, dizziness
still need formal workup since acts like primary rhythm disturbance

panic disorder

14

tall
scoliosis
pectus excavatum
long, thin digits (arachnodactyly)
high-arched palate
arm span exceeding height
MVP
aortic root dilation → aortic arch aneurysm

marfan syndrome

15

if > 50 yo + palpitations think

CAD

16

if palpitation + syncope

usually pathologic, hospitalize

17

work up for palpitations

bp, HR, orthostatics
thyroid gland, resting tremor, brisk reflexes (hyper)
PMI (if enlarged then cardiomegaly), rate, rhythm, murmurs
EKG - even if currently asymptomatic: LVH, delta waves, atrial enlargement, AV block, old MI, prolonged QT
holter monitor: EKG rhythym monitoring for 24-72 hrs if daily palpitations
30 day cardiac event monitor: activated when patient feels palpitation if infrequent
echo: if think structural
TEE to r/o thrombus before cardioversion
exercise stress test: if think arrhythmia triggered by exercise and suspect CAD (symptomatic PVC), do echo before stress test to r/o structural issues, contraindications to stress test: suspected HCM, severe AS, or marfan
EP study: recreate rhythm disturbance and identify hyperactive foci and accessory tracts (like WPW)

18

tx of afib

rate control PREFERRED strategy (keep

19

acute tx of vfib

electrical defibrillation

20

acute tx of vtach

cardioversion if unstable (low bp, high HR, not confused)
IV amiodarone if stable and if just cardioverted
(lidocaine if allergic to amiodarone)

21

ventricular arrhythmias most often due to

ischemia

22

long-term tx of ventricular arrhythmias caused by dilated CM, long QT, HCM, Brugada

implanted cardioverter-defibrillator