Palpitatio
n
Definition
Palpitation may be defined as
an awareness of the beating of the
heart,an awareness most commonly
brought about by a change in the
heart's rhythm or rate or by an
augmentation of its contractility,
Definition
? Palpitation is not pathognomonic of any
particular group of disorders; indeed,often it
signifies not a primary physical disorder but
rather a psychio disturbance,
? The diagnosis of the underlying disease is made
largely on the basis of other associated symptoms
and the data,
Characteristics
? Concern is more pronounced in patients
who know or who have been told that
they may have heart disease; to them
palpitation may seem to be an omen of
impeding disaster,
Characteristics
? The resulting anxiety may be associated
with increased activity of the autonomic
nervous system,with consequent increases
of the cardiac rate and rhythm and the vigor
of contraction,the patients awareness of
these changes may then lead to a vicious
cycle,which ultimately be responsible for
this incapacitation,
Characteristics
? Palpitation may be described in various
terms,such as "fluttering","flopping",and
"skipping“,In most cases the complaint is
of a sensation of disturbed heartbeat,
? There’s wide variability in the sensitivity to
alteration in cardiac activity among
different individuals,
Variability of the sensitivity
? Some patients seem to be unaware of the
most serious and chaotic dysrrhythmias;
others are seriously troubled by an
occasional extrasystole,
? The awareness of the heartbeat tends to be
more common at night and during
introspective moments,but is less marked
during activity,
Variability of the sensitivity
? Patients with organic heart disease and
chronic disorders tend to accommodate to
these abnormalities and are often less
sensitive than normal persons to such events,
? Palpitation is particularly prominent when
the precipitating cause for increased heart
rate or contractility or arrhythmia is recent,
transient,and episodic,
Accompanied Symptom
? Precordial pain
? Fever
? Syncope or spasm
? Anemia
? Tabification
Mechanism
? Increased Stroke Volume
? Tachycardia
? Arrhythmia
? Individual differences
Increased Stroke Volume
When palpitation is heavy and regular,it is
usually caused by an augmented stroke
volume,e.g,aortic or mitral regurgitation,
ventricular septal defect,or of a variety of
hyperkinetic circulatory states (anemia,
arteriovenous fistula,thyrotoxicosis),
Tachycardia
? Palpitation may be experienced by normal persons
who have engaged in strenuous physical effort or
have been aroused emotionally,
? It may occur also in pathologic states,e,g.,high
fever,severe anemia,or thyrotoxicosis,generally
associated with several other alterations in cardiac
function including acceleration of heart rate,more
rapid development of intraventricular pressure
during isometric contraction,increased intensity of
the heart sounds(especially S1),a short duration of
systole,and a greater ejection velocity,
Arrhythmia
? It may also occur immediately after the onset of
cardiac slowing,as with the sudden development
of heart block,or upon the conversion of sinus
rhythm from atrial fibrillation,
? The ectopic beat and/or the compensatory pause
may be the mechanism of palpitation,since both
are associated with alteration in cardiac function,
Important causes of palpitation
? Disorders of the mechanism of the
heartbeat,
? Organic or functional disturbance
origination outside the circulatory system
? Palpitation as a manifestation of the
anxiety state
Disorders of the mechanism of the heartbeat
-- Extrasystole
? Patients may feel if "the heart turns over",The
pause following the premature contraction may
be felt as an actual cessation of the heartbeat,in
contrast with the complete unawarness of pauses
of similar duration when atrial fibrillation with a
slow ventricular rate occurs,
? The first ventricular contraction succeeding the
pause may be felt as an unusually vigorous beat
and will be described as "ourding" or "thudding",
Disorders of the mechanism of the heartbeat
--Extrasystole
? When extrasystoles are numerous,clinical
differentiation from Af can be made by any
procedure that will bring about a definite increase
in the ventricular rate; at increasingly rapid heart
rate,the extrasystoles usually diminish in
frequency and then disappear,whereas the
irregularity of atrial fibrillation increases,
? A-V block with dropped beats,is the only other
common arrhythmia with which the premature
contraction is likely to be confused; but simple
auscultation will reveal the difference,
Disorders of the mechanism of the heartbeat
--Ectopic Tachycardia
? Ectopic Tachycardias are common and medically
important causes of palpitation,(but Ventricular
tachycardia is rarely manifested as palpitation)
? The mode of onset and offset gives the most
important lead in distinguishing sinus from one of
the various forms of ectopio tachycardias; sinus
tachycardia commences and ceases over the
course of minutes or seconds,but not
instantaneously as is characteristic of ectopic
rhythm,
Disorder of the mechanism of the heartbeat
--Ectopic Tachycardia
? If the patient is seen between attacks,the
diagnosis,of ectopic tachycardia and its type will
have to depend upon the history,
? Monitoring of the ECG with a portable tape
recording system and asking the patient to record
the time of onset and cessation of the palpitations
are extremely helpful in determining their cause,
Organic or functional disturbance origination
outside the circulatory system
? Thyrotoxicosis
? Anemia
? acute infections
? Hypoglycemia
? Drugs
? Tumors of the adrenal medulla
(pheochromecytoma)
Thyrotoxicosis
In its fully developed form,thyrotoxicosis will
usually be evident and offers little difficulty in
diagnosis except in the elderly,in whom so-
called apathetic hyperthyroidism may be
present,Thyrotoxicosis is particularly likely to
be over-looked in the presence of myocardial
failure,
Anemia
When mild,anemia may cause palpitation
during exertion; when severe,palpitation may
be present at rest,Appropriate studies of the
blood will clarify the situation,
Hypoglycemia
Palpitation is often a prominent feature of the
condition and appears to be related to release of
catecholaminels,The diagnosis is confirmed by
appropriate blood sugar estimations,by
reproduction of the symptom when insulin is
administered,and by prompt relief of symptoms
on the administration of glucose,
Drugs
The relationship between the
development of palpitation and the
use tobacco,tea,alcohol epinephrine,
ephedrine,aminophylline,atroping,
or thyroid extract is obvious,