Palpitations

A neighbor came a-knocking just last night with the sense of a racing or “flipping” heartbeat, aka “palpitations.” Most immediately useful when someone has this symptom is the EKG, so I sent her to Sierra Vista – outpatient – for an EKG and some labs (CBC, BMP, TSH, pregnancy test). If you stop reading here, remember this: It’s best to address palpitations in less than 48 hours. Explanation below.

Red Flags:

• Chest pain
• Syncope (especially during exercise)
• Light headedness
• Shortness of breath
• Existing pacemaker
• Underlying cardiac disease (heart blocks, cardiomyopathy)
• Dialysis
• Endocrine disease (diabetes, hypo/hyperthyroidism, pheochromocytoma)
• Heart rate in the 100s (practice checking your own pulse)
• “My defibrillator keeps firing.”
• “I have a history of A. fib, V. fib, SVT, etc.”
• “I died once and they had to shock me.”

Happy Words

• Exhaustion
• Emotional upset
• Inebriation
• Dehydration
• Chemical hyper stimulation (caffeine, diet pills, cocaine…)
• Situational hyper stimulation (“The Beatles!”)
• “I have mitral valve prolapse and PVCs.”
• “I have a physics exam tomorrow I haven’t studied for.”
• “They arrested me for using meth, and I’d rather be in the ER than in jail.”

When patients have palpitations, our minds go straight to cardiac arrhythmias. Quite honestly, we we hope to find something fixable on EKG, with supra-ventricular tachycardia (SVT) our favorite for being so easily fixed. Atrial fibrillation is another common arrhythmia, but it’s a little more involved. That’s the one we like to discover in less than 48 hours. For patients in “AF” longer than 48 we start to worry about clots forming in the atria, which could then lead to strokes. So these patients are frequently put on anticoagulants like Coumadin or Xarelto first… a big drag. Under 48, many “convert” in the ER with medicines and/or electrical “cardioversion.”

There are a variety of other arrhythmias and conditions to consider, Wolff-Parkinson-White Syndrome being an interesting one. Also Takotsubo cardiomyopathy or “broken heart syndrome” for those of you who want to dig deeper.

For patients who have intermittent symptoms, they may get a “Holter monitor,” or perhaps an “event recorder” which enables patients to record when they feel their symptoms.

While we like to find easily fixed problems on EKG, often we find nothing. Occasionally we discover low or high potassium levels, anemia, thyroid pathology or even pregnancy. But when labs also come up normal we have to actually listen and think. Happily, the simple act of listening can be quite therapeutic. Calm conversation followed by a good, alcohol-free, night sleep, very often does the trick.

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