Palpitations match the abnormal perception of heartbeat, which usually are not seen. They are a frequent reason for consultation with the cardiologist.
The challenge is to differentiate benign palpitations, favored by stress, a rhythm disorder requiring specific treatment.
DIAGNOSIS:
Examination:
It is crucial for the diagnostic orientation.
Any personal cardiac history is sought first (concept of congenital heart disease, heart murmur) or family (concept of rhythm disorder, heart disease or sudden death in the family), the patient’s lifestyle (athletic or sedentary ), and evaluated vis-à-vis the symptom anxiety.
It is necessary to explain to the patient the most accurate way possible how he feels. We therefore asked to describe the palpitations:
– Their circumstance occurred: exertion or stress, rest;
– Periodicity, time of onset, and duration;
– Tolerance: simple discomfort, malaise, angina, dyspnea or syncope;
– The factors favoring their occurrence: digestion, taking stimulants (coffee, tea, alcohol);
– The exact sequence of what the patient feels: a secluded feel stronger beat than others evokes premature; rapid and prolonged palpitations evoke, if irregular, atrial fibrillation, or if they are regular, a jonctionelle tachycardia or ventricular tachycardia; slow and regular palpitations gravitating towards bradycardia and conduction disorder;
– It also asks the patient if he took his pulse during palpitations, what he felt and he counted the heart rate;
– Finally, we look for symptoms that suggest an underlying heart disease: dyspnoea exertional or rest appearance of anginal pain, etc.
Clinical examination:
Cardiac auscultation for the presence of each breath or a gallop up towards heart disease. It can be used to guide the diagnosis towards extrasystoles, atrial fibrillation or about whether the rhythm is very irregular, or even to bradycardia. Also search hypertension (HTA) and signs suggestive of endocrine disease, including thyroid dysfunction.
Additional tests:
Their strategy depends on the severity of symptoms and the presence or absence of severe underlying cardiac disease: if somewhat disturbing symptoms, the preferred documentation of arrhythmia by non-invasive means, whereas in case severe heart damage underlying worrying symptoms (malaise, syncope), or a family history of sudden death, we adopt a more aggressive strategy not to neglect serious rhythm disorder.
In case of persistent palpitations an hour or more, it can also encourage the patient to consult urgently for an ECG during a crisis.
Electrocardiogram:
It is the examination of choice, but is rarely contributory. Indeed, more often, patients have symptoms intermittently, and it is rare that happen at the time of consultation.
Nevertheless, it is essential because it can diagnose atrial fibrillation, persistent atrial flutter or bradycardia (sinoatrial or atrioventricular block).
It also allows the diagnosis of Wolf-Parkinson-White syndrome. The presence of extrasystoles, atrial or ventricular, is common and banal, and diagnosis should be retained after eliminating other causes of palpitations.
Rhythmic Holter:
If palpitations occurring daily, the 24-hour Holter monitoring may be contributory. It consists of recording an electrocardiogram for 24 to 48 hours on a magnetic medium contained in a small device that is worn over the shoulder and allows the patient to go about their usual activities. The plot is then analyzed using a computer system.The patient keeps a diary of symptoms and the ability to place markers on the track at the time of symptoms.
Event Recorder:
These are highly miniaturized devices, with significant autonomy, which can be assigned to the patient for periods from 15 days to 1 month for external models or implanted under the patient’s skin, with a battery life of 18 months.They are useful in case of infrequent symptoms. Recording can be activated by the patient when symptoms or automatically on a schedule determined by the physician, depending on the condition of the desired pace. The recorded data is then analyzed by a computer system.
Stress test:
It is particularly useful in cases of palpitations occurring effort: jonctionelle tachycardia, ventricular tachycardia on healthy heart, adrenergic atrial fibrillation. It is also useful in case of Wolf Parkinson White syndrome or to diagnose a disorder that occurs only conductive effort, as well as coronary artery disease.
Echocardiography:
It is not automatic but is performed as soon as the suspected existence of an underlying heart disease: valvular or hypertensive heart disease often associated with atrial fibrillation, ischemic heart disease.
Electrophysiological:
This is an invasive procedure that is carried out if there is a strong suspicion of palpitations associated with an arrhythmia which has not been documented by other tests. This exploration is to introduce probes in the right cavities by right femoral venous route in an attempt to cause disorder auriculaireou ventricular rhythm, reproducing the patient’s symptomatology. It may be supplemented with an endocardial ablation, which is to destroy the area responsible for the arrhythmia.
ETIOLOGY:
Premature:
Extrasystoles are very common in the general population, but are felt in very different ways depending on the individual, ranging from intense pain perception among some in the complete absence of symptoms in others. They are probably the most frequent reason for consultation for palpitations.
The patient feels an irregularity in rhythm with “missing a beat” (extrasystole which is not directly perceived) and “beat faster” (systole that follows the premature beat is more intense).
The diagnosis can be done heartbeat or auscultation, and confirmed by ECG that establishes if atrial premature (Fig. 1) or ventricular. Holter 24 hours can be done to quantify these extrasystoles, and look for repetitive forms (doublets, triplets or bursts) or sustained arrhythmias.
If premature “benign”, in the absence of underlying heart disease, we begin by reassuring the patient, without proposing treatment, which usually allows alleviating symptoms. In case of persistent symptoms, we can offer the patient a beta-blocker treatment or mild anxiolytic.
In contrast, many with premature ventricular bursts if underlying heart disease, including ischemic, should lead to further tests, these extrasystoles may be the “trigger” a disorder of initiating more serious pace. Extrasystoles arising from a patient without heart disease but in whom there is the notion of discomfort, loss of consciousness or sudden death in the family, should lead to further investigation.Indeed, they can be a rhythm disorder linked to an electric charge of abnormal functioning genetic disease of the heart by a disturbance of ionic movements in heart cells (channelopathies), the best known are Brugada syndrome and the syndrome congenital long QT. The diagnosis is usually established by the ECG.
These diseases may present a risk of sudden death and require specific treatment.
Atrial fibrillation and atrial flutter:
Atrial fibrillation:
Atrial fibrillation (AF) is the most common disorder of rhythm. Its incidence increases with age. It can be completely asymptomatic and discovered incidentally during a routine examination or be felt more or less painful to the patient.Typically, the patient feels irregular palpitations, anarchic. The pulse can be taken to its more or less rapid, but still irregular. The onset may be abrupt or preceded by a spate of extrasystoles. Tolerance varies with heart rate, and especially the underlying myocardial state.
The crisis may last from minutes to hours (called paroxysmal AF) to several days (persistent AF) or months (permanent AF). The judgment of the crisis is not always felt by the patient.
AF occurs more frequently on a plot of valvular heart disease, ischemic or hypertensive, but can also occur in a normal heart.
It is important during questioning to clarify crisis occurrence of circumstances: an early crisis with exercise or during an emotion towards a FA called “adrenergic” in contrast its occurrence in a period of rest, especially at night or during the digestion towards a FA called “vagal”. This distinction is important because the treatments are different in different triggers.
A significant alcohol intake may also be a contributory factor. The ECG shows a chaotic atrial activity, with an irregular ventricular response, more or less rapidly (Fig. 2a and 2b).
Atrial flutter:
Atrial flutter is an arrhythmia corresponding to the occurrence of a reentry circuit turning it counterclockwise a watch in the right atrium. The atrial activity is organized and regular frequency between 200 and 300 / min; it is sent to variably ventricles Mode 2 for 1 (2 atria to ventricle), 3: 1, respectively, giving an atrial rate of 300 / min ventricular frequency of 150 (2/1) or 100 / min ( 3/1) or more irregularly (flutter with variable conduction). The patient feels more consistent arrhythmia AF, and usually flutter is less well tolerated than FA. Both arrhythmias often coexist in the same patient, and some patients arrive perfectly to differentiate. The ECG shows a regular atrial activity, sawtooth, clearly visible in the inferior leads (Fig. 3).
Note F waves in visible sawtooth D2 and D3, regular ventricular activity.
Atrial fibrillation:
Flutter like FA produce a fault contraction of the atria with consequences, firstly a decrease in cardiac output up to 30% for underlying heart disease, and also the risk of thrombus formation in atria, as a corollary the possible occurrence of such cerebral thromboembolism (Table I).
The embolic risk from 2.5% in the absence of risk factor over 17% when there is 3 risk factors. In other words, in the absence of risk factor, treat 417 patients to prevent embolic accident; if there are 6 risk factors, you just treat 44 patients to avoid an accident.
Echocardiography is an essential complement to the clinical assessment. The parameters to consider are listed in Table II. These parameters are better evaluated than transesophageal echocardiography transthoracic echocardiography.
Treatment:
These arrhythmias require cardiac care. Treatment involves effective anticoagulation, reduced by external electric shock or drugs in case of persistent AF or flutter, antiarrhythmic therapy to prevent relapse, and in some cases the endocardial radiofrequency ablation of arrhythmia.
Effective anticoagulation of at least three weeks must precede cardioversion attempt, the alternative being to achieve a echocardiography to ensure the absence of thrombus in the left chambers.
Cardioversion can be drug, using an oral loading dose of amiodarone (4-6 cp / day for 5 days, to 30 tablets), which can be performed as an outpatient.
In the absence of reduction, electrical cardioversion is performed under general anesthesia during a brief hospitalization.
Atrial fibrillation and anticoagulation:
In principle, any atrial fibrillation (AC / AF) supported is an indication for treatment with vitamin K antagonists
The therapeutic strategy is determined based on the age of the patient, the tolerance of the arrhythmia, and the existence or not of underlying cardiac disease. Table III summarizes the absolute cons-indications for the use of vitamin-K in the elderly.
In light of these cons-indications to the use of VKA, simplified recommendations of antithrombotic therapy during atrial fibrillation are summarized in Table IV.
The indication for this treatment must, however, be discussed again in each patient by weighing the risk of systemic embolism and bleeding risk. We see that it is particularly difficult to decide in the age 65-75 years.This is where the echocardiography data can be particularly useful.
Preventive treatment:
Preventive treatment of recurrences is provided by an antiarrhythmic medication: Class Ic antiarrhythmics (flecainide, propafenone) are used in preference to class Ia antiarrhythmics (quinidine), which are less well tolerated (digestive disorders) and carry the risk of torsades de peaks.
One can also use sotalol, which is both class III antiarrhythmics and beta-blocker.
Amiodarone is the most effective drug, but is not used as first-line because of its side effects including thyroid.However, it remains the only antiarrhythmic against non-indicated in cases of underlying heart disease and left ventricular dysfunction.
Junctional tachycardia:
These tachycardias occur most often in the absence of heart disease in young patients, but it is not uncommon to meet in older patients. The clinical description is quite grotesque: the patient described episodes of palpitations fast, regular, to early and brutal end. The trigger conditions are highly variable from one subject to another, but often reproducible in the same subject: stress, anteflexion the trunk, postprandial period.
Seizures vary in length from less than a minute to several hours, tolerance also varies from one subject to another.When it was able to take a pulse, the patient described as regular, fast, a rate of between 150 and 250 / min.
Diagnosis:
It is sometimes difficult to make the diagnosis when seizures are brief and the patient does not have time to go to a cardiologist or emergency to record an electrocardiogram.
In this case, you can use either the stress test, to try to provoke a crisis or at the 24-hour Holter or an event recorder (R test) that the patient carries with him for two weeks and with which it can record a crisis. Ultimately, electrophysiologic testing with provocatives maneuvers often allows for a diagnosis.
The ECG during a crisis shows often complex tachycardia purposes, the P waves can be hidden in the QRS complex or visible behind the QRS complex (retrograde P wave) (Fig. 4)
Accessory pathway:
These tachycardias are caused by the occurrence of a reentry circuit using the normal atrioventricular conduction path in one direction and an accessory pathway in the other direction. This second pathway may be at the level of the tricuspid and mitral rings (Kent bundle under Wolf Parkinson White syndrome) or atrioventricular node (nodal reentry).
Some accessory pathways can be dangerous because very permeable atrial activity: these are the so-called “malignant” accessory pathways, which, in case of occurrence of atrial fibrillation can lead to a very high ventricular rate, up to 300 / min, with a potentially lethal risk. Therefore if even fortuitous discovery of a type of accessory pathway beam Kent, make sure its not dangerous by a stress test, and if it does not disappear when tested for effort, consider an electrophysiological study with endocardial radiofrequency ablation of the accessory pathway.
Treatment:
These tachycardias usually have a good prognosis, but can be annoying by the symptoms they produce. Their treatment varies depending on the frequency of seizures and tolerance.
Sometimes the patient was able to identify crises stopping maneuvers: the most effective are the Valsalva maneuver (forced expiration closed glottis), the sinocarotidien massage and the gag reflex. These crises rarely occur and the patient stops by itself require no treatment.
When the crisis does not yield spontaneously or after reduction maneuvers, it requires a reduction drug (intravenous Striadyne® or diltiazem) in hospital and under electrocardiographic monitoring.
Sometimes the patient described brisk diuresis occurred at the waning of the crisis (natriuretic crisis).
If more frequent crises, we propose a beta-blocker or calcium channel blocker therapy, rarely an antiarrhythmic. If seizures are not controlled by this treatment, then proposes the endocardial ablation of the accessory pathway, the success rate is 95%.
Ventricular tachycardia:
There are two types of ventricular tachycardia (TV): those that occur in healthy hearts and those that occur in patients with heart disease. They are distinguished by their prognosis, usually good in the first case, while the TV comes on heart disease may be poorly tolerated or lead to ventricular fibrillation and cardiac arrest at.
Ventricular tachycardia on healthy heart:
TV on healthy heart usually have the same symptoms as junctional tachycardia: beginning and end brutal, fast and regular palpitations, variable tolerance, but accompanied or discomfort or syncope.
They can either be supported, which can last from several minutes to several hours (Fig. 5), or longer or shorter bursts (Fig. 6).
The diagnosis of ventricular tachycardia “idiopathic” requires a cardiological assessment, including ECG Holter 24-hour echocardiogram to rule out underlying heart disease.
The treatment is first drug based beta blockers or calcium channel blockers (verapamil) or radical endocardial ablation of the arrhythmogenic area.
Ventricular tachycardia occurring on heart disease:
The TV comes on heart disease with impaired left ventricular function (Fig. 7) often result in discomfort, hypotension, collapse, syncope or even cardiac arrest.
Palpitations often are not perceived by the patient.
On physical examination, pulse is rapid, thready.
This TV is a medical emergency requiring care by EMS and hospital admission in cardiology intensive care. In case of bad tolerance, an external electric shock must be performed immediately or by the UAS or by firefighters or rescue workers using a semi-automatic defibrillator that makes the diagnosis and advise whether the realization of the shock . These devices, installed in many public places and transportation in the United States, are beginning to appear in France. They represent the most effective way to reduce sudden death rhythmic origin. During hospitalization a full assessment is made and the proposed treatment is most often implantation of an implantable cardioverter defibrillator (ICD), barely bigger than a pacemaker device and automatically shocks the patient TV case of recurrence. Indeed, in the case of heart disease, all except antiarrhythmic amiodarone are cons-indicated, and only the DAI has been shown to effectively prevent sudden death and reduce mortality.
Bradycardia:
In general, the symptoms at the forefront of bradycardia associated with a conductive disorder (sinoatrial or atrioventricular block) were asthenia, dyspnea on exertion, or syncope. Rarely, these symptoms are not present, and the patient does not feel as palpitations. Indeed, the core being slower, each systole is stronger and can give the impression that the heart “hits hard.”
The diagnosis is suspected in the recognition of bradycardia and confirmed by an electrocardiogram.
Palpitations without arrhythmia:
They usually occur in anxious patients, in a context of stress and overwork.
They are described as regular, usually slightly faster (pulse rarely exceeds 110 / minute), with the impression of a heart that “hits hard,” similar to what anyone can feel under stress brutal or emotion. They generally associate with other functional symptoms (anxiety, puncture type of chest pain related by the patient to cardiac origin). These palpitations cede most often after the patient was reassured about his heart condition, and the elimination of predisposing factors.
If they persist, we may offer temporary treatment a mild sedative or beta-blocker treatment. However, this diagnosis should be worn only after eliminating other possible causes.
CONCLUSION:
Palpitations are a frequent reason for cardiology consultation. Rhythm disorders that cause them are extremely varied: Simple heart erethism related to overwork, premature atrial or ventricular benign, or ventricular tachycardia on jonctionelle healthy heart, atrial fibrillation or atrial flutter occurring with or without heart disease, to ventricular tachycardia occurring on ischemic heart disease, dilated or hypertrophic valve, which carry a risk of sudden death.
The questioning is fundamental to guide the diagnosis.
Any patient palpitations consultant must have a cardiological assessment and further tests to make a diagnosis and provide treatment.
The occurrence of discomfort or syncope, family history of sudden death, the presence of known heart disease, when combined with palpitations should alert the physician must refer the patient quickly in specialized cardiological community.
The diagnosis of benign palpitations are worn after elimination of other causes.