This article examines the approach to the patient's palpitations and survey methods and therapeutic procedures.
Definition of DEFINITION:
A throbbing feeling or sense of chest discomfort caused by strikes, violent sensation in the chest and the neck sometimes, and this description may be directed to the underlying reason behind the flickering in some cases.
Etiology ETIOLOGY:
The differential diagnosis is broad and that the causes of palpitations varied strongly depending on the studies that have been reported, in a study on 190 patients were Chkaathm core is throbbing identified the underlying cause of palpitations in 84% of cases, with about 43% was the reason his heart, and 31% myself origin, and cases of a variety of other in 10% of cases (drug Cal thyrotoxicosis, caffeine, cocaine, amphetamine, or other diseases such as anemia and mastocytosis), where the causes heart attacks more frequently in patients returning to the emergency department compared with patients who attended the outpatient clinic, while psychological reasons more frequently with the Board of outpatient clinics, and cardiac causes were more frequent in patients with heart specialist reviewers.
- Psychiatric disorders Psychiatric disorders:
Pretended to be throbbing for many of strikes Knubh psychological panic and generalized anxiety disorder and somatization (Altgsmon) and depression.
Showing palpitations may occur even in even in the absence of arrhythmias In the case of palpitations associated with anxiety or panic can be difficult to distinguish the disease in perpetuating panic, palpitations, anxiety, or as a result of the two and that in many patients.
Psychological causes may be associated with other disorders causing palpitations in the previous study was 24 patients (13%) suffer from more than one reason for the palpitations and 21 of them have caused myself involved in pathogenicity.
In a study of 107 patients put them speed up the diagnosis of heart over the ventricular depending on the study of electrical heart show that the medium between the first clinical demonstration and a final diagnosis was of About 3.3 years, 67% of these patients had him meet the diagnostic criteria for panic attack.
59 of these patients are not diagnosed supraventricular tachycardia with and 32 were diagnosed disorder myself and 65% of them were from women, and that causes psychological cause is common for the palpitations, it can not be adopted Ki_khis final except in the case was denied dysrhythmias heart study electrical heart.
- Cardiac disorders Cardiac disorders:
Heart disease is the leading cause of palpitations and has a great importance in assessing the condition of the patient, where the spectrum of diseases Kulbh causing palpitations and a very broad and includes many of the diseases Kallanzemiat (the cases where changes in a fixed and known systems is Pocket Kalrgevan fibrillation), heart disease Dezamih (such as Qso coronary or aortic prolapse or coronary), and sinus syndrome and atrial myocardiopathy atrial tumor and mucosa are all diseases that manifest with tachycardia.
Shows the ECG laptop in patients with palpitations or systems over the ventricular (not linked to Benazm error) or systems ventricular ectopic or sinus rhythm accelerated, as seen systems sinus in more than a third of cases, as you see cases of contraction of ventricular early and premature ventricular non-synergistic and nonsustained ventricular tachycardia in a significant proportion of patients with AF, and these cases are associated with risk of death in patients who do not suffer from problems in the structure of the heart.
In the previous study was the appointment of four independent factors predispose to heart palpitations:
- Males more than females.
- The presence of any type of disturbance in heart beat.
- The story of heart disease.
- Abort a sense of more than 5 minutes.
Where 26% of patients show a predisposing factor, and 48% have two factors and 71% have 3 factors, while there was no patient is not suffering from factors predictors.
And the neglect of the danger that causes problems heart being subject to the control well, the warning in the near term is considered excellent, during the year of observation death occurred only in 3 women all of whom are over the 70-year-old has not been any deaths from sudden or directly related to the reason underlying behind the beat, as that the risk of stroke during the first year was also low and is estimated at 1.1%.
In a study of regressive other results were similar to those of the previous study, it has been studied 109 patients with palpitations where it came from mortality or morbidity similar to those in people, comparable to patients in age and sex by monitoring continued for 42 months. It was rush is responsible for ventricular fibrillation in four patients only.
Dysrhythmias during the excessive catechol Secretary Arrhythmias during catecholamine excess:
The hyperstimulation friendly or excessive catechol Secretary is responsible for many cases of Allanzemih supraventricular mutually supportive and ventricular especially in cases of exercise or stress, showing a test voltage disturbances systemic supraventricular is synergistic nonsustained supraventricular or strikes early origin of ventricular were more frequent than dysrhythmias synergistic sustained arrhythmias and dysrhythmias occur more frequently in patients who suffer from pest attack.
On the other hand commonly occurring ventricular tachycardia in patients with idiopathic in the third and fourth decades of life and the origin is often the right ventricle and occurs suddenly with the hearts structurally sound, and pretend play or in the form of syncope or palpitations.
Altasaraah also common supraventricular dysrhythmias, including atrial fibrillation between the third and sixth decades of age and the frequency is higher among athletes as a challenge near the end of the exercise is associated with the high level of catechol with the Secretary of the increase in the effectiveness Almpehmah Unfriendliness in this period.
May cause excessive catechol Anzemiat to the Secretary of a heart attack is associated with passion, especially in patients with long QT syndrome distance, especially congenital type 1 and 2 (a genetic disorder in the mechanism of cardiac repolarization) and pretend mainly during the emotional and physical stress.
Pocket inappropriate haste: more commonly in young women with a simple effort or passion, and pretending to be accelerated heart beat and palpitations, and is believed to be sensitive to the excess return
Aladreynalanah receptor beta in the heart.
Diagnostic evaluation DIAGNOSTIC EVALUATION:
Be the cause of palpitations in the vast majority of outpatient Hamid, and there is no justification for the extensive and costly investigations.
The attention to the characteristics that define patients at high risk for serious reasons and mission of the palpitations will help to identify the smaller percentage of patients who suffer from palpitations and really need more extensive diagnostic tests, and the management of their condition.
And must include a diagnostic evaluation for all patients with palpitations: detailed clinical history, physical examination, medical and ECG.
The Hmabaladafah to some laboratory tests, Ltd. _ enough to put the final diagnosis in more than a third of patients, and useful mobile ECG Ambulatory monitoring in the rest, and rare patients are in need of more specialized tests.
Story History:
Should include information about the privacy of the arrival of palpitations, and sensations associated with it, and the patient's age at the beginning of its occurrence.
Age of onset Age of onset: does not seem to age an independent predictor of the presence or absence of the pathogenesis of heart palpitations.
On the other hand, can help narrow the age in the differential diagnosis with respect to certain Anzemiat attack. For example, a patient who has had a rapid palpitations since childhood is the most likely to have a speed above the ventricular heart, especially the person who uses the bypass tract, although the rush to atrioventricular nodal (AVNRT) is also possible. There are other types of supraventricular tachycardia paroxysmal, such as rushing or atrial fibrillation, is likely to occur in active ages.
Serious ventricular dysrhythmias occur typically when elderly patients suffering from structural heart disease. However, the rush to idiopathic ventricular sometimes occurs in adolescence.
Description Description:
Described as throbbing in several ways, but there are some specific sensations are common and useful to narrow the differential diagnosis. Thus, it is important that the patient and provides a detailed description of the sensations associated with symptoms of palpitations. In particular, it is important to determine the rate and degree of irregular palpitations, but it may be useful to a patient in ways that throbbing fingers. It may also be useful for the doctor to submit examples of Alnzemiat rapid and systematic, rapid and irregular, slow and regular, slow and irregular. Valaiqaat rapid and systematic suggests rush paroxysmal supraventricular or ventricular premature. The Alnzemiat rapid and irregular indicate atrial fibrillation, atrial flutter, or tachycardia with variable siege.
This and other recipes can also provide useful information such as:
• The phenomenon of Flip-flopping in the chest:
Feel the heart in some cases like a stand and then begins a new product from roads or a sense of Flip-flopping.
And generally causes this type of flickering over the early ventricular contractions or ventricular.
The sense that the heart has stopped producing for the next stop early contractions, or a sense of the ways you flipping
Thereby creating the strong contraction of the next stop and the resulting increase in intensity beyond the contraction after contraction or by the force of ventricular muscle.
• rapid flutter in the chest Rapid fluttering in the chest:
Often produces a sense of Balrverwh fast in the chest from heart Anzemiat sustained ventricular or supraventricular, including Pocket rush.
A regular or irregular palpitations that indicate a potential pathogenesis of palpitations, for example, atrial fibrillation is irregular, while rushing Pocket AVNRT and the regular palpitations.
• bombing (whipping strongly) in the neck Pounding in the neck:
The cause of the irregular bombardment feeling in the neck is atrioventricular dissociation with contraction independent of both the atria and ventricles, which result Yade to atrial contraction against irregular tricuspid valves and the closed-Taji.
This produces waves A artillery cannon A waves intermittent increase in the wave "A" of Alordede jugular pulse. You can see the waves A artillery in ventricular premature contractions, cardiac Oalhsar class Aiih or full, or ventricular premature.
You can see the pulses cervical regular and rapid, which date back to the waves A regular and prominent Kantfaj or swelling in the neck, sometimes called the "sign of the frog."
The sense of the rapid and systematic ways in the neck is more typical of the ultra-ventricular dysrhythmias reentrant, AVNRT, in particular, impulsive or reentrant ventricular sinus, which dates back to the preexcitation syndrome.
AVNRT is the most common form of speed over the ventricular paroxysmal Kmanh more common in women three times than in men.
The atria and ventricles in the typical speed of atrioventricular nodal animators together at 160 to 180 beats per minute, and as a result of shrinking the atria and ventricles together, will always reduce the atria against coronary valves and honor the closed triangle to complete or partial.
The beginning and netting Onset and offset:
Indicate the beginning and the end of the throbbing sometimes caused. Where returns are generally flickering that occurs at random and accidental and is no longer in immediate early palpitations, while proposing the beginning and gradual rush Pocket netting.
The throbbing with a start and end Mufajitin Baltsrat can cause supraventricular or ventricular.
Patients often become adept at ending the state of the elite Pettmsid throbbing carotid sinus or vagal maneuvers other Valsalva maneuver.
And suggests this pattern of termination in the case of supraventricular Altsrat particular rush ventricular nodal sinus, or when those users to bypass tract.
Throbbing spatial Positional palpitations:
Patients who have a story of AVNRT often Allanzemih stand straight after bending, and can be completed Anzemih lying.
Often, the patient noted a sense of intermittent shelling while lying in bed, especially in the supine position or in the pressure of a painful and brutal easier.
These symptoms are commonly palpitations due to ventricular or supraventricular premature, which occur frequently in the slow heart rates, as happens when a person is resting in bed.
In the case of pressure into the brutal painful left, the top of the heart near the chest wall and the strong sense of Mayall abort in this position.
Palpitations associated with syncope or pre-fainting Palpitations associated with syncope or presyncope:
Can be accompanied by palpitations dizzy, or pre-syncope, or fainting should be cut immediately irregular flow of blood circulation and the potential for serious dysrhythmias, and most important to rush ventricular VT.
Fainting is sometimes accompanied by rushing supraventricular, especially at the beginning of rush.
Believed that this type of fainting due to a sharp expansion in the blood vessels, or because of rapid heart rate with a low cardiac output, or both.
Murr Z psychological Psychiatric illness:
There is no tool to examine the optimal psychological reasons that cause Anzemih attack.
In one study, for 125 outpatients equipped device planning electric portable monitoring ECG to assess the problem palpitations have had palpitations in patients with mental disorders continue to more than 15 minutes is likely to add to their association with additional symptoms, and were more a call to visit the emergency department.
Has developed diagnostic criteria for major psychiatric disorders associated with palpitations (panic attacks, general anxiety disorder, somatization (Altgsmon), depression)
Medicines and habits Medications and habits:
Should be obtained on the story of pharmaceutical full including drugs covered without a prescription, and in particular, in Alkhfaqanat that can occur while taking all of the sympathomimetic activity, or expanders blood, or drugs for Colin, or during the period of withdrawal of beta blockers.
In addition to recognition of abuse and should be banned real estate (Kalkuaian and amphetamine) and the use of nicotine.
Also looking for answers to any relationship between the flickering and temporary handling of excessive caffeine.
Alatdharabat other medical Other medical disorders:
Must identify the story or all of the symptoms belonging to any medical disorder, which can be associated with palpitations (low blood sugar - thyrotoxicosis - pheochromocytoma)
Some studies show that the flickering can be more frequent during pregnancy.
Clinical examination Physical examination:
Rarely Maimlk doctor the opportunity to examine the patient during the incident of beating, but remains a clinical examination useful to clarify the abnormalities of cardiovascular potential which can lead to Anzemiat, and clarify some of the medical disorders that can be associated with palpitations, and an example is worth mentioning crackling mid-crunch midsystolic click or bloating associated with mitral valve prolapse mitral valve prolapse.
Offer a full contraction coarse murmur audible along the left edge of the cut and the Valsalva maneuver, which increases myocardiopathy Ackami Obstructive hypertrophic obstructive cardiomyopathy, atrial fibrillation is a common cause of palpitations in this disorder, but also associated with ventricular premature.
Raise the clinical evidence of myocardiopathy expansion dilated cardiomyopathy and heart failure, the likelihood of a rush as well as ventricular fibrillation.
The physical examination may be very useful in the evaluation of patients with palpitations and chronic atrial fibrillation. Although palpitations may not be present at rest, when the ventricular response is slow, which happens when a sympathetic activation and an increase in catecholamines, which enhance the transport atrioventricular nodal and reveals a weak response to ventricular tachycardia and control output.
Planning ECG with the electrodes 12 Twelve-lead ECG:
The causes of palpitations should be known in patients with Allanzemih associated with heart palpitations in the planning, if there have been documented to Anzemih attack (as in atrial fibrillation or ventricular tachycardia) should be treated according to the patient and Anzimh potential.
However, most patients are in the case of sinus rhythm when they are being planning for the heart. In this case, the ECG with a 12-electrode may help in narrowing the differential diagnosis of palpitations.
- The ECG should be scrutinized to look for the presence of delta waves and palace in the distance PR (syndrome Wolff-Parkinson-White), which confirms the presence of ventricular preexcitation and suppose a reason for supraventricular tachycardia.
- The left ventricular hypertrophy is clear with a deep septal Q waves in the electrodes I, aVL, and V4 through V6 assumes the existence of ill-obstructive hypertrophic heart muscle. The left ventricular hypertrophy with evidence of abnormalities in the right atrium (as seen from the strength of the final P wave in V1, where the negative more than 0.04 milliseconds and jagged in the electrode II) assumes that there is a potential substrate for atrial fibrillation.
- The presence of Q waves in the feature before myocardial infarction allows for a broader research ventricular tachycardia synergistic and non-synergistic.
- The ventricular ectopia and / or supraventricular had sometimes seen in the ECG of a 12-electrode. As the morphology of ventricular premature strikes, particularly in patients Salimi heart, may suggest that ventricular tachycardia of unknown etiology is the cause of palpitations.
- The increase in the length of the distance QT and abnormal morphology of the T wave may suggest the presence of long QT syndrome distance.
- The bradycardia caused by any reason may be associated with the early demise of polarization of ventricular tachycardia and companion. In particular, complete heart block may be associated with the demise of early ventricular attract or increase in the length of the distance and QT (torsades de pointes).
Laboratory testing Laboratory testing:
There are no guidelines based on evidence to directly work in the laboratory with patients who suffer from palpitations. The limited laboratory tests to exclude anemia and hyperthyroidism are acceptable, as well as to test specific disorders may be suggested by clinical history and physical examination.
Additional diagnostic tests Further diagnostic testing:.
Although there is no danger to the lives of most patients with palpitations but the danger lies in the presence of frequent symptoms affecting the quality of life by Dr. Le Coultre patient. Therefore, if you do not get to the definite diagnosis by clinical history and physical examination and ECG and laboratory testing, it is possible to do tests additional even rule out the risk and come to treatment for any Anzemih attack Kalrgevan fibrillation, can also be the goal of these tests to reassure the patient.
The diagnostic test is required in 3 groups of patients:
- Those who are still in the process of initial diagnostic evaluation (clinical history, physical examination and ECG) and this suggests a reason for Anzemia. Test is particularly necessary in patients who suffer from pre-Algshe Algshe or associated with palpitations.
- Those who are at high risk of infection Ballanzemih. Where is the patient in the case of high risk if they have heart disease, organic or any abnormalities in heart muscle may lead to the Anzemiat serious, including a scarring of myocardial infarction, or myocardiopathy expansion idiopathic, or valvular regurgitation and a clear clinical lesions or stenosal, or hypertrophic myocardiopathy. All previous disturbances associated with the development of ventricular tachycardia. And patients at high risk of infection Ballanzemih are those who have a family history of Allanzemih, Algshe or sudden death from cardiac causes Kaatlal heart muscle, and the long-QT syndrome distance. Patients who have a low risk are those who do not have the foundation for a possible injury Ballanzemiat.
- Those who remain keen to get a specific explanation for their symptoms.
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