Chapters Transcript Video Work Up Palpitations Click here to view presentation deck Back to Symposium So, when I think of palpitations, I think of a person who reports symptoms and it's not a medical diagnosis, it's more what your patient feels. And they usually say, you know, I, I feel my heart beating more rapidly or irregularly or it feels like my heart's jumping out of the chest. Most notably, these symptoms occur at night time and that might be because they're sleeping on their stomach or they're just more in tune to their body at night. Um when the environment's quieter. So the first part is it's not always electricity, right? So a lot of patients will report palpitations and it's other things going on which primary care is at the forefront of. So it could be anxiety or panic attacks. It could be they're dehydrated and not drinking enough water. It could be, they have an infection like a viral ur I or they could be anemic. Um And so it's important to do a full physical exam and get and get lab draws, right? And associated with that is endocrine disorders such as hyperthyroidism. Um, drugs can certainly worsen palpitations. Um They could have valve disorders and so hearing for systolic and diastolic murmurs with the stethoscope is important and they may be in heart failure and they may feel they're worsening heart failure and tachycardia might be a response of a lower um stroke volume. So the history and physical exam is very important. Um You should ask about stressors in life. Um Look for shortness of breath or rapid neck, neck pulsation. So if they feel that their neck is pulsating when they're in tachycardia may be a sign of a BN RT. They may have palpitations with exercise which may tell you it could be sympathetically driven. Um And then you could ask him, how are they aborting these, are they doing bagel maneuvers um which are indicative of more svts that we can diagnose in the EP lab. Um And then the two most common things I look for or which are very concerning um for an arrhythmia or prodrome. So, the lack of prodrome, if they don't have, feel it coming on and it hits all of a sudden, it's concerning for an arrhythmia. And do they have any associated trauma associated with it? So, if they have facial trauma, anything like that, it's very highly concerning for an electrical abnormality. Um Heart cult auscultation, as I mentioned will be important for diagnosis of valvular disorders or heart failure. And then the ne nail, skin and thyroid exam are all important, especially if you feel for goiters or thyroid nodules might help diagnose stuff. So the first work up, I get in my office and I encourage primary care doctors to get or nurse practitioners or pas to get is in 12 lead EKG and you may see something off the bat that may look different to you. And so here we have a patient with Wolf Parkinson White syndrome and they have an accessory pathway and their palpitations might be explained by either an arrhythmia going down the accessory pathway or going down the A V node and coming up the accessory pathway. And so this helps because this would automatically warrant a referral to electrophysiology and we could fix this and solve their issue. Here's a patient with an EKG finding you'll notice after the CRS is there's a little bump and they have negative T waves and this is indicative of arrhythmogenic right ventricular um dysplasia or a RVD. And they may be getting palpitations when they exercise and they may need an echocardiogram um and cardiac MRI. So I think the EKG tells us a lot and if it looks weird, it is weird and you could always send us an inbasket message or say, hey, do you think this EKG is weird? Um Because we will review it and we're EKG nerds. So we like seeing this stuff and we can help you out. Here's another patient who had palpitations and you could see that they're having multiple PV CS and it can be explained by outflow uh morphology, PV CS and we can either start them on medications to suppress it or we can do a catheter based ablation to target the PV C um, to provide them true symptom relief. So the next part is if the EKG looks ok, and they're still reporting palpitations, what should I do? And I, I would say the next best thing to do is put a monitor on them. And so these are the different types of monitors that you have available at your disposal and what we have as well as electrophysiologist. So the first one's a holter monitor which is for 24 or 48 hours and it's a very short time frame. So if the palpitations are happening once a month, once every two months, it's not going to be helpful. You have a loop or event recorder where they can trigger when you want it recorded. And a lot of times this will be helpful rule in what is real cardiac or what is anxiety? A lot of times it's difficult um as physicians or providers to know, is it really in their head or is it an arrhythmia that can be fixed? And these kinds of recorders can tell the patient um It's not a arrhythmia that which is causing your symptoms. You could have handheld event recorders. The Cardia Mobile is the main one that people like to use. Um Zio patch or you see the vendors out front, there's a couple of vendors that have long term stickers which stick on for 1 to 2 weeks, they mail it in it, analyzes it and a physician reads it and let's say you don't re you have, concerning symptoms, patients are blacking out. They don't feel it coming on. They have rapid palpitations, but you can't figure it out. You would put in what's called the loop recorder. And these basically stay in for about three years and monitors their heart rhythm all the time. And you could set different parameters of when uh electrophysiologist do implants that um can see what's happening when they feel these coming on. So it's both an event triggered and it triggers automatically if the heart rate gets too fast or slow or if it notices a V block or new onset atrial fibrillation. So this is just a chart showing you that short duration monitors should not really be used because the yield is very low. It, it's not good at diagnosing arrhythmias. A lot of patients may have arrhythmia. So 24 and 48 hours in patients who have palpitations I would not personally use uh because the yield is so low. So I would go for more of a two week monitor. Um It, it's my preference because the yield of what you'll get information of diagnosis or is much higher. And so here's a sample monitor recording in which you can get from a two week monitor. So this is made by I rhythm and it's a Z report monitor, it says the prescribing clinician. So usually a primary care doc or the doctor who's putting it, who prescribed the monitor. You get a nice report of arrhythmias from the top chamber, the bottom chamber pauses and you could see what they triggered and whether it corresponds to any of these arrhythmias and then it makes a preliminary finding and it has a lot of words in it which we as electrical doctors and cardiologists have to interpret. And so on the right, we'll usually put in an interpretation. So a lot of times these monitors will have very short runs of SVT, eight beats of SVT everyone has that. It is not abnormal, especially if they didn't trigger it. So I wouldn't refer to cardiology or electrophysiology because they had eight beats of atrial tachycardia. If it, they're not triggering it, that's not causing their palpitations. But if you see long episodes lasting greater than 30 seconds to minutes where the heart rate's jumping above 180 it, and it's the patient triggered it. That should think about referral to electrophysiology. And usually on the right side, I'll make comments like new onset atrial fibrillation, symptomatic, refer to electrophysiology, further work up on the right. Um But if there's nothing abnormal, my com my interpretations when I write these are usually like clinical benign um or monitor without any sustained brady or tachy arrhythmias. And so that prevents over referral, it prevents the bog down of um referrals to specialists that can't help the patient's issue. Here's an implantable loop recorder. So let's say monitors, uh didn't show information. Patient still feels it. Um And we're really worried, it's an arrhythmia causing their symptoms. We'll sometimes put a loop recorder, especially in older patients who may have Brady arrhythmias. We're not sure why they're passing out and it takes about 30 seconds to put in. We numb the skin um near the left breast. Um In the pectoralis, we just numb it with lidocaine. We make one small incision like a paper cut and we insert the device, the whole procedure from start to finish, takes about a minute and we're able to get nice p waves and recordings for up to three years and we glue it on. So it works very well. And so here is the loop recorder data versus conventional diagnostic strategy. So conventional recording being just regular monitoring with 1 to 2 week monitoring and then loop recorder on the right. And you could see that the loop recorder yield a diagnosis in 73% of patients. So much higher rate of diagnosing a FB and flutter, much higher rate of diagnosing SVT. Um and pauses and so in patients who have concerning signs, right? If they don't have a prodrome and they just black out or their heart rate jumps really high. I think a loop recorder is a good strategy to find out the mechanism of their um syncope, but here's where stuff is evolving, right? I think one of the ways medicine is evolving is in the past, it was very traditional medicine FDA approval where you have devices, you have medicines and then the health care provider prescribes a zio patch or any of these other recordings. Now, people are getting stuff at home, right? You could go to Best Buy and pick up a cardio mobile, you could get an Apple Watch, you could get whatever kind of watch and recordable and wearables don't really require FDA clearance. They're very small studies if any and they're coming to a doctor's office and saying I have this, what do you think about my Apple Watch recording? But I think that is where we're seeing inundation of data. But a lot of times it's good, like I'll have patients send me cardiac recordings and Apple watch and they'll come to my office and say, look at my Apple watch recording and I'm like, yeah, your heart rate really is 200. You need an EP study um and ablation. And so I think we're, we're seeing this, but it has to be verified by a provider who's an expert um in interpreting arrhythmias. So, here's a patient um that we wrote up um when I was a fellow at the Cleveland Clinic where the patient had a stroke and they were being referred to us because they wanted a loop recorder. But the patient said, hey, while I was waiting to figure out whether I need a loop recorder, I got an Apple watch and my Apple watch keeps saying I'm an A fe and I was, and we looked this in the office and I was like, sure enough, if you could see on the right panel, it's irregularly irregular, which is the hallmark of atrial fibrillation. And we said, you don't need a loop recorder. You have a diagnosis of atrial fibrillation. You need to be on a blood thinner to prevent recurrent stroke. And so the Apple watch prevented them from getting a loop recorder and it was smart. Um It told them their exact diagnosis, but the important part was the patient had no clue how to interpret it. So they brought it to us and we were able to verify um as providers that it was atrial fibrillation. And so you could see here it was a nice study um in the basil wearable study where they looked at five different devices which show EKG recordings and you could see the sensitivity is high. So it's be anywhere between 70 95%. So it's really good at picking up new A FB um and other arrhythmias, the specificity is low. So it's not going to be good at recognizing sinus rhythm with premature atrial contraction or PAC S. It's not gonna be able to recognize flutter verse fibrillation, but it is good if your patient has palpitations and they want to know, is it a fib or not? It's probably good, but it's not going to be highly specific. It might call something a fib when it's just sinus rhythm with Pac S. And that's why you need sometimes expertise to look into this until A I takes over the rest of our lives. So the conclusion is the work up with palpitation starts with careful history and physical exam. Um which is the first rule, I was a primary care doctor at the VA um a while back. And so it, it we just focused mostly on the history and physical exam and did not do as much testing. Uh But then if you are worried, the yield of EKG and short term monitoring is low, but it can provide important clues. And I think the next step will be digital health in the diagnosis and work up of palpitations. And then we, we will see, I think A I will play an important role as well in interpreting these EKG S that patients get for. Thank you very much. Published November 1, 2024 Created by Related Presenters Divyang Patel, M.D. Sentara Cardiology Specialists View Full Profile
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