Palpitation overview

# Overview
Palpitations are a nonspecific symptom that are often defined as a rapid disagreeable sensation/pulsation that may be momentary or sustained and regular or irregular.Patient often present with a flip flopping,fluttering,pounding or thud like sensation in one particular area or all over the precordium. It may or may not be associated with symptoms such as chest pain, dyspnea, presyncope, syncope or haemodynamic compromise. A detailed history, physical examination and 12 lead ECG constitute the initial evaluation necessary.  Based on this, a decision regarding investigative modalities such as ambulatory ECG monitoring, laboratory investigations, echocardiography and electrophysiology study may be made. Treatment is directed at treating the underlying cause.

# Historical Perspective
There is limited information about the historical perspective of palpitations.

# Classification
Palpitations may be classified based on cause, duration, rhythm and clinical presentation.

# Pathophysiology
Palpitations are a nonspecific symptom that are often defined as a rapid disagreeable sensation/pulsation that may be momentary or sustained and regular or irregular. It is one thing to understand the pathophysiology of palpitations as a symptom and another to understand the pathophysiology of conditions that cause palpitations. Palpitations are hypothesized to be due to neural-afferent sensory pathways located at both cardiac and extracardiac levels.It may be caused due to abnormal adjustments in the rate, rhythm and contractility of the heart.

# Causes
There are a vast number of causes of palpitations, including namely any condition that causes the heart to be rapidly, forcefully, or irregularly. In general, palpitations may be caused by primary abnormalities in the heart (tachycardia or forceful heart beating), reductions in oxygen carrying capacity (anemia), reductions in the volume of blood circulating (dehydration), sympathetic nervous system stimulation (fever, exertion, panic attacks, drugs), excess hormone production (hyperthyroidism). Pharmacological causes should also be taken into consideration.

# Differentiating Xyz from Other Diseases
When coming up with a differential diagnoses, it would be useful to link positive history,physical examination and ECG findings to cardiac (arrhythmia Related), cardiac (not related to arrhythmia), systemic causes (Non Cardiac), pharmacological causes and psychiatric causes.

# Epidemiology and Demographics
Scarce data is available regarding the epidemiology of palpitations.

# Risk Factors
Common risk factors in the development of palpitations include a past history of cardiac disease, atherosclerotic risk factors, caffeine intake, substance abuse and a family history of sudden cardiac death or psychiatric disease.

# Screening
There is insufficient evidence to recommend routine screening for palpitations.

# Natural History, Complications, and Prognosis
Patient often present with a flip flopping,fluttering,pounding or thud like sensation in one particular area or all over the precordium. It may or may not be associated with symptoms such as chest pain, dyspnea, presyncope, syncope or haemodynamic compromise. Complications include impairment of quality of life, hypotension, ventricular fibrillation and sudden cardiac death. Prognosis depends on the underlying cause but is generally good.

# Diagnosis

## Diagnostic Study of Choice
There is no single diagnostic study of choice for palpitations.

## History and Symptoms
Many times, the person experiencing palpitations may not be aware of anything apart from the abnormal heart rhythm itself. But palpitations can be associated with other things such as tightness in the chest, shortness of breath, dizziness or lightheadedness. Depending on the type of rhythm problem, these symptoms may be just momentary or more prolonged. Actual blackouts or near blackouts, associated with palpitations, should be taken seriously because they often indicate the presence of important underlying heart disease. There are certain key questions that need to be asked while taking a patient's history.

## Physical Examination
Palpitations are typically a transient symptoms. Patients may or may not be in physical distress and may even present with altered mental status secondary to substance abuse. During a physical examination one must look for signs and symptoms of hyperthyroidism, hypothyroidism, congestive heart failure, rhythm disturbances and structural heart disease.

## Laboratory Findings
Laboratory investigations are often performed when a systemic/pharmacological cause of palpitations is suspected. These would be directed towards diagnosing kidney problems, pheochromocytoma, thyroid dysfunction and substance abuse.

## Electrocardiogram
A 12 lead ECG is an important diagnostic tool used in the initial evaluation of patients presenting with palpitations. Based on the presence or absence of positive ECG findings physicians can determine the need for ambulatory ECG monitoring, echocardiography, lab investigations or electrophysiology study.

## X-ray
A x-ray may be employed in the diagnosis of patients presenting with palpitations when there is an increased suspicion of structural heart disease.

## Echocardiography and Ultrasound
An echocardiography is a second line investigation that is employed in the diagnosis of patients presenting with palpitations when there is an increased suspicion of structural heart disease.

## CT scan
A CT may be employed in the diagnosis of patients presenting with palpitations when there is an increased suspicion of structural heart disease.

## MRI
A MRI may be employed in the diagnosis of patients presenting with palpitations when there is an increased suspicion of structural heart disease.

## Other Imaging Findings
There are no other imaging findings associated with palpitations.

## Other Diagnostic Studies
An electrophysiology study (EPS) is used as a diagnostic tool in patients presenting with palpitations associated with serious symptoms such as syncope or presyncope. It is often used when other studies have proven to be non-diagnostic.

# Treatment

## Medical Therapy
The treatment strategy for patients presenting with palpitations is directed towards treating the underlying cause. A physician needs to follow a standardized approach (which varies from institution to institution) in order to decide which patients can be discharged with the advice to follow up with a cardiologist and which patients require further work up.

## Interventions
There are no recommended interventions that are specifically used for patients presenting with palpitations.

## Surgery
The mainstay of treatment for palpitations is directed at treating the underlying cause. Surgery is usually reserved for patients with structural heart diseases.

## Primary Prevention
There are no established measures for the primary prevention of palpitations.

## Secondary Prevention
There are no established measures for the secondary prevention of palpitations.