PALPITATIONS: All you should know about it

Palpitation of heart is a fairly common symptom reported by many persons at all ages and in both sexes, although more often in females.  It is a common cause of seeking medical attention and can range in terms of seriousness from absolutely benign to potentially a life threatening problem.

A palpitation is an abnormality of heartbeat that ranges from often unnoticed skipped beats or a rapid heart rate to very noticeable changes accompanied by dizziness or difficulty breathing. Abnormal awareness of heart beat is also labelled under the same term. Frequently persons after going to bed complain that they can hear their heart sounds and it interferes with their sleep. This symptom is usually just an awareness of heart beat in an anxious person and only needs reassurance and no specific treatment. An anti-anxiety tablet could be used for extreme cases.

Heart palpitation symptoms can feel like:

•             Skipped or irregular heartbeats

•             Fluttering heartbeats

•             Heartbeats that are too fast

•             Heartbeats that are pumping harder than usual

Heart palpitations can be felt as a symptom in your throat or neck, as well as your chest. Heart palpitations can occur whether you’re active or at rest, and in any posture. Sometimes these increase when lying down on the left side because of a relative change in the position of heart.

Palpitations can be attributed to one of the 3 major causes:

1.            Anxiety is one of the important causes in young highly strung personalities and is affected by the state of mind. Psychological problems can thus induce one to palpitate. It is therefore important to consider the psycho-social aspect before coming to a conclusion. This is often due to sympathetic over drive which can be associated with panic disorders, lowering of blood sugar levels especially in diabetics, certain drugs like common cold medicines, anemia and low oxygen in the atmosphere or lung disease. These can get aggravated during increase in dust in the atmosphere (pollution)

2.            Hyper dynamic circulation  : This occurs when the work of heart increases due to many common causes : Leaking heart valves , disorders of thyroid gland (usually increase in thyroid hormones like T3 and T4, hyper thyroidism), fever, anemia and pregnancy. Hyper-thyroidism often is associated with excessive sweating and weight loss. It should be differentiated from hypo thyroidism where thyroid function is low and is associated with high levels of Thyroid stimulating hormone (TSH) and a slow heartbeat.

3.            Disorders of Heart rhythm:  Premature atrial or ventricular beats, atrial fibrillation, supra ventricular tachycardia, ventricular tachycardia ,ventricular fibrillation etc. Some of these disorders like a ventricular tachycardia and ventricular fibrillation can be life threatening if not recognized in time. Recording an ECG is essential to diagnose these disorders.

Symptoms to be noted:

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 light-headedness. 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. Another symptom is pain in arms or breathlessness sometimes lasting through the night after the palpitation.

It is important to enquire whether the patient has a past history of heart disease like a heart attack. These patients can get palpitations of a more severe variety needing early attention.

Approach to Risk stratifies:

An important clue to the diagnosis is the description of the palpitation. The approximate age of the person when first noticed and the circumstances under which they occur are important. Often these symptoms start after heavy tea or coffee drinking.

The method adopted by the subject to stop or halt the palpitation can also give a clue to the diagnosis. Palpitation relief after vomiting or pressing neck is often associated with a classical type of palpitation called, Paroxysmal supra ventricular tachycardia (PSVT) which is a problem which can be cured by a cardiologist.

 The diagnosis is usually not made by a routine medical examination and an electrocardiography (ECG) which is widely available is recommended. It is best to get it done while the symptom is ongoing because it is often only transient and reaching a doctor may not be possible because by that time the episode may have aborted.

Nevertheless a clinical examination by a doctor and findings such as a heart murmur or an abnormality of the ECG, could point to the probable diagnosis. In particular, ECG changes that can be associated with specific disturbances of the heart rhythm may be picked up; so routine physical examination and ECG remain important in the assessment of palpitations.

Blood tests, particularly tests of thyroid gland function are also important baseline investigations (an overactive thyroid gland is a potential cause for palpitations; the treatment in that case is to treat the thyroid gland over-activity). Measuring the hemoglobin is also useful to rule out anemia which can be a common cause of palpitations especially in females.

The next level of diagnostic testing is usually 24 hour (or longer) ECG monitoring, using a form of tape recorder called a Holter monitor, which can record the ECG continuously during a 24 or 48 hours  period. If symptoms occur during monitoring it is a simple matter to examine the ECG recording and see what the cardiac rhythm was at the time. For this type of monitoring to be helpful, the symptoms must be occurring at least once a day. If they are less frequent, the chances of detecting anything with continuous 24, or even 48-hour monitoring, are substantially lowered.

Other forms of monitoring are available, and these can be useful when symptoms are infrequent. A continuous-loop event recorder monitors the ECG continuously, but only saves the data when the wearer activates it. Once activated, it will save the ECG data for a period of time before the activation and for a period of time afterwards – the cardiologist who is investigating the palpitations can program the length of these periods. A new type of continuous-loop recorder has been introduced recently that may be helpful in people with very infrequent, but disabling symptoms. It is of 2 types:

External Extended Loop Recorder (ELR): It is a small device firmly attached to skin over the chest or abdomen and can remain there for up to a few weeks also depending upon the need. Person can wash and bath during this period without any disturbance in recording. The machine gives alerts to your doctor during the recording period. A serious arrhythmia clinches the diagnosis and makes treatment easy.

Implantable Extended Loop Recorder (IELR):

This recorder is implanted under the skin on the front of the chest, like a pacemaker. It can be programmed and the data examined using an external device that communicates with it by means of a radio signal. It can be kept for several months to a few years. This is reserved for persons who get very symptomatic palpitation very infrequently but makes them very sick or fall down.

Evaluating Function of Heart:

Investigation of heart structure can also be important. The heart in most people with palpitations is completely normal in its physical structure, but occasionally abnormalities such as valve problems may be present. Usually, the physician or cardiologist will be able to detect a murmur in such cases, and an ultrasound scan of the heart (echocardiogram) will often be performed to document the heart’s structure. If the heart function is impaired with a low ejection fraction, palpitation of any kind needs to be taken seriously. For patients who have a history of heart disease this investigation is important.

Echocardiography is a non-invasive test performed using ultra sound waves and is virtually identical to the ultra sound examination of the abdomen so often done to diagnose gall bladder or kidney stones.

Things to Remember

Patients with underlying heart disease especially with old or recent heart attacks and long standing disease of heart valves, patients with poorly functioning heart muscle should take a serious note of palpitations, dizzy spells and short lasting episodes of unconsciousness. These are the subjects who need detailed evaluation because these palpitations may be warning symptoms of something more sinister. There are many gratifying treatment modalities available these days to prevent serious events. These include pacemakers, implantable defibrillators which recognize serious arrhythmias and treat them before a nearly fatal event.

There are some disorders like paroxysmal supra ventricular tachycardia (PSVT) which occur because of abnormal connections in the electrical system of heart. These present as sudden onset acceleration of heart rate to 160 to 200 per minute. These disorders can be cured by specialized methods of non-surgical treatment like radiofrequency ablation (RFA) after mapping the heart by cardiac electrophysiology in a cardiology centre.

RFA is a non-surgical procedure carried out after puncturing the veins of Upper thigh and neck and done under X Ray control in a cardiac catheterization laboratory under local anesthesia in a fully conscious patient after introducing catheters inside the heart to get electro grams from various heart chambers.

Patients with normal hearts with no underlying problems palpitations can usually be ignored but if these interfere with day to day life need to be brought to the attention of your treating physician. Very often it just needs a reassurance or some simple medicines like tranquillizers or beta adrenergic blocking drugs.

Atrial fibrillation

This is a relatively common arrhythmia with advancing age and needs to be recognized early. It presents as a rapid and very irregular heartbeat. ECG is diagnostic. It sometimes is episodic and needs long term ECG monitoring in that case. The importance of this arrhythmia is that it can lead to brain strokes which can be prevented by administering long term blood thinners. Aspirin alone is not enough to prevent these serious complications.

These patients need lifelong anti coagulation (Warfarin). Lot of research has been done in this area and many new drugs which do need frequent blood monitoring are available now (Dabigatran, Apixaban, Rivaroxaban etc).

These agents are at least as effective as the traditional anticoagulants, safer and easier to use and do not have interactions with many vegetables etc. which is a problem with warfarin or acitrom users. These agents however cannot be used in patients with implanted metallic valves

Palpitations not to be ignored:

In patients with palpitations associated with underlying heart disease and accompanied with fainting or severe shortness of breath medical attention should be sought at the earliest.

Prevention of palpitations

Healthy life style from a young age can go a long way to keep your heart healthy and prevent palpitations and many serious complications. These are, Regular exercise, eating a heart healthy diet, keeping blood pressure, blood sugar and blood cholesterol levels under strict control. Diabetics should watch their blood sugars regularly and keep them under control and last but not the least any tobacco in any form.

Prof Upendra Kaul is Executive Director and Dean Batra Hospital & Medical Research Centre