Palpitation of heart is a fairly common symptom reported bymany persons at all ages and in both sexes, although more often infemales. It is a common cause of seekingmedical attention and can range in terms of seriousness from absolutely benignto 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 throator neck, as well as your chest. Heart palpitations can occur whether you’reactive or at rest, and in any posture. Sometimes these increase when lying downon 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 beaware of anything apart from the abnormal heart rhythm itself. But palpitationscan be associated with other things such as tightness in the chest, shortnessof breath, dizziness or light-headedness. Depending on the type of rhythmproblem, these symptoms may be just momentary or more prolonged. Actualblackouts or near blackouts, associated with palpitations, should be takenseriously because they often indicate the presence of important underlyingheart disease. Another symptom is pain in arms or breathlessness sometimeslasting through the night after the palpitation.
It is important to enquire whether the patient has a pasthistory of heart disease like a heart attack. These patients can getpalpitations of a more severe variety needing early attention.
Approach to Risk stratifies:
An important clue to the diagnosis is the description of thepalpitation. The approximate age of the person when first noticed and the circumstancesunder which they occur are important. Often these symptoms start after heavytea or coffee drinking.
The method adopted by the subject to stop or halt thepalpitation can also give a clue to the diagnosis. Palpitation relief aftervomiting or pressing neck is often associated with a classical type ofpalpitation called, Paroxysmal supra ventricular tachycardia (PSVT) which is aproblem which can be cured by a cardiologist.
The diagnosis isusually not made by a routine medical examination and an electrocardiography(ECG) which is widely available is recommended. It is best to get it done whilethe symptom is ongoing because it is often only transient and reaching a doctormay not be possible because by that time the episode may have aborted.
Nevertheless a clinical examination by a doctor and findingssuch as a heart murmur or an abnormality of the ECG, could point to theprobable diagnosis. In particular, ECG changes that can be associated withspecific disturbances of the heart rhythm may be picked up; so routine physicalexamination and ECG remain important in the assessment of palpitations.
Blood tests, particularly tests of thyroid gland functionare also important baseline investigations (an overactive thyroid gland is apotential cause for palpitations; the treatment in that case is to treat thethyroid gland over-activity). Measuring the hemoglobin is also useful to ruleout anemia which can be a common cause of palpitations especially in females.
The next level of diagnostic testing is usually 24 hour (orlonger) 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 monitoringit is a simple matter to examine the ECG recording and see what the cardiacrhythm was at the time. For this type of monitoring to be helpful, the symptomsmust be occurring at least once a day. If they are less frequent, the chancesof detecting anything with continuous 24, or even 48-hour monitoring, aresubstantially lowered.
Other forms of monitoring are available, and these can beuseful when symptoms are infrequent. A continuous-loop event recorder monitorsthe 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 theactivation and for a period of time afterwards – the cardiologist who isinvestigating the palpitations can program the length of these periods. A newtype of continuous-loop recorder has been introduced recently that may behelpful in people with very infrequent, but disabling symptoms. It is of 2types:
External Extended Loop Recorder (ELR): It is a small devicefirmly attached to skin over the chest or abdomen and can remain there for upto a few weeks also depending upon the need. Person can wash and bath duringthis period without any disturbance in recording. The machine gives alerts toyour doctor during the recording period. A serious arrhythmia clinches thediagnosis and makes treatment easy.
Implantable Extended Loop Recorder (IELR):
This recorder is implanted under the skin on the front ofthe chest, like a pacemaker. It can be programmed and the data examined usingan external device that communicates with it by means of a radio signal. It canbe kept for several months to a few years. This is reserved for persons who getvery symptomatic palpitation very infrequently but makes them very sick or falldown.
Evaluating Function of Heart:
Investigation of heart structure can also be important. Theheart in most people with palpitations is completely normal in its physicalstructure, but occasionally abnormalities such as valve problems may bepresent. Usually, the physician or cardiologist will be able to detect a murmurin such cases, and an ultrasound scan of the heart (echocardiogram) will oftenbe performed to document the heart’s structure. If the heart function isimpaired with a low ejection fraction, palpitation of any kind needs to betaken seriously. For patients who have a history of heart disease thisinvestigation is important.
Echocardiography is a non-invasive test performed usingultra sound waves and is virtually identical to the ultra sound examination ofthe abdomen so often done to diagnose gall bladder or kidney stones.
Things to Remember
Patients with underlying heart disease especially with oldor recent heart attacks and long standing disease of heart valves, patientswith poorly functioning heart muscle should take a serious note ofpalpitations, dizzy spells and short lasting episodes of unconsciousness. Theseare the subjects who need detailed evaluation because these palpitations may bewarning symptoms of something more sinister. There are many gratifyingtreatment modalities available these days to prevent serious events. These includepacemakers, implantable defibrillators which recognize serious arrhythmias andtreat them before a nearly fatal event.
There are some disorders like paroxysmal supra ventriculartachycardia (PSVT) which occur because of abnormal connections in the electricalsystem of heart. These present as sudden onset acceleration of heart rate to160 to 200 per minute. These disorders can be cured by specialized methods ofnon-surgical treatment like radiofrequency ablation (RFA) after mapping theheart by cardiac electrophysiology in a cardiology centre.
RFA is a non-surgical procedure carried out after puncturingthe veins of Upper thigh and neck and done under X Ray control in a cardiaccatheterization laboratory under local anesthesia in a fully conscious patientafter introducing catheters inside the heart to get electro grams from variousheart chambers.
Patients with normal hearts with no underlying problemspalpitations can usually be ignored but if these interfere with day to day lifeneed to be brought to the attention of your treating physician. Very often itjust needs a reassurance or some simple medicines like tranquillizers or betaadrenergic 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 underlyingheart disease and accompanied with fainting or severe shortness of breathmedical attention should be sought at the earliest.
Prevention of palpitations
Healthy life style from a young age can go a long way tokeep your heart healthy and prevent palpitations and many seriouscomplications. These are, Regular exercise, eating a heart healthy diet,keeping blood pressure, blood sugar and blood cholesterol levels under strictcontrol. Diabetics should watch their blood sugars regularly and keep themunder 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