Palpitations

Rationale

Palpitations are sensations of a rapid or irregular heartbeat. Palpitations are a common symptom, and although the cause is often benign, it may indicate the presence of a serious underlying condition.

Causal Conditions

(list not exhaustive)

1. Supraventricular
   1. Sinus tachycardia
      1. Increased demand (e.g., pregnancy, anemia)
      2. Metabolic (e.g., thyrotoxicosis, pheochromocytoma)
      3. Anxiety
      4. Pharmacologic (e.g., cocaine, caffeine)
   2. Atrial fibrillation or atrial flutter
   3. Supraventricular tachycardia (atrioventricular nodal re-entrant tachycardia, Wolff-Parkinson-White syndrome)
   4. Junctional tachycardia
   5. Premature atrial contractions and premature junctional complexes
2. Ventricular
   1. Ventricular tachycardia
   2. Premature ventricular contractions
   3. Ventricular fibrillation

Key Objectives

Given a patient with palpitations, the candidate will diagnose the cause, severity, and complications, and will initiate an appropriate management plan. The candidate will differentiate palpitations due to intrinsic heart disease from palpitations that are a manifestation of anxiety, physical exertion, or other systemic disease. In particular, the candidate will identify patients in need of urgent treatment.

Enabling Objectives

Given a patient with palpitations, the candidate will

1. list and interpret critical clinical findings, including those based on
   1. a history and physical examination,
   2. the cardiac rate and rhythm and the hemodynamic stability of the patient, and
   3. underlying precipitants of cardiac arrhythmia;
2. list critical investigations and interpret the results of the investigations, including
   1. electrocardiography or other investigations to assess cardiac rhythm, and
   2. appropriate investigations to determine the underlying causes of cardiac arrhythmia (e.g., echocardiography, thyrotropin level);
3. construct an effective initial management plan, including
   1. providing immediate management in case of hemodynamic instability,
   2. initiating anticoagulation for stroke prevention if indicated,
   3. determining whether the patient requires hospitalization and/or specialized care, and
   4. reassuring the patient if they have a benign condition.