Palpitations, when to attend the emergency room?


Dr. Gricely Pozo, Emergenciologist, Master in Critical Ill Care. Emergency Department Hospital Plaza de la Salud.

Palpitations constitute the perception of our heartbeat, frequent symptomatology in the population and cause of multiple consultations in the emergency room.

On a regular basis we do not notice the heartbeat, however, sometimes we can perceive that our heart beats very hard, very fast or irregularly, constituting a common symptom and cause of great concern, for patients, but it is important to argue that Palpitations are usually benign and do not translate serious disease.

Most are due to extrasystoles, which are heart rhythm disorders and consist of an advanced heartbeat compared to normal heart rate and that the patient is able to feel like a jump in the heartbeat. A large part of the population has extrasystoles, but not everyone perceives them. They do not regularly constitute a danger to the patient, and if there are no basic cardiac structural alterations, they do not usually require specific treatment.

The mechanisms responsible for the perception of palpitations are unknown, usually people do not perceive the normal rhythm (sinus rhythm), whose characteristics include a regular rhythm and with a number of beats per minute between 60 and 100. This implies that palpitations reflect changes in heart rate or rhythm. In all cases, what is felt is the abnormal movement of the heart inside the chest.

The clinical presentation of cardiac phenomena is very variable, where some patients perceive almost all extrasystoles, while others do not have any other symptoms. Perception increases in sedentary, anxious or depressed individuals and decreases in active and happy people, in fact, some individuals feel palpitations without abnormal cardiac activity.

Some individuals only have a greater sensitivity to the perception of normal cardiac activity, particularly when they exercise, they have a febrile illness or go through a state of anxiety that increases the heart rate.

However, rapid evaluation of an arrhythmia is justified as a cause of palpitations, which can range from benign to life-threatening.

The most frequent rhythm disorders or arrhythmias are, atrial extrasystoles and ventricular extrasystoles, both arrhythmias are usually harmless.

However, there are other arrhythmias that may be frequent, such as: paroxysmal supraventricular tachycardia, ventricular tachycardia, which merit immediate medical evaluation and urgent treatment. Rhythm disorders that involve heartbeat frequency, below 60 beats per minute, are included in bradyarrhythmias, which rarely cause a palpitation consultation, although some patients are aware of the slow speed.

Causes of palpitations

Regular palpitations usually occur in the presence of some arrhythmias, such as atrial and ventricular extrasystoles, paroxysmal supraventricular tachycardia, which may appear spontaneously in people without serious underlying diseases, others being the result of severe heart disease.

Among the causes of serious cardiac origin arrhythmias, we can list myocardial ischemia, (which occurs when blood flow to the heart is reduced, which prevents the heart muscle from receiving enough oxygen), other myocardial diseases, congenital heart disease such as Syndrome Brugada, arrhythmogenic right ventricular cardiomyopathy, congenital long QT syndrome, valvulopathies and cardiac conduction disorders, within these alterations those that cause bradycardia or cardiac block (ventricular atrium).

Patients with orthostatic or postural hypotension usually perceive palpitations caused by sinus tachycardia that appears when standing up.

Other causes of heart rhythm disorder, which can cause palpitations, are non-cardiac diseases that increase the contractility of the heart, such as disorders of the thyroid gland, (thyrotoxicosis), pheochromocytoma (a tumor of the adrenal medulla of the adranal gland, which causes an increased and unregulated secretion of catecholamines), and anxiety.

In this order there are metabolic alterations that can cause or exacerbate palpitations such as: anemia, hypoxia, hypovolemia and electrolyte imbalances, such as the decrease in potassium in the blood (hypokalemia) induced by diuretic drugs.

Some drugs, such as digoxin, caffeine, alcohol, nicotine and sympathomimetics (albuterol, amphetamines, cocaine, dobutamine, adrenaline, ephedrine, isoproterenol, norepinephrine and theophylline) frequently cause or exacerbate palpitations.

Evaluation and alarm signs

Palpitations are common and often a scary symptom for the patient, but they are generally benign, however, in all patients with this symptomatology, we must establish, frequency and duration of palpitations, factors that cause or exacerbate them, for example, situations emotional, physical activity, postural changes, caffeine consumption or other medications.

It is useful to know the associated symptoms, paying special interest to the presence of syncope, dizziness, blurred vision, dyspnea and chest pain.

It is necessary to conduct a careful medical history, an adequate physical examination, take blood samples for laboratory tests, and a 12-lead electrocardiogram is essential at the time of symptoms, which will help the doctor stratify the patient's risk, determining in the emergency room, how quickly you will need a referral or evaluation by a subspecialist.

Especially in the face of some findings that suggest a more serious etiology, such as dizziness, syncope, chest pain, dyspnea, significant underlying heart disease, family history of recurrent syncope or sudden death and exercise-induced syncope.

Palpitations associated with a previous history of Vascular Brain Accident (CVA), without a specific cause, should be studied in order to rule out arrhythmias that in particular lead to additional treatment with anticoagulant drugs to prevent the recurrence of CVA; cause of great morbidity, and currently particularly underdiagnosed.

If there are no warning signs, the doctor may recommend ambulatory heart rate monitoring through Holter monitoring, event recorders (specific devices or modified smartphones) activated by the patient, long-term monitors (3 to 4 weeks), and the implantable Holter.


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