Makindo Medical Notes

📖 Introduction

Palpitations are the subjective awareness of one’s heartbeat, often described as pounding, racing, fluttering, or irregular. They are a symptom, not a diagnosis, and can arise from benign physiological states (stress, caffeine, pregnancy) or from serious arrhythmias (AF, SVT, VT). Accurate history and rhythm documentation are crucial because many arrhythmias are paroxysmal and transient.

🧬 Pathophysiology

• ⚡ Increased automaticity: enhanced pacemaker activity (e.g., sinus tachycardia in fever, anxiety, thyrotoxicosis).
• 🔁 Re-entry circuits: electrical impulses loop abnormally, causing paroxysmal SVT or AF.
• 🚫 Triggered activity: after-depolarisations in myocardial cells ➝ ectopics, tachyarrhythmias (digitalis toxicity, electrolyte imbalance).
• ❤️ Structural disease: scarring or fibrosis from IHD, cardiomyopathy, or valvular disease disrupts conduction.
• 🫁 Physiological states: pregnancy, fever, dehydration, anaemia, or stimulants (caffeine, nicotine) increase sympathetic drive and perceived heartbeat.
• 🧠 Heightened awareness: anxiety, panic disorder, or heightened central perception may amplify normal beats.

🩺 Clinical

• 💓 Palpitation = increased awareness of the heartbeat.
• ⚡ Descriptions: “fluttering,” “racing,” “thumping,” or “missed beats.”
• ⏸️ A missed beat ➝ compensatory pause ➝ strong thump (often ectopics).
• 🔀 Irregular rhythm awareness often points to atrial fibrillation or ectopy.

💡 Tips

• 🫳 Ask the patient to tap out the rhythm as they felt it.
• ➕ Explore associated features: chest pain, dyspnoea, syncope/presyncope.
• 🚽 Post-tachycardia polyuria ➝ suggests SVT (atrial natriuretic peptide release).
• 🔥 Screen for hyperthyroidism (sweats, tremor, weight loss).
• ❤️ Enquire about history of structural heart disease or family history of SCD.

❓ Key Questions to Ask

• 🔂 Single skipped beat or prolonged episodes?
• 📏 Rate regular or irregular? (patient taps it out)
• 😮‍💨 Associated symptoms: breathlessness, presyncope, syncope.
• ⏱️ Duration and frequency of episodes.
• 📍 Circumstances: exertion, rest, sleep, alcohol, stimulants.
• ⚖️ Relieving factors: Valsalva manoeuvre, rest, anxiolytics.

🔬 Investigations

• 🧪 Bloods: FBC (anaemia), U&E (electrolytes), LFT, TFT (thyroid disease), ESR/CRP (systemic).
• 📉 ECG during palpitations is diagnostic gold standard. If captured, it can confirm AF, SVT, VT, or ectopics.
• 📊 Ambulatory monitoring: 24hr Holter ➝ 7-day patch ➝ event recorder.
• 📍 Implantable loop recorder for rare but severe events (esp. with syncope).
• ⚡ Electrophysiological studies for precise diagnosis if ablation considered.
• 🩺 Consider echo if structural disease suspected (valve disease, cardiomyopathy).