Symptom Finder - Palpitations
PALPITATIONS
Because anxiety is the common cause of palpitations, there is a tremendous temptation to jump to this conclusion as the cause in an otherwise healthy looking individual. If we use the mnemonic VINDICATE, we may avoid a misdiagnosis in many cases.
V—Vascular causes help to recall aortic aneurysms, arteriovenous fistulas, anemia, postural hypotension, migraine, and cardiac disorders such as aortic regurgitation, aortic stenosis, tricuspid insufficiency, mitral valve prolapse, CHF, and various arrhythmias.
I—Inflammation reminds us of fever, pericarditis, subacute bacterial endocarditis, and rheumatic fever.
N—Neoplasms are not usually associated with palpitations.
D—Deficiency of thiamine can lead to beriberi heart disease resulting in palpitations.
I—Intoxication prompts us to recall that alcohol, tobacco, coffee, soft drinks, and tea can cause palpitations. It should also remind us that palpitations are common side effects of many drugs, including digitalis, aminophylline, sympathomimetics, ganglionic blocking agents, nitrates, and other drugs.
C—Congenital disorders that may cause palpitations include patent ductus, ventricular septal defect, and hiatal hernia. Disorders of the conduction system such as Wolff–Parkinson–White syndrome should be considered here.
A—Anxiety is a common cause of palpitations.
T—Trauma causes palpitations by inducing the release of epinephrine, but there is no diagnostic dilemma in these cases.
E—Endocrine disorders that cause palpitations include thyrotoxicosis, pheochromocytoma, menopausal syndrome, and hypoglycemia.
Approach to the Diagnosis
Valvular heart disease, anemia, and febrile disorders will usually be revealed on physical examination. It is important to inquire about drug, alcohol, and tobacco use. Caffeine is a frequent offender. It is helpful to eliminate any suspicious medications if possible. A drug screen may be useful in many cases. The initial diagnostic workup should include a CBC, chemistry profile, thyroid profile, sedimentation rate, antistreptolysin O (ASO) titer, ECG, and chest x-ray. If these have normal findings, 24- to 48-hour Holter monitoring or continuous loop event recording of the ECG should be undertaken. Be aware of the long QT syndrome when evaluating the ECG.
Other Useful Tests
1. 24-hour urine catecholamine or vanillylmandelic acid
(pheochromocytoma)
2. Arm-to-tongue circulation time (CHF)
3. Echocardiography (CHF, valvular heart disease)
4. Exercise tolerance test (coronary insufficiency)
5. Upper GI series and esophagram (hiatal hernia)
6. 24-hour blood pressure monitoring (pheochromocytoma)
7. Psychometric testing (hysteria)
8. Serum estradiol, follicle-stimulating hormone (FSH), and
luteinizing hormone (LH) (menopause)
Because anxiety is the common cause of palpitations, there is a tremendous temptation to jump to this conclusion as the cause in an otherwise healthy looking individual. If we use the mnemonic VINDICATE, we may avoid a misdiagnosis in many cases.
V—Vascular causes help to recall aortic aneurysms, arteriovenous fistulas, anemia, postural hypotension, migraine, and cardiac disorders such as aortic regurgitation, aortic stenosis, tricuspid insufficiency, mitral valve prolapse, CHF, and various arrhythmias.
I—Inflammation reminds us of fever, pericarditis, subacute bacterial endocarditis, and rheumatic fever.
N—Neoplasms are not usually associated with palpitations.
D—Deficiency of thiamine can lead to beriberi heart disease resulting in palpitations.
I—Intoxication prompts us to recall that alcohol, tobacco, coffee, soft drinks, and tea can cause palpitations. It should also remind us that palpitations are common side effects of many drugs, including digitalis, aminophylline, sympathomimetics, ganglionic blocking agents, nitrates, and other drugs.
C—Congenital disorders that may cause palpitations include patent ductus, ventricular septal defect, and hiatal hernia. Disorders of the conduction system such as Wolff–Parkinson–White syndrome should be considered here.
A—Anxiety is a common cause of palpitations.
T—Trauma causes palpitations by inducing the release of epinephrine, but there is no diagnostic dilemma in these cases.
E—Endocrine disorders that cause palpitations include thyrotoxicosis, pheochromocytoma, menopausal syndrome, and hypoglycemia.
Approach to the Diagnosis
Valvular heart disease, anemia, and febrile disorders will usually be revealed on physical examination. It is important to inquire about drug, alcohol, and tobacco use. Caffeine is a frequent offender. It is helpful to eliminate any suspicious medications if possible. A drug screen may be useful in many cases. The initial diagnostic workup should include a CBC, chemistry profile, thyroid profile, sedimentation rate, antistreptolysin O (ASO) titer, ECG, and chest x-ray. If these have normal findings, 24- to 48-hour Holter monitoring or continuous loop event recording of the ECG should be undertaken. Be aware of the long QT syndrome when evaluating the ECG.
Other Useful Tests
1. 24-hour urine catecholamine or vanillylmandelic acid
(pheochromocytoma)
2. Arm-to-tongue circulation time (CHF)
3. Echocardiography (CHF, valvular heart disease)
4. Exercise tolerance test (coronary insufficiency)
5. Upper GI series and esophagram (hiatal hernia)
6. 24-hour blood pressure monitoring (pheochromocytoma)
7. Psychometric testing (hysteria)
8. Serum estradiol, follicle-stimulating hormone (FSH), and
luteinizing hormone (LH) (menopause)
