Overview
Definition:
Palpitations are the perception of one's own heartbeat, often described as a forceful, rapid, or irregular beating of the heart
In adolescents, this symptom can be benign or indicative of an underlying cardiac or systemic condition requiring investigation.
Epidemiology:
Palpitations are a common complaint among adolescents, with estimates of prevalence varying widely
A significant proportion of these complaints are functional or benign
Cardiac arrhythmias are the most concerning etiology, with supraventricular tachycardias (SVTs) and atrial fibrillation being notable causes.
Clinical Significance:
Accurate diagnosis of the cause of palpitations in teens is crucial for appropriate management, prevention of complications such as syncope or heart failure, and reassurance for patients and families
Distinguishing benign causes from potentially serious arrhythmias is a key clinical skill for pediatricians and residents preparing for DNB and NEET SS exams.
Clinical Presentation
Symptoms:
The patient may report a racing sensation
A fluttering feeling in the chest
Skipped beats
Pounding in the chest
Episodes may be intermittent
Associated symptoms can include lightheadedness
Dizziness
Shortness of breath
Chest discomfort
Syncope is a red flag.
Signs:
A thorough physical examination is paramount
Assess vital signs: heart rate, blood pressure, respiratory rate
Auscultate heart sounds for murmurs, gallops, or extra sounds
Palpate peripheral pulses for rate and rhythm
Assess for signs of anemia or thyroid dysfunction
Any abnormality warrants further investigation.
Diagnostic Criteria:
There are no specific diagnostic criteria for palpitations themselves, as it is a subjective symptom
Diagnosis relies on characterizing the symptom, identifying triggers, and correlating findings with objective diagnostic tests like ECG, Holter monitoring, or event monitoring
Guidelines from organizations like the American Heart Association (AHA) or European Society of Cardiology (ESC) provide frameworks for evaluation.
Diagnostic Approach
History Taking:
Detailed history is critical
Ask about the frequency, duration, and character of palpitations
Identify triggers: exercise, stress, caffeine, medications
Inquire about associated symptoms: syncope, presyncope, chest pain, dyspnea
Screen for systemic conditions: anemia, thyroid disease, anxiety
Red flags include syncope, exertional symptoms, a family history of sudden cardiac death, or known congenital heart disease.
Physical Examination:
Systematic cardiovascular examination
Assess pulse rate and rhythm for regularity and character
Listen for irregular rhythms, pauses, or extra sounds
Check for a pulse deficit
Examine for signs of underlying systemic illness such as goiter (thyroid dysfunction) or pallor (anemia)
A normal physical exam in a symptomatic patient often necessitates further ambulatory monitoring.
Investigations:
Initial investigations typically include a 12-lead ECG to capture any rhythm abnormalities
Laboratory tests may include a complete blood count (CBC) to rule out anemia, thyroid function tests (TSH, T3, T4) to exclude thyroid dysfunction, and serum electrolytes
For prolonged or intermittent symptoms, ambulatory cardiac monitoring is essential: Holter monitoring for 24-48 hours, or an event monitor for longer periods when symptoms are less frequent
Echocardiography may be indicated if structural heart disease is suspected.
Differential Diagnosis:
The differential diagnosis is broad
Common causes include supraventricular tachycardias (e.g., AVNRT, AVRT)
Ventricular tachycardias are less common but more serious
Atrial fibrillation
Sinus tachycardia, often exacerbated by anxiety or stimulants
Premature atrial or ventricular contractions (PACs/PVCs)
Non-cardiac causes include anxiety/panic disorder, hyperthyroidism, anemia, hypoglycemia, and certain medications (e.g., decongestants, stimulants).
Comparison Of Monitoring Modalities
Holter Monitor:
A Holter monitor is a portable, battery-operated ECG device worn continuously for 24-48 hours (sometimes up to 7 days)
It records all cardiac electrical activity over this period, allowing for detailed analysis of heart rhythm
It is most effective for patients with frequent or near-daily palpitations.
Event Monitor:
An event monitor is a portable ECG device that patients activate when they experience symptoms
It records ECG data only during symptomatic episodes and for a short period before and after activation
These can be worn for weeks or even months and are useful for less frequent but bothersome palpitations.
Indications For Use:
Holter monitoring is indicated for frequent symptoms occurring daily or several times a week
Event monitoring is preferred for infrequent symptoms occurring less than daily but regularly enough to warrant investigation over a prolonged period
If symptoms are extremely rare or associated with syncope, an implantable loop recorder might be considered.
Yield And Limitations:
Holter monitors have a high diagnostic yield for symptomatic patients with frequent events
However, if the patient is asymptomatic during the monitoring period, the yield is low
Event monitors are less likely to capture an event if symptoms are very brief or infrequent, potentially leading to a false negative if the patient does not activate the device correctly or in time
Patient compliance is key for event monitors.
Management
Initial Management:
Management begins with a thorough history and physical examination
Reassurance is often a significant part of management if a benign cause is identified
For symptomatic patients, identifying and avoiding triggers (e.g., caffeine, stimulants) is the first step
If an underlying cardiac arrhythmia is identified, management is directed at that specific condition.
Medical Management:
For symptomatic arrhythmias, pharmacological therapy may be initiated
Beta-blockers (e.g., propranolol, metoprolol) are often first-line agents for rate control and symptom management
Calcium channel blockers (e.g., verapamil, diltiazem) can also be used
Antiarrhythmic drugs (e.g., amiodarone, flecainide) are reserved for more severe or refractory cases, with careful consideration of pediatric-specific dosing and potential side effects.
Surgical Management:
Catheter ablation is a curative option for certain supraventricular tachycardias (e.g., AVNRT, AVRT) and can be considered for symptomatic ventricular arrhythmias
This procedure involves ablating the abnormal electrical pathway using radiofrequency energy
It has a high success rate and is generally well-tolerated in adolescents.
Supportive Care:
Supportive care involves patient education regarding triggers and lifestyle modifications
For anxiety-related palpitations, cognitive behavioral therapy (CBT) and counseling can be highly effective
Regular follow-up to assess symptom control and medication efficacy is essential
Education on when to seek immediate medical attention is also crucial.
Complications
Early Complications:
Early complications are rare but can include syncope due to a sustained arrhythmia
Palpitations can lead to significant anxiety, impacting quality of life and school performance
In rare cases, a rapid and sustained arrhythmia can precipitate heart failure or even sudden cardiac death, particularly if there is an underlying structural heart disease.
Late Complications:
Late complications are typically related to the underlying cause of the palpitations if left untreated
Chronic, uncontrolled arrhythmias can lead to atrial or ventricular remodeling, heart failure, and an increased risk of thromboembolic events, though this is less common in the pediatric population compared to adults
Persistent anxiety can lead to long-term psychological distress.
Prevention Strategies:
Prevention focuses on early and accurate diagnosis
For identified arrhythmias, appropriate medical or interventional therapy is key
Lifestyle modifications, such as avoiding triggers and managing stress, are important preventive measures
Screening for underlying cardiac conditions in high-risk individuals can prevent catastrophic outcomes.
Prognosis
Factors Affecting Prognosis:
Prognosis is generally excellent for most benign causes of palpitations
For identified arrhythmias, prognosis depends on the type of arrhythmia, presence of structural heart disease, and response to treatment
Factors indicating a poorer prognosis include syncope, significant structural heart disease, and sustained ventricular arrhythmias.
Outcomes:
The majority of adolescents with palpitations, especially those with functional causes, experience resolution of symptoms with reassurance and lifestyle adjustments
Patients undergoing successful ablation for SVTs typically have a complete cure
Long-term outcomes for managed arrhythmias are generally good, allowing for a normal lifestyle.
Follow Up:
Follow-up protocols vary based on the diagnosis
Patients with benign palpitations may only require occasional check-ups
Those with identified arrhythmias on Holter or event monitoring will require regular cardiology follow-up to assess symptom recurrence, monitor for adverse effects of medications, and evaluate the need for ongoing or advanced treatment such as ablation
This is crucial for DNB and NEET SS exam preparation.
Key Points
Exam Focus:
Differentiate between benign and malignant causes of palpitations
Understand the indications for Holter vs
event monitoring in adolescents
Recall common pediatric arrhythmias like SVT
Be aware of red flags like syncope, chest pain, and family history
DNB/NEET SS often test management algorithms.
Clinical Pearls:
Always consider non-cardiac causes like anxiety, hyperthyroidism, and anemia
A normal resting ECG does not rule out an intermittent arrhythmia
Patient education and reassurance are powerful therapeutic tools
Event monitors require excellent patient compliance.
Common Mistakes:
Over-reliance on resting ECG for intermittent symptoms
Inadequate history taking regarding triggers and associated symptoms
Misinterpreting benign ectopy as clinically significant
Delaying referral to cardiology for concerning symptoms like syncope or exertional palpitations.