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S2D: The Symptom to Diagnosis Podcast - Episode 35: Palpitations
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S2D: The Symptom to Diagnosis Podcast - Episode 35: Palpitations
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[upbeat intro music] [upbeat intro music] [upbeat intro music] [Dr. Cifu] I'm Adam Cifu. [Dr. Stern] And I'm Scott Stern. [Dr. Cifu] And we're here with another episode of S2D, the Symptom to Diagnosis podcast. This podcast teaches evidence-based strategies for diagnosing common medical symptoms.
We begin each episode with a case unknown to one of us. We then discuss five high yield features that help to accurately diagnose the cause of the symptom at hand. We then return to our case before finishing up with a discussion of fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge. The cases that we discuss are drawn from our clinical experiences, but because protecting patient privacy is part of our oath, we never discuss actual patients.
What are we talking about today, Scott? [Dr. Stern] Well, be still my beating heart, we're talking about palpitations and you are the expert of the day so do you have a case to present to me? [Dr. Cifu] I do, I do. So this is a 70-year-old woman. Imagine, she's healthy and she's coming to see you for routine follow-up. You know her well. You've taken such good care of her that she really is fine, has no medications, nothing, but she comes in today with palpitations.
She noted them probably about three months ago at night, she said is when she first felt them, she felt them mostly when she was lying on her left side. More recently and that's probably for maybe the last month, she's been troubled by them mostly when she exercises, and she says sometimes actually when she exercises and she gets the palpitations, she actually feels some chest pressure as well. That's about it.
[Dr. Stern] Well, that's a little scary. [Dr. Cifu] Okay. [Dr. Stern] So palpitations are common and I would say the overwhelming majority of patients, they're pretty benign, often associated with PACs or PVCs even though patients say they skipped a beat, but several things you've told me worry me. Not the fact that she notices them more when she lays on her left side, because the heart's closer to the chest many patients are going to notice their heart beating more on their left side, but the fact that it sounds like they can last for a period of time and she's getting them when she exercises is worrisome because most of the time exercise will increase your sinus rate and decrease the amount of ectopy that patients feel.
And the fact they're associated with chest pressure is particularly concerning and so the thoughts that come to my mind are one of two things. Either she's having an arrhythmia that's fast or slow enough to cause angina or she's having ischemia and the arrhythmia is a manifestation of the ischemia. [Dr. Cifu] Got it. [Dr. Stern] So pretty worrisome. I would think about atrial fibrillation because it's very common, I would think about ventricular tachycardia.
Atrial fibrillation would not typically be precipitated by exercise, V-tach if she was ischemic- - [Dr. Cifu] Sure. - [Dr. Stern] -could be. She may have some form of heart block and so when she exercises, she's not able to accelerate her heart rate enough and notices chest pain then, but this is definitely one of those patients with palpitations where I would work her up in a pretty careful way and I would certainly start with- And you know, obviously her physical exam, I'm going to want to make sure she doesn't have aortic stenosis or something serious and what is her rhythm while you're seeing her? Although that won't tell us much- - [Dr. Cifu] Got it. - [De. Stern] -but an EKG, probably an event monitor, an echo and probably given the chest pressure with it if it's not immediately clear to me what's going on, some form of stress testing.
[Dr. Cifu] Okay, okay. I'm trying to think, is there anything specific when you're examining this woman that you would focus on, kind of given where you are with your differential diagnosis and everything? [Dr. Stern] Well, so clearly I want to know what her heart rate and blood pressure is, right? And I want to know whether it's regular or irregular. Clearly I want to know about murmurs or any signs of heart failure.
Heart failure clearly increases the risk for serious arrhythmia, so if she had an S3 or a JVD, or a lot of edema, I'd be worried. If she's got a significant systolic murmur, critical AS could present this way. I guess, would anything else come to mind? I mean, someone could be hyperthyroid, it's conceivable if she was very hyperdynamic and tachycardic, I might think about that but that'll be it.
[Dr. Cifu] Great. I wanted to also point out one other thing. It seems like you suggested when you were talking about lying on the left side of her in bed, I think you kind of reasoned through some anatomy and it sounds like that the heart's on the left side of the chest? [Dr. Stern] Yeah, and I think as you lay to your left side, it particularly swings to the left side.
I'll double check my old anatomy book and dig it out of the formalin it's in. [Dr. Cifu] I was just impressed. Okay, let's stop there actually because the case is pretty short and I'll save the vital signs, physical exam and everything until after we do some key points. [Dr. Stern] All right, so do you have five key points to tell us about palpitations?
[Dr. Cifu] I do, I do. [Dr. Stern] Okay. [Dr. Cifu] So I'm going to start with point one is the differential diagnosis. And this is because I think we all jump to cardiac cause of palpitations immediately, but we should sort of give a pause and say there is a differential diagnosis. The big things on the differential diagnosis are I think, cardiac causes, arrhythmia as you said sort of way up front, mitral valve prolapse is always thrown out as a cause of palpitations that people at least feel more, pacemaker dysfunction if someone has a pacemaker that I think is a lot less common these days with how good pacemakers have become.
High output states which you mentioned, pregnancy, anemia, fever, endocrinologic causes, hyperthyroidism, hypoglycemia, right? If you have someone who's diabetic and is dropping their glucose, they'll get a catecholamine surge and palpitations with that. Fourth category, catecholamine so just stress, exercise, that's usually not really a diagnostic dilemma.
Substances of all kinds which I think we'll sort of get into more later, but certainly caffeine and cocaine jump to the top of the list. Psychiatric, right? Panic disorder, anxiety disorder, common. And so since I'm just trying to give you a mnemonic every week these days, I came up with a mnemonic which is CHEKSP, that is C-H-E-K-S-P, and that's cardiac, high output states, endocrine, catecholamine, substances, psychiatric - CHEKSP.
[Dr. Stern] And I think that's about as valuable as most mnemonics I've heard, meaning it's completely useless, but okay, if the listeners like it, fine. I would add two things to what you mentioned. One is substances, people have to remember alcohol, too. [Dr. Cifu] Yep. [Dr. Stern] Even just binging the night before, drinking the night before can often precipitate palpitations or AFib.
And also psychiatric disorder, so the tough part about that, right, is what's the chicken and the egg. And so I just want to remind everyone that a lot of palpitations and cardiac symptoms make people feel anxious. So the fact that someone comes in feeling anxious, doesn't prove it was the anxiety causing the palpitations, it maybe a consequence of the palpitation, so be careful. [Dr. Cifu] Right. So it's like anxiety with asthma as well, where like there's nothing like an asthma flare, asthma attack to get you feeling anxious.
[Dr. Stern] Right. [Dr. Cifu] And yes, panic disorder can make people feel short of breath, but shortness of breath can certainly make - people feel anxious. - [Dr. Stern] Dizziness - as well. - [Dr. Cifu] Yes. [Dr. Stern] You know, I often tell our students that remember that people who are anxious are still going to die like everyone else, and so that means sooner or later they're going to have something serious.
[Dr. Cifu] Right. [Dr. Stern] And I'm waiting to have something serious so I can show up with it to you and see if you can figure it out. [Dr. Cifu] It's that classic gravestone of the hypochondriac which says on it like, "I told you I was sick." [Dr. Stern chuckles] Never heard that one. [Dr. Cifu] I'm going to throw out one more story at the risk of getting way far off.
You talked about alcohol. Alcohol classically a cause of atrial fibrillation, right? Holiday heart, actually quite potent at that. And I always remember that because when I started my internship, the first person I admitted, I started at a VA hospital, a veteran's administration hospital, first person I admitted was on July 4th, okay? Where the guy drank, he got Afib, and as I looked through his chart, the last time he was admitted with AFib was on Memorial Day.
[Dr. Stern] Oh my goodness, that's a riot. You should have written him up. [Dr. Cifu] I was like, ah, this so perfect, I know. [Dr. Stern] Truly the ultimate holiday heart. [Dr. Cifu] Yes, yes. [Dr. Stern] All right, do you have another point for us? [Dr. Cifu] Okay, number two. So though we always think of arrhythmia as I said, cardiac causes interestingly are probably the minority of causes of patients coming in with palpitations.
There's this study from 1996 which is really widely quoted. I think it's because it's maybe the only study that's designed in this way and it was just such a way to answer questions. It took 190 consecutive patients who came in with palpitations and they evaluated these people just to find out like what's sending people into the hospital. And yeah, we're talking 20-30 years ago, so things are going to change somewhat, but it's instructive.
The interesting points of this article are first and foremost, 84% of the patients could be diagnosed with a cause of their palpitations. So it makes you understand that most people who come in with palpitations, you'll be able to give them a definitive diagnosis. And that's actually more than a lot of the things we talk about. Only a minority of the patients, 43% were actually cardiac in origin so the etiology of their palpitation was cardiac, 31% were psychiatric, predominantly panic disorder, 10% were caused by sort of diagnoses across the spectrum.
Substances actually led the list, they talked about caffeine, cocaine, amphetamines as the top there. Hypothyroidism, anemia were other causes. And then as I said, 16% were left undiagnosed. In this population, only about 16% of the patients, their palpitations were caused by atrial fibrillation, atrial flutter which is I think often kind of at the top of our list as kind of a must-not-miss diagnosis.
[Dr. Stern] You know what I wonder about that though in terms of reversing the medical literature is - and I think you know something about that - is the study was done in 1996, which was before we had this armamentarium of long term monitoring that we have now. And so I wonder if the number of arrhythmias would actually be higher today with what we have. [Dr. Cifu] Right. So I bet both the undiagnosed goes down, but I bet buried in probably the psychiatric group- [Dr. Stern] Right, exactly.
[Dr. Cifu] -is a group of people who actually have cardiac arrhythmia. [Dr. Stern] But even if you cut that by half, you're still probably only about 50% cardiac. - [Dr. Cifu] Yeah. - [Dr. Stern] Huh. Okay, so we had a differential and we talked about about half of them being cardiac. What's your third key point? [Dr. Cifu] So my third key point is predictors of cardiac etiology.
As you've heard about what causes these, clearly what's important is not to miss a cardiac cause of palpitations because these can be dangerous arrhythmias. And so there were interesting points from this study about predictors of cardiac etiology and I'm going to give these with the odds ratios, kind of compared to people with non-cardiac causes. So greater than five minute duration had an odds ratio of 5.7, okay?
So someone who says, it's not just a single bum-bum-bum, it's something which lasts, that sounds cardiac. History of heart disease kind of obvious, right? Heart failure, coronary disease. Description of an irregular beat so people who say, I feel tum, tum, tum-tum-tum, tum, tum, tum, tum rather than a regular beat. Male sex 2.6 and though not listed probably just because it was so uncommon in this population, if palpitations are associated with presyncope or syncope, just take that really seriously because that's really when you worry about ventricular tachycardia.
[Dr. Stern] That's great. And I think one thing that you put in there that we didn't actually explicitly say is it really helps to have patients describe explicitly - what they felt. - [Dr. Cifu] Yeah. [Dr. Stern] The most common thing people will say, is it just is a second and it's a flip flop and you're probably not going to find anything, but if they can tap it out on the table for you, that's very helpful, so on.
[Dr. Cifu] Yeah, and certainly when I send people home to say, look, this doesn't sound like something I'm terribly worried about, but I'd like more information, I teach them to take their pulse. These days maybe they've got a watch that can monitor their pulse. And I tap out like, look, this is a regular beat. Feel your pulse, this is regular now, this is what it feels like and then tap out what it'll sound like if it's not regular.
[Dr. Stern] All right, so we're worried about heart disease, syncope, irregular beats and prolonged palpitations. What's your next pivotal point? [Dr. Cifu] So next pivotal point is some of the time if you're lucky, you can actually make a diagnosis in the office using basically just your ears and an EKG machine, right? So things like premature atrial contractions, PAC, premature ventricular contractions, PVCs, you may be able to pick those up because you'll hear that early beat followed by a compensatory pause.
You may feel that or hear that when you're examining the person. Sometimes if you're doing the EKG in your office, just stand there next to it for a little while and let the paper run off for a minute. And if you see the PVC and you can say to the person, "Was that your palpitation?" and they say, "Yes," you've made your diagnosis. Anemia, hyperthyroidism, you mentioned when you went over this case.
And then really, really, really look at your EKG, right? Your EKG is not just to say is this person having VT when I did the EKG? Look for things like Wolff-Parkinson-White, an EKG that's consistent with hypertrophic obstructive cardiomyopathy. Q waves which would suggest coronary disease past MI. Supraventricular or ventricular ectopy we talked about, a prolonged QT interval or various kinds of heart block, which may not be symptomatic when you're seeing the person, but may be symptomatic at other times.
[Dr. Stern] Yeah, that's great. [Dr. Cifu] And then the very last thing is continuous monitoring. You already mentioned this and boy, this is just so useful. The things we have are the classic holter monitor is generally 24-48 hours, and that's for someone who's just having symptoms all the time. We now can very easily do two week or four week continuous and loop event recorders.
Those are wonderful if you're trying to get an arrhythmia or palpitations which is less frequent or if you're trying to figure out what's the burden of this person's atrial fibrillation, something like that. And then now we have these implantable continuous event recorders which are also terrific, usually people describe them as about the size of a pack of gum. They go under the skin in the chest and they're great, last for a couple of years and can monitor people remotely that way.
[Dr. Stern] When would you tend to use that? I mean, I think of that in a person who's having what sounds serious and you haven't been able to diagnose it, so I'm thinking I'm not going to do that routinely, but maybe if I had somebody who the workup is negative, but is really having problematic symptoms associated with it, then it might push me to it. What was your thought? [Dr. Cifu] I agree, so either diagnostically this is someone I'm concerned about and I just can't make the diagnosis or often therapeutically, right?
So this is someone with atrial fibrillation and either you think you've done away with their atrial fibrillation and they're at high risk for anticoagulation. So you're hoping to get them off anticoagulation, but you want to make absolutely sure that they're not having AFib or you're trying to figure - and this is obviously with a cardiologist -, does this person need more aggressive treatment for their atrial fibrillation?
Let's see what their AFib burden is. Are they progressing over time? [Dr. Stern] That's great. All right, so let's go back to our case. Tell me her exam. [Dr. Cifu] Okay, so vital signs, her pulse was 102. [Dr. Cifu] Okay, so vital signs, her pulse was 102. When you look back in the chart, her pulse in the past had averaged kind of in the 70s, low 80s every time you've seen her.
Her blood pressure was normal. She runs sort of 130s/80s and that is as it was. Lungs were clear, head and neck exam was fine, her thyroid exam was fine. Her heart besides being a little bit tachycardic, she was regular and did have a bit of a flow murmur, which when you look back on your notes, you had not documented in the past. So crescendo-decrescendo murmur at the aortic area and the rest of her exam really unremarkable.
and the rest of her exam really unremarkable. [Dr. Stern] So you said she was a little tachycardic, regular? [Dr. Cifu] Tachycardic and regular, yeah. [Dr. Stern] Tachycardic, so presumably, I mean, we'll check this, she has sinus tach now which is peculiar in that it's new and a flow murmur, so it does point to things like anemia. Does she have conjunctival pallor? [Dr. Cifu] Not that was noticed by the physician.
[Dr. Stern] Not that was noticed? So you'd wonder about severe anemia. That could actually explain the chest pressure she has as well if she's trying to exercise and is very anemic, she might have ischemia not because of coronary disease, but because of inadequate oxygen carrying capacity, right? She could be hyperthyroid. I don't think the normal thyroid exam excludes - that in any way. - [Dr. Cifu] Yeah.
[Dr. Stern] She's not febrile, right? So she's not tachycardic from a fever- - [Dr. Cifu] Right. - [Dr. Stern] -or infection that you're aware of, so I'm absolutely still getting that you're aware of, so I'm absolutely still getting the EKG, a CBC, a TSH to add to that. [Dr. Cifu] Yeah. [Dr. Stern] Probably going to get an echo. See what's going on with those initial tests because you're definitely leading me in that way.
[Dr. Cifu] Yeah, so her EKG just showed sinus tach as you said, was otherwise unchanged from an EKG which was done for unknown reasons five years before. Blood tests come back with a normal TSH, a hemoglobin of 6.8 and otherwise things were quite normal. a hemoglobin of 6.8 and otherwise things were quite normal. [Dr. Stern] Well, now we change to our podcast on anemia. [Dr. Cifu] Yes. So we pivot at that point. You cancel the stress test that you've already scheduled for her.
It turns out that she has a large colonic polyp, which has been bleeding and with removal of the polyp and iron supplementation, her palpitations go away. [Dr. Stern] Well, that's great. I mean, she's pretty lucky. That's a good outcome for the various possibilities we were thinking about. [Dr. Cifu] Happy case, right? [Dr. Stern] All right, so let's go on to fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge.
Adam, how about fingerprints? [Dr. Cifu] Yeah, so nothing really for fingerprints. I talked a little bit about odds ratios for things that would hint or suggest a cardiac etiology. I guess we could sort of go back to some of the fingerprints that we'd thrown out in the past for heart failure because really when you're examining someone, you should be looking for these even if you're not thinking about heart failure, because if there's, say, an S3 gallop or a JVD because if there's, say, an S3 gallop or a JVD likelihood ratios of those respectively 11 and 5.1 for heart failure, that would be super important, right?
Because going from someone who just has palpitations to someone who's got heart failure and palpitations make them much, much, much likely to have a cardiac cause and a sinister cause. [Dr. Stern] Right, I mean, as a matter of fact you'd probably say if you had palpitations and known heart failure, you're going to say it's VT until proven otherwise, right? [Dr. Cifu] Sure. Agree. [Dr. Stern] Okay, so and I have another cardiac one which is that if you have a murmur that goes, that is quieter when someone is squatting and increases when they're standing, that would suggest hypertrophic cardiomyopathy because as you remember, when people stand up, their preload drops, as their preload drops, the chamber size decreases which brings the septum and the free wall closer together which makes the stenosis worse and the murmur louder.
And actually the likelihood ratio for that is almost 6. [Dr. Cifu] Right. Just to underline, we always say fingerprints are uncommon, when you find them, you should believe in them. And that's why at podcast number whatever we're up to, 34, 35, we're going back to fingerprints really for other diagnoses because they're so rare. And both of us kind of stretched our definition a little bit, right? We usually say a fingerprint has a positive likelihood ratio above 10, I quoted one that was 5.1, you quoted one that was 5.9 so- [Dr. Stern] Yeah, we'd have to take the fingerprints out of the whole podcast if we stuck to our strict definition.
[Dr. Cifu] We're getting soft. [Dr. Stern] Oh, that's us. All right, common misconceptions, what do you got? [Dr. Cifu] So, how about this? I'm going to give you an analogy, okay? [Dr. Stern] Go ahead. [Dr. Cifu] So common misconception is that palpitations are to long duration cardiac monitoring as dysphasia is to an EKG. What I mean by that is- - [Dr. Stern] EGD? - [Dr. Cifu] EGD.
[Dr. Stern] Okay. [Dr. Cifu] What I mean by that is this, when we talked about dysphasia, we were sort of like you hear dysphasia, you're probably going to scope the person. Not really true with palpitations that you're going to get long duration cardiac monitoring because you can really think about the cause of palpitations. you can really think about the cause of palpitations, you can often make a diagnosis without that.
Often that's not even the right test to do. And so although it's so easy to get, it's even pretty easy for the patient to wear the Zio patches and event recorders these days, you can often do without it. [Dr. Stern] Now, that's provided though that the patient does have underlying heart disease, agreed? - [Dr. Cifu] Agreed. - [Dr. Stern] Okay. So my common misconception which I actually didn't understand as a medical student is that the patient can have a completely normal EKG when you see them and still have intermittent life-threatening arrhythmias.
So the thing that's shocking is that VT can self-terminate and so can bradyarrhythmias, they can be transient. And so patients can have very severe and even life-threatening arrhythmias come in to see you and they're in completely normal sinus rhythm. So you cannot take a normal EKG and say, well, they don't have V-tach, they don't have heart block because it may have been transient. [Dr. Cifu] What if they have VT on their EKG when you see them?
[Dr. Stern chuckles] Call a code, get somebody there with some paddles, that's what I would say. And then I would probably take something myself to calm myself down. [both chuckle] [Dr. Stern] All right, pet peeves. [Dr. Cifu] So this is an interesting one, you ready? [Dr. Stern] Okay, go on. [Dr. Cifu] You think that my pet peeve is going to be the Apple watch, don't you?
[Dr. Stern] I would, yeah. [Dr. Cifu] And you think that because-? [Dr. Stern] You love watches and you hate electronic watches. [Dr. Cifu] So on the one hand I'm a mechanical watch guy and so Apple watches kind of drive me crazy, but the other thing is that I went into Apple watches but the other thing is that I went into Apple watches very worried that they were going to be pitched as we should all be doing constant monitoring for atrial fibrillation.
And I worried what that would do because I thought what it would do is we turn up a lot of really, really, really rare atrial fibrillation, you know, people whose burden was really low, we're at a time where anticoagulation is so much easier than it was 10 years ago, right? We don't need to use warfarin, we don't need to check INRs. And there are companies which are still making money, right? Of the DOACs and so I thought what's going to happen is, oh my God, we're going to be picking up really infrequent Afib, drug companies are going to be pushing to treat this.
We're not going to know if the treatment helped and what's going to happen is we're just going to have a whole lot of CNS bleeds without decreasing stroke from AFib, but in fact, I don't think that's happened. And I think what has happened is that the are a lot of people who've got low risk palpitations and Apple watches, people who've got low risk palpitations and Apple watches, you might not know this, Dr. Stern, but are the most common watch sold in the world these days.
And so there's so many people with this device which is very accurate for rhythm and you can tell people, "Hey, when you have this do an EKG on your Apple watch and you can send me the PDF of it and it's kind of a wonderful tool." [Dr. Stern] Okay, well, I'll go to the store next and get myself an Apple watch so that I'll send you daily reports on my EKG reading so that you can put me on anticoagulation for my next bike ride, how's that?
[Dr. Cifu] I would love to see that. [Dr. Stern] All right, so- [Dr. Cifu] Do you have a pet peeve? [Dr. Stern chuckles] No, I don't. [Dr. Cifu] I drew mine out and it was a negative pet peeve so I think that's fine. [Dr. Stern] All right, how about pearls? [Dr. Cifu] Okay, I think maybe we've beat this to death. It's really worth emphasizing that you got to ask people about any substance you can think of that might be kicking off their palpitations.
So have you changed how much caffeine you drink? Have you changed what kind of coffee you drink? Ask about alcohol. People are always... Not always, people are sometimes a little bit squirrely about admitting to their alcohol use and then ask specifically about other substances, decongestants, cocaine, methamphetamines, anything that can sort of rev people up. [Dr. Stern] I love that about the different types of coffee you can drink because some of those now really carry a kick, I like that.
[Dr. Cifu] No question, no question. [Dr. Stern] All right, well, my pearl has to do with what you might think periodically about getting an echocardiogram because as we've already said heart failure markedly increases the likelihood of a life-threatening arrhythmia, and the physical exam although there are some fingerprints that are very specific, it's fairly insensitive. There was a study done of people where they looked at heart failure and they not only showed that they had heart failure, but these were people whose wedge pressure was over 22.
So very high wedge pressures and still a large number of them didn't have any findings that suggest a heart failure. They saw edema in 50%, but that means 50% didn't. JVD in 39% and an S3 gallop in only 13%. So it wouldn't take a lot for me to be pushed to get an echocardiogram in somebody who's having palpitations because I can risk stratify them in part based on that. [Dr. Cifu] I buy all that, I'll push back a little bit because I often think the trainees feel like they don't really know a patient until they have an echo.
And the fact is, I mean, it is the rare patient And the fact is, I mean, it is the rare patient who not only do not know they have heart failure because of their symptoms and signs, but also they don't even have a history that would make you think that this person might have heart failure, right? And getting an echo in those people as a test to work up palpitations though I totally understand where you're coming from, maybe a little bit of a stretch.
[Dr. Stern] So maybe we could define it a little better. So the things that would make me less worried would be the people who say it lasts for a second. [Dr. Cifu] Yeah, yeah, yeah. [Dr. Stern] The things that would make me more worried are things you mentioned, prolonged. [Dr. Cifu] Yeah, yeah, yeah. [Dr. Stern] You did mention risk factors for heart disease so I think that's appropriate.
So if somebody has longstanding hypertension, that's not well-controlled, if they have any coronary disease whatsoever, I probably would think that's appropriate or I guess the other thing would be how symptom-limited are they in general life? So if they say, the guy can go out and run five miles, it's unlikely he's got heart failure, if they're sedentary, you'd be less sure.
[Dr. Cifu] Great, and I know that you are saying this, but I'll underline, is that your echo is an add-on test to your evaluation of the person's rhythm, right? [Dr. Stern] Totally, totally. Right, because if I don't find anything on, let's say, I did a 48-hour monitor, but they had heart failure, I know I need to go further, right? Whereas if they have a normal EF and I found nothing on the 48-hour monitor and their palpitations didn't sound serious, I might just stop there.
[Dr. Cifu] You got it. Okay, I got another clinical pearl and we're getting I think to the part in the podcast where we're getting to much rare things, but when you're taking a history of palpitations, ask people if their palpitations are induced by exercise or even startle, okay? Exercise is because if you hear someone who gets palpitations with exercise, you got to think about coronary disease and oh man, if someone's exercising, getting ischemic and then having palpitations, you got to worry a lot that that's like polymorphic ventricular tachycardia and a bad thing, right?
And then startle, sort of interesting, I don't think I've ever seen this as a non-electrophysiology doctor, but exercise or emotionally startling experiences doctor, but exercise or emotionally startling experiences causing palpitations can suggest long QT syndromes. And that's where people get polymorphic VT, classically Torsades which is kicked off by being frightened. [Dr. Stern] And I have one other comment to make which is, we've talked a lot about substances, but we haven't probably emphasized medications enough.
So there's a large number of medications that are pro-arrhythmic including things that seem pretty benign, some of the antihistamines, some of the fluoroquinolones and antibiotics as well as a variety of psychiatric medications. So you really want to look at the QT interval and review the medications to make sure that they're not on anything that's predisposing them to serious arrhythmias.
[Dr. Cifu] Yeah. I think that's gotten for me to be sort of like the medications I keep tucked in my head for like I always have to think about interactions when I use these or I always have to think about re-dosing these for renal insufficiency. Now, I've got that bunch of medications that like, boy, I really got to think about QT prolongation with these medications. [Dr. Stern] Right, and there's a lot of them now.
[Dr. Cifu] Totally. I got to say, our residents are amazing at this. I think they're always a step ahead of me on this, kind of on the wards where I suggest anything and they like have somehow memorized every patient's QT interval to push back at me. [Dr. Stern chuckles] [Dr. Cifu] Either that, or they're just trolling me. Okay, so we hope you found this episode of the Symptom to Diagnosis podcast useful and a bit enjoyable.
As a reminder, our textbook, Symptom to Diagnosis An Evidence-Based Guide takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations. The book is available in print, on your handheld device, and in a fully searchable mode via the AccessMedicine website available worldwide from McGraw Hill. The music for this podcast, the S2D podcast is courtesy of Dr. Maylyn Martinez.
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