KEYWORDS: ..“가슴이 두근거린다.” “가슴이 떨린다.” “심장이 멈추는 것 같다.” “박동이 건너뛰는 것을 느낀다.”라고 표현한다. ..심계항진은 불안증,우울증,공황장애와 같은 정신적인 문제가 원인인 경우가 가장 많다. 이때엔 심박수가 정상이거나 약간 증가하고 리듬은 규칙적이다. ..실제 임상에서 Chest pain 다음으로 Cardiologist에게 많이 의뢰하게 되는 원인 이다. ..생명을 위협하는 심장문제 때문에 심계항진이 생기는 경우는 드물며, 오히려 심각한 상태를 두려워하는 마음이 더욱 심계항진을 악화시킨다. 1. Can you tap out the rhythm or fluttering you feel in your chest? 2. Do you feel any chest pain or shortness of breath during your palpitations? 3. Do you feel dizzy or light-headed, or even pass out, when you have symptoms? 4. Are there any particular triggers to your symptoms? Causes of palpitation 1. Sinus Tachycardia 유발원인 - anxiety, panic disorder, exercise, heat, stress, post menopause 2. Drugs - alcohol, smoking, coffee, tea, epinephrine, aminophylline, atropine 3. Cardiac output 증가상태 - hyperthyroidism, hypoglycemia, anemia, pregnancy 4. Arrhythmia (AF, SVT, VT), hypokalemia, hypomagnesemia, pheochromocytoma, 저산소증 Palpitation Key Questions EKG (Holter monitors ) Additional test to consider CBC / TFT / Electrolyte / Chest X ray Echocardiogram / EP test ..140 beats/m 이하의 HR는 보통 benign etiology를 시사하며 증상은 wax and wane 양상을 띤다. ..Palpitations시 heart rhythm의 건너뜀은 arrhythmia의 존재를 시사한다. 29 The Root of ambulatory care Key test ECG Findings Condition Suggested Etiology Short PR interval, delta waves Wolff-Parkinson-White syndrome Atrivoventricular re-entrant tachycardia P mitrale, left ventricular hypertrophy(LVH), Left atrial abnormality Atrial fibrillation Atrial premature depolarizations Marked LVH, deep septal Q waves in Hypertrophic obstructive Atrial fibrillation I, aVL and V4~6 cardiomyopathy Ventricular premature depolarizations, Idiopathic VT, right ventricular Left bundle-branch block with positive axis outflow tract type (in patients without structural heart disease) Ventricular premature depolarizations, Idiopathic VT, left ventricular type Right bundle-branch block with positive axis (in patients without structural heart disease) Q waves Prior myocardial infarction VPCs, nonsustained or sustained VT Complete heart block Complete heart block VPCs, polymorphic VT(torsade de pointes) Long QT interval Long QT syndrome Polymorphic VT Inverted T wave in V2, Arrhythmogenic tract ventricular VT with or without epsilon wave dysplasia Palpitation ..Occasional premature heartbeats are harmless and require no treatment other than reassurance. ..Decreasing stimulants in the patient's diet is a simple intervention that can be done on the first visit. ..Idiopathic inappropriate sinus tachycardia인 경우 β-blockers 사용을 고려해 볼 수 있으나, 이 경우에도 secondary cause를 반드시 배제해야 한다. Palpitations Detailed history / Physical examination / 12-lead ECG / Limited lab, tests : TFT, CBC(Anemia), Electrolyte(Potassium, Magnesium) Sustained arrhythmia or poorly tolerated (syncope or presyncope) High risk for arrhythmia : Scar from prior myocardial infarction Idiopathic dilated cardiomyopathy Clinically significant valvular regurgitant or stenotic lesions Hypertrophic cardiomyopathy OR Low risk but history or ECG suggestive of arrhythmia Not suggestive of arrhythmia (unsustained and well tolerated) Observe/reassure Persistent symptoms or patient anxiety about diagnosis Ambulatory ECG Ambulatory ECG An episode of palpitations is rarely captured on a routine ECG. Electrophysiology consult with or without prior ambulatory ECG monitoring Fig 1. Algorithm for evaluation of palpitations 31 The Root of ambulatory care Risk factors : thromboembolism include heart failure, LVEF less than 35%, thyrotoxicosis, or history of hypertension. < Risk-based approach to antithrombotic therapy in chronic atrial fibrillation> Patient features Antithrombotic therapy Age h 60 years : No heart disease Aspirin 325mg daily or no therapy Age h 60 years : Heart disease but no risk factors Aspirin 325mg daily Age ≥ 60 years : No risk factors Aspirin 325mg daily Age ≥ 60 years : With diabetes or CAD Warfarin(INR 2.0~3.0) addition of Aspirin 81~162mg/day optional Age ≥ 75 years : especially women Warfarin(INR ~2.0) Warfarin (INR 2.0~3.0) Any age patient with Heart failure LVEF ≤ 35% Thyrotoxicosis Hypertension Warfarin (INR 2.5~3.5 or higher may be appropriate) Rheumatic heart disease(mitral stenosis) Prosthetic heart valves Prior thromboembolism Persistent atrial thrombus on transesophageal echocardiography 참고 문헌 D. Mike Hardin, Jr., M.D. : Palpitations, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D. (ed). United States of America, The McGrwa-Hill Companies, Inc., 2005, P 300-306 James D. Alexander : Palpitation, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 285-287 김철환 : 심계항진, in 가정의학 임상편. 서울, 계측문화사, 2002, P 611-613 Martin S. Lipsky, M.D., Mitchell S. King, M.D. : Palpitations, in Blueprints in Family Medicine. Massachusetts, Blackwell Publishing, 2003, P 83-85