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Initial Differential Diagnoses
On the whole, the patients heart skipping a beat may be associated with the following conditions: heart palpitations, atrial fibrillation (AF; a type of supraventricular tachycardia, SVT), and paroxysmal supraventricular tachycardia (PSVT, another type of SVT; Chopra, Chandra, Wander, & Kumar, 2017; Peritz, Howard, Ciocca, & Chung, 2015).
Pathophysiology
Heart palpitations: the normal rhythm of the heart is disrupted by a premature beat, which may arise either from the atria or from the ventricles, and might be caused by the sympathetic nervous system (Crawford, 2017).
AF: electrical charges emerge from the atria and travel to the ventricles very frequently and in a disorganized manner; the myocardium is unable to contract with such frequencies, and only responds to some of the waves in an arrhythmic manner; the valves close and open chaotically (Chopra et al., 2017).
PSVT: there are abnormalities in the formation or conduction of electric charges; e.g., if the conduction pathways near the atrioventricular nodes have different conduction velocities, this results in complex narrow tachycardia (Al-Zaiti & Magdic, 2016).
History Questions
Asking the patient about her history of cardiovascular diseases is possible, but will not allow for differentiating between conditions, for all the three stated conditions may occur in individuals without any special history (Al-Zaiti & Magdic, 2016; Crawford, 2017). The patient can be asked to describe her feelings in more detaile.g., when the skipped beats occur, are there any ways to dispose of the feelings, does the patient intake caffeine, etc.
Components of PE
It will be difficult to rule in or out of the heart palpitations via a physical exam since the symptoms only occur randomly from time to time. As for AF, it is useful to check the pulse (it should be frequent and arrhythmic), the presence of the peripheral pulse (some beats of the heart may fail to produce peripheral pulse), the sounds and murmurs of the heart (their intensity and timing may be changing all the time; Chopra et al., 2017). When it comes to PSVT, a physical examination may also yield no remarkable results (Al-Zaiti & Magdic, 2016).
Expected History and PE Findings
Heart palpitations may be the most likely condition, since AF often causes symptoms, and PSVT might also cause some additional symptoms. If the patient has heart palpitations, it is likely that she will have no specific history or signs detected via PE. However, PE may help rule out AF (Crawford, 2017).
Study to Confirm Diagnosis
To confirm heart palpitations, it will be needed to subject the patient to 24-hour (or longer) electrocardiogram monitoring. This is because the palpitations can be seen on ECG, but they only occur occasionally, so constant monitoring is needed to detect them when they take place (Peritz et al., 2015). An echocardiogram may also be recommended to find out if there are any anatomic issues with the heart, for these may be present sometimes (Crawford, 2017).
Also, a simple 12-lead ECG may help detect AF or PSVT and differentiate between them (Crawford, 2017).
Selecting Treatment
It will be needed to find out the cause of heart palpitations and address them. The treatment will depend on the cause; for instance, anatomic defects of the heart will require treatment depending on the specifics of these defects. Completely different treatments will be needed if the palpitations result from inappropriate stimulations coming from the vagus nerve; it is possible that the parasympathetic nervous system, in general, may need to be addressed (Crawford, 2017).
Patient Education
It should be explained to the patient that heart palpitations occur when the heart executes a beat too early before it is filled with blood, so the beat is not perceptible. The continuous 24-hour-long ECG monitoring will allow for recording the beats of the heart, and it is needed because palpitations may occur at random times and are difficult to catch. The follow-up includes visiting the medic after the ECG monitoring, confirming the diagnosis, and finding out its causes. The drugs and treatment will be prescribed based on the causes of the condition (Crawford, 2017).
References
Al-Zaiti, S. S., & Magdic, K. S. (2016). Paroxysmal supraventricular tachycardia: Pathophysiology, diagnosis, and management. Critical Care Nursing Clinics, 28(3), 309-316.
Chopra, H. K., Chandra, P., Wander, G. S., & Kumar, V. (Eds.). (2017). Atrial fibrillation update: A textbook of cardiology. New Delhi, India: Jaypee Brothers Medical Publishers Ltd.
Crawford, M. H. (2017). Current diagnosis and treatment: Cardiology (5th ed.). New York, NY: McGraw-Hill Education.
Peritz, D. C., Howard, A., Ciocca, M., & Chung, E. H. (2015). Smartphone ECG aids real time diagnosis of palpitations in the competitive college athlete. Journal of Electrocardiology, 48(5), 896-899.
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