Chapter Title: Evaluation and Management of Perceived Strong Heartbeats with Normal Heart Rate
Introduction to Pathophysiology
- The American College of Cardiology describes ventricular or atrial extrasystoles as pauses or missed beats followed by the sensation of a strong heartbeat, which represents the post-extrasystolic contraction with increased stroke volume due to greater ventricular filling during the compensatory pause 1, 2, 3
- The perception of a strong heartbeat and the ability of others to feel it easily suggest vigorous post-extrasystolic contractions 1, 3
Diagnostic Considerations
- A normal frequency of 60-70 bpm excludes tachycardia as the primary cause 4, 5
- The sensation of a strong heartbeat corresponds to the post-extrasystolic contraction, which is the most common cause of perceived strong heartbeats with a normal heart rate 1, 2, 3
Differential Diagnosis
- Anemia can increase cardiac output to compensate, leading to a strong heartbeat sensation 6, 7
- Hyperthyroidism causes a hypermetabolic state, which can lead to a strong heartbeat sensation 6, 7
- Fever or infection can increase the demand for cardiac output, resulting in a strong heartbeat sensation 6, 7
- Anxiety or adrenergic stimulation can increase contractility, leading to a strong heartbeat sensation 8
Clinical Evaluation
- The American College of Cardiology recommends a specific clinical history, including pattern of onset, duration, and frequency of episodes, as well as associated symptoms such as dizziness, presyncope, syncope, chest pain, and dyspnea 1, 2, 3
- The European Heart Journal suggests examining for signs of structural heart disease, such as cardiac murmurs, gallop, or signs of heart failure 2, 9
- The American College of Cardiology recommends a 12-lead ECG to identify extrasystoles, pre-excitation, or underlying structural anomalies 2, 9
Diagnostic Investigations
- A 24-hour Holter monitor is essential to quantify the number of extrasystoles and correlate symptoms with arrhythmias 2, 9
- An echocardiogram is necessary to exclude hypertrophic cardiomyopathy and evaluate ventricular function 2, 9
Management
- The European Heart Journal recommends treating the underlying cause, such as anemia, hyperthyroidism, or infection 6, 7
- The American College of Cardiology suggests lifestyle modifications, such as reducing caffeine, alcohol, and stress, for patients with extrasystoles in a structurally normal heart 1