今日の臨床サポート

動悸

著者: 武村克哉 琉球大学病院 地域・国際医療部

監修: 徳田安春 一般社団法人 群星沖縄臨床研修センター

著者校正/監修レビュー済:2021/10/27
患者向け説明資料

概要・推奨   

概要:
  1. 動悸とは、通常自覚しない心臓の鼓動を不快に感じる症状の総称である。
  1. 息切れ、呼吸困難、失神などの随伴症状を有する場合は心疾患の有無を必ず確認する必要がある。
  1. 動悸の特徴(どのような動悸か、頻拍や脈不整はあるかなど)を詳細に聴取することは、動悸の原因を探る重要な手がかりとなる。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
武村克哉 : 特に申告事項無し[2021年]
監修:徳田安春 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、概要・推奨、疫学情報・病態・注意事項、問診・診察の項目について加筆修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 動悸はよくみられる症状の一つであり、外来受診患者500人のうち80人(16%)が動悸が主要な問題であると回答したというデータがある。(参考文献:[1]
  1. 動悸の原因として、不整脈などの心疾患、パニック障害などの精神疾患の他、低血糖、甲状腺機能亢進症や褐色細胞腫などの代謝内分泌要因、内服薬、カフェイン、違法ドラッグの影響などが挙げられる。Review of systemsを用いて、幅広い視点で診察する姿勢が大切である。
  1. パニック障害など精神疾患に罹患している患者に動悸が生じた場合には、精神的な部分で症状を自覚することもあるが、上室性不整脈の合併率が高いという報告もある。器質的心疾患が原因で症状が出現している場合もあるため、精神疾患があるからといって、はじめから器質的心疾患を無視してはいけない。
 
  1. 動悸は日常臨床で遭遇する機会の多い、一般的な症状のうちの1つである。また、多くの場合は生命予後に影響を与えないことが知られている。ただし、症状の再発率が高く、仕事の生産性への影響があることが報告されており、生活への影響に配慮する必要がある。(参考文献:[1][2]
  1. 動悸の頻度や予後を検討した疫学研究は、複数行われている。その中で頻度を検討した研究のうちの1つが1990年に発表された。500人の外来受診患者のうち16%の患者の訴えが動悸であり、動悸はcommonな症状であることが示された。また、予後に関して検討された研究のうちの1つが、1987年に発表された。動悸の訴えを持つ109人の患者と年齢、性別をマッチさせた対照群とを平均42カ月間追跡した結果、両群における心疾患の罹患および死亡率に統計的有意差はなかった。動悸はcommon diseaseの1つであり、生命予後にも大きくは影響しない場合が多いことがわかる。ある前向きコホート研究では、動悸を訴えて来院した190人の患者の1年死亡率は1.6%と低いものの、患者の75%が動悸の再発を経験し、患者の19%が仕事のパフォーマンス低下、患者の12%が動悸によって仕事を休み、患者の33%が自宅での仕事の達成度が通常よりも低下したと報告しており、症状の再発率が高く、生産性への影響があることが述べられている。(参考文献:[2]
問診・診察のポイント  
  1. 診察時動悸症状がある場合にはすぐに12誘導心電図検査を行う。もし不整脈が認められれば、患者の血行動態を評価し、不整脈およびその基礎疾患について適切に治療を行う。

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文献 

著者: K Kroenke, M E Arrington, A D Mangelsdorff
雑誌名: Arch Intern Med. 1990 Aug;150(8):1685-9.
Abstract/Text Common symptoms account for substantial patient disability and health services utilization. To determine the prevalence of 15 symptoms and the adequacy of therapy, 500 medical outpatients were surveyed. The 410 respondents indicated which symptoms were "major problems" and what therapy, if any, had been helpful. Each symptom was present in at least 10% of patients, with the most prevalent symptoms being fatigue (33%) and back pain (32%). Patients were clustered into three groups: (1) 140 were asymptomatic or monosymptomatic, (2) 135 reported 2 or 3 symptoms, and (3) 135 had 4 or more symptoms. The majority (77%) of these symptoms had been previously reported to a physician. Whereas 80% of patients with pain syndromes and gastrointestinal complaints had obtained some therapeutic benefit, only 39% of the individuals with fatigue, dyspnea, dizziness, insomnia, sexual dysfunction, depression, and anxiety reported any relief. Better therapy is needed for these common outpatient complaints.

PMID 2383163  Arch Intern Med. 1990 Aug;150(8):1685-9.
著者: M P Knudson
雑誌名: J Fam Pract. 1987 Apr;24(4):357-60.
Abstract/Text A retrospective cohort study was conducted to assess whether palpitations are an independent risk factor for increased cardiac morbidity or mortality. A cohort of 109 patients with palpitations, seen over a five-year period in a primary care setting, was compared with an age- and sex-matched control cohort. Mean length of follow-up was 42 months. There was no statistically significant difference in incidence of morbidity or mortality (6.4 percent for the cohort with palpitations and 7.2 percent for the control cohort) between the two groups. This study suggests that palpitations are not an independent risk factor for increased cardiac morbidity or mortality.

PMID 3559487  J Fam Pract. 1987 Apr;24(4):357-60.
著者: B E Weber, W N Kapoor
雑誌名: Am J Med. 1996 Feb;100(2):138-48.
Abstract/Text PURPOSE: To determine: (1) the etiologies of palpitations, (2) the usefulness of diagnostic tests in determining the etiologies of palpitations, and (3) the outcomes of patients with palpitations.
PATIENTS AND METHODS: One hundred and ninety consecutive patients presenting with a complaint of palpitations at a university medical center were enrolled in this prospective cohort study. Patients underwent a structured clinical interview and psychiatric screening. The charts were abstracted for results of the physical exam and tests ordered by the primary physician. Assignment of an etiology of palpitations was based on strict adherence to predetermined criteria and achieved by consensus of the two physician investigators. One-year follow-up was obtained in 96% of the patients.
RESULTS: An etiology of palpitations was determined in 84% of the patients. The etiology of palpitations was cardiac in 43%, psychiatric in 31%, miscellaneous in 10%, and unknown in 16%. Forty percent of the etiologies could be determined with the history and physical examination, an electrocardiogram, and/or laboratory data. The 1-year mortality rate was 1.6% (95% confidence interval [CI] 0% to 3.4%) and the 1-year stroke rate was 1.1% (95% CI 0% to 2.6%). Within the first year, 75% of the patients experienced recurrent palpitations. At 1-year follow-up, 89% reported that their health was the same or improved compared to that at enrollment, 19% reported that their work performance was impaired, 12% reported that workdays were missed, and 33% reported accomplishing less than usual work at home.
CONCLUSIONS: The etiology of palpitations can often be diagnosed with a simple initial evaluation. Psychiatric illness accounts for the etiology in nearly one third of all patients. The short-term prognosis of patients with palpitations is excellent with low rates of death and stroke at 1 year, but there is a high rate of recurrence of symptoms and a moderate impact on productivity.

PMID 8629647  Am J Med. 1996 Feb;100(2):138-48.
著者: S M Zeldis, B J Levine, E L Michelson, J Morganroth
雑誌名: Chest. 1980 Sep;78(3):456-61.
Abstract/Text Long-term ambulatory electrocardiographic (Holter) monitoring is frequently used to evaluate patients with various cardiovascular complaints, including palpitations, dyspnea, discomfort in the chest, dizziness, and syncope. In the present study, 518 consecutive 24-hour electrocardiographic recordings were reviewed to determine correlations between cardiac diagnoses, presenting complaints, and specific electrocardiographic abnormalities. Two hundred seventy-four patients (53 percent) had significant arrhythmias; 212 (41 percent) had significant ventricular arrhythmias, and 106 (20 percent) significant atrial arrhythmias, including 44 patients (8 percent) with both. No presenting complaint or cardiovascular diagnosis correlated closely with any specific cardiac arrhythmia. Major arrhythmias, including supraventricular and ventricular tachycardias, often occurred asymptomatically (in 44/54 and 37/40 patients, respectively); however, among 371 patients with accurate historic logs, only 176 (47 percent) had long-term electrocardiographic studies in which their typical symptoms occurred during the monitoring period. Fifty (13 percent) of the 371 patients had concurrence of their presenting complaints with an arrhythmia, and 126 patients (34 percent) had their typical symptoms associated with a normal electrocardiogram, which was helpful in excluding an abnormality of rhythm or conduction as the primary cause for their complaints.

PMID 7418465  Chest. 1980 Sep;78(3):456-61.
著者: R Mayou, D Sprigings, J Birkhead, J Price
雑誌名: QJM. 2003 Feb;96(2):115-23.
Abstract/Text BACKGROUND: Palpitation is a very common presenting symptom in primary care and in cardiac clinics, associated with marked disability. Although serious arrhythmias are uncommon causes, treatment of persistent palpitation is difficult.
AIM: To describe the cardiological, behavioural and psychological characteristics of consecutive patients presenting to a cardiac clinic with the main complaint of palpitation.
DESIGN: Prospective evaluation of consecutive out-patients.
METHODS: Participants were 184 consecutive patients with the complaint of palpitation referred to an out-patient cardiac clinic. Three assessments were used. Three to four weeks prior to clinic attendance, measures of symptoms, distress and disability were gathered, and a heart rate perception test was conducted. At the out-patient clinic, a routine clinical assessment was made. Three months later, patients received a questionnaire which included baseline measures of symptoms, distress and disability.
RESULTS: Palpitation was associated with arrhythmias in 62 patients (34%), extrasystoles in 75 patients (41%) and awareness of sinus rhythm in 47 patients (26%). Distress and disability were common and persistent. There were significant differences in the characteristics of the three groups.
DISCUSSION: Most patients presenting to secondary care with palpitation do not have serious underlying cardiovascular conditions. Concurrent psychological problems are common and persistent. Aetiology may be seen as an interaction of pathology, awareness of normal physiology, and psychological variables. Few patients require specialist cardiological treatment, but simple reassurance is of limited effectiveness. A stepped care approach may improve outcomes and needs rigorous evaluation.

PMID 12589009  QJM. 2003 Feb;96(2):115-23.
著者: J W Leitch, G J Klein, R Yee, R A Leather, Y H Kim
雑誌名: Circulation. 1992 Mar;85(3):1064-71.
Abstract/Text BACKGROUND: Syncope in patients with supraventricular tachycardia has been suggested to be an ominous finding, predictive of rapid rates during tachycardia.
METHODS AND RESULTS: To explore the mechanism of syncope during supraventricular tachycardia, tachycardia was induced in the supine position and after passive head-up tilting to 60 degrees in 13 patients with atrioventricular (AV) node reentry, eight patients with AV reentry, and one patient with atrial tachycardia. Tilt testing was also performed in sinus rhythm for 30 minutes (the last 15 minutes with isoproterenol infusion). Mean +/- SEM age was 38 +/- 3 years, and 11 patients had a history of syncope (median number of syncopal episodes, three; range, one to 30). The cycle length of tachycardia when upright was shorter than when supine (297 +/- 9 compared with 357 +/- 10 msec, p less than 0.001), and mean blood pressure fell to a greater extent after the onset of tachycardia (fall in mean blood pressure, 53 +/- 6 compared with 24 +/- 3 mm Hg, p less than 0.001). Mean blood pressure correlated significantly with tachycardia cycle length when supine (r = 0.58, p = 0.005) but not when tilted upright (r = 0.18, p = 0.45). Syncope occurred in seven patients during upright tachycardia. These seven patients had a greater fall in mean blood pressure with upright tachycardia than the 15 patients without syncope (fall in mean blood pressure, 70 +/- 4 compared with 45 +/- 5 mm Hg, p = 0.01), but there was no difference in the tachycardia cycle length (311 +/- 10 compared with 290 +/- 11 msec, p = 0.29). Six of the seven patients with tachycardia-induced syncope also had syncope with tilt testing in sinus rhythm compared with four of the 15 patients without tachycardia-induced syncope (p = 0.02).
CONCLUSIONS: These data support the view that syncope during supraventricular tachycardia is related to vasomotor factors and does not predict a more rapid tachycardia rate.

PMID 1537103  Circulation. 1992 Mar;85(3):1064-71.
著者: P Brugada, S Gürsoy, J Brugada, E Andries
雑誌名: Lancet. 1993 May 15;341(8855):1254-8.
Abstract/Text The uncomfortable awareness of a beating heart--palpitations--is a common complaint that can occur under normal or abnormal circumstances. For example, normal palpitations occur with exercise, emotions, and stress, or after taking substances that increase adrenergic tone or diminish vagal activity (coffee, nicotine, and adrenergic or anticholinergic drugs). Normal palpitations are recognised as such because individuals who experience them realise or are told that something happened to accelerate the normal rhythm of the heart. However, some people find sinus tachycardia troublesome enough to seek medical attention. In other situations palpitations are clearly abnormal. The heart beat which is felt for no apparent reason, may be fast, or strong and slow, or feel like a missed or extra beat. Although these abnormal palpitations usually point to a cardiac arrhythmia, this is not always the case. Moreover, many patients with arrhythmias do not have palpitations but manifestations such as syncope, shock, and chest pain (sudden death is also possible). We will discuss the approach to the patient who seeks medical attention because of a history of palpitations, with special emphasis on the history, physical examination, and 12-lead electrocardiogram (ECG) because they are simple and inexpensive diagnostic tools that are available to most physicians.

PMID 8098401  Lancet. 1993 May 15;341(8855):1254-8.
著者: Jonathan S Steinberg, Niraj Varma, Iwona Cygankiewicz, Peter Aziz, Paweł Balsam, Adrian Baranchuk, Daniel J Cantillon, Polychronis Dilaveris, Sergio J Dubner, Nabil El-Sherif, Jaroslaw Krol, Malgorzata Kurpesa, Maria Teresa La Rovere, Suave S Lobodzinski, Emanuela T Locati, Suneet Mittal, Brian Olshansky, Ewa Piotrowicz, Leslie Saxon, Peter H Stone, Larisa Tereshchenko, Gioia Turitto, Neil J Wimmer, Richard L Verrier, Wojciech Zareba, Ryszard Piotrowicz
雑誌名: Heart Rhythm. 2017 Jul;14(7):e55-e96. doi: 10.1016/j.hrthm.2017.03.038. Epub 2017 May 8.
Abstract/Text Ambulatory ECG (AECG) is very commonly employed in a variety of clinical contexts to detect cardiac arrhythmias and/or arrhythmia patterns which are not readily obtained from the standard ECG. Accurate and timely characterization of arrhythmias is crucial to direct therapies that can have an important impact on diagnosis, prognosis or patient symptom status. The rhythm information derived from the large variety of AECG recording systems can often lead to appropriate and patient-specific medical and interventional management. The details in this document provide background and framework from which to apply AECG techniques in clinical practice, as well as clinical research.

Copyright © 2017 International Society for Holter and Noninvasive Electrocardiology, Heart Rhythm Society, and Wiley Periodicals, Inc. Published by Elsevier Inc. All rights reserved.
PMID 28495301  Heart Rhythm. 2017 Jul;14(7):e55-e96. doi: 10.1016/j.hr・・・
著者: M H Crawford, S J Bernstein, P C Deedwania, J P DiMarco, K J Ferrick, A Garson, L A Green, H L Greene, M J Silka, P H Stone, C M Tracy, R J Gibbons, J S Alpert, K A Eagle, T J Gardner, G Gregoratos, R O Russell, T J Ryan, S C Smith
雑誌名: Circulation. 1999 Aug 24;100(8):886-93.
Abstract/Text
PMID 10458728  Circulation. 1999 Aug 24;100(8):886-93.
著者: P J Zimetbaum, M E Josephson
雑誌名: Ann Intern Med. 1999 May 18;130(10):848-56.
Abstract/Text PURPOSE: To evaluate the efficacy of various ambulatory electrocardiographic monitors for the diagnosis of arrhythmia-related disorders and to provide recommendations for their use in clinical practice.
DATA SOURCES: Studies published since 1988 were identified through search of the MEDLINE database.
STUDY SELECTION: Studies that met methodologic criteria for minimal bias and had clinical relevance were selected.
DATA EXTRACTION: Descriptive and analytic data from each study.
DATA SYNTHESIS: Ambulatory electrocardiographic monitors, specifically transtelephonic continuous-loop event recorders, are highly effective for establishing a diagnosis in patients with palpitations but are less effective for establishing a diagnosis in patients with syncope. Clinicians may use these devices to monitor for nonsustained ventricular tachycardia in patients at potentially high risk for sudden arrhythmic death; however, few data are available to support this practice. Ambulatory monitors are useful for assessment of the safety and efficacy of antiarrhythmic medications and the recurrence of symptomatic supraventricular arrhythmias. New ambulatory arrhythmia monitoring devices are being developed that may facilitate outpatient management of chronic cardiac disease.
CONCLUSIONS: Ambulatory electrocardiographic monitors, particularly transtelephonic continuous-loop event recorders, aid in the diagnosis of symptomatic arrhythmias. These devices are also useful for monitoring the effectiveness and safety of antiarrhythmic medications. Guidelines are lacking for use of these devices to assess prognosis in patients at potential risk for sudden arrhythmic death.

PMID 10366376  Ann Intern Med. 1999 May 18;130(10):848-56.
著者: A J Barsky, P D Cleary, R R Coeytaux, J N Ruskin
雑誌名: J Gen Intern Med. 1994 Jun;9(6):306-13.
Abstract/Text OBJECTIVE: To determine the prevalence of psychiatric disorders in ambulatory patients undergoing Holter monitoring to evaluate palpitations.
DESIGN: Patients referred for 24-hour ambulatory electrocardiographic (ECG) monitoring were studied with a structured diagnostic interview and self-report questionnaires prior to monitoring.
SETTING: Holter laboratory of a large academic medical center.
PATIENTS AND OTHER PARTICIPANTS: One hundred forty-five consecutive patients complaining of palpitations and 70 asymptomatic non-patient volunteers.
OUTCOME MEASURES: DSM-III-R psychiatric diagnoses.
RESULTS: Forty-five percent (44.8%) of the participants had at least one lifetime anxiety or depressive disorder and 24.8% had at least one current (one month) disorder. The lifetime prevalence of panic disorder was 27.6%, and that of major depression was 20.8%. Current prevalence rates showed a similar pattern; the current prevalence of panic disorder was 18.6%. Panic disorder and somatization disorder symptoms were significantly more prevalent in the palpitation group than in the general medical clinic at the same hospital. Patients with a psychiatric diagnosis were more likely to report cardiac symptoms during monitoring than were those without psychiatric disorder, and more commonly described their symptoms as "pounding" and reported faintness, lightheadedness, and vertigo. Although cardiac histories and ECG results were no more serious, the patients with psychiatric diagnoses rated their overall health status as significantly worse.
CONCLUSIONS: Almost half of palpitation patients referred for Holter monitoring have a psychiatric disorder. More than a fourth have lifetime panic disorder and a fifth have had panic attacks in the month before monitoring.

PMID 8077994  J Gen Intern Med. 1994 Jun;9(6):306-13.
著者: A J Barsky, P D Cleary, M K Sarnie, J N Ruskin
雑誌名: J Nerv Ment Dis. 1994 Feb;182(2):63-71.
Abstract/Text One hundred forty-five consecutive patients referred for ambulatory electrocardiographic monitoring for the evaluation of palpitations were studied just before monitoring. They were compared with 75 asymptomatic, nonpatient volunteers. The research battery included a structured diagnostic interview, self-report questionnaires, and perceptual tasks measuring awareness of cardiac activity. After monitoring, symptom reports were compared with concurrent electrocardiographic recordings to determine their accuracy. Forty palpitation patients (27.6%) had DSM-III-R lifetime panic disorder, and 27 (18.6%) had current (1-month) panic disorder. Panic patients were significantly more likely to describe their palpitations as "racing" or "pounding" and to have been awakened from sleep by them. They did not have more cardiac arrhythmias during 24-hour, electrocardiographic monitoring, and their symptom reports were significantly less likely to be due to demonstrable cardiac irregularities. They were not more accurately aware of resting heartbeat than nonpanic palpitation patients. They did score higher on self-report measures of somatization, hypochondriasis, and bodily amplification.

PMID 8308534  J Nerv Ment Dis. 1994 Feb;182(2):63-71.
著者: T J Lessmeier, D Gamperling, V Johnson-Liddon, B S Fromm, R T Steinman, M D Meissner, M H Lehmann
雑誌名: Arch Intern Med. 1997 Mar 10;157(5):537-43.
Abstract/Text BACKGROUND: The diagnostic criteria for panic disorder include symptoms commonly experienced by patients with paroxysmal supraventricular tachycardia (PSVT). Since electrocardiographic documentation of PSVT can be elusive, symptoms may be ascribed to other conditions.
OBJECTIVE: To systematically evaluate the potential for PSVT to simulate panic disorder.
METHODS: A retrospective survey of 107 consecutive patients with reentrant PSVT was conducted. Objective and subjective assessments of PSVT symptomatology were made, including the application of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), panic disorder criteria.
RESULTS: The criteria for panic disorder according to DSM-IV were fulfilled by 67% of patients. Paroxysmal supraventricular tachycardia was unrecognized after initial medical evaluation in 59 patients (55%), including 13 (41%) of 32 patients with ventricular preexcitation by electrocardiogram, and remained unrecognized for a median of 3.3 years. Prior to eventual identification of PSVT, physicians (nonpsychiatrists) attributed symptoms to panic, anxiety, or stress in 32 (54%) of the 59 patients. When PSVT was unrecognized, women were more likely than men to have symptoms ascribed to psychiatric origins (65% vs 32%, respectively; P < .04). Paroxysmal supraventricular tachycardia was detected in only 6 (9%) of 64 patients undergoing Holter monitoring vs 8 (47%) of 17 patients who wore an event monitor (P < .001). During a 20-month median follow-up, electrophysiologically guided therapy (ablation in 81% of patients) resolved symptoms in 86% of patients; only 4% continued to meet DSM-IV panic disorder criteria without evidence of PSVT recurrence.
CONCLUSIONS: The clinical characteristics of patients with PSVT referred for electrophysiologically guided therapy can mimic panic disorder. Diagnosis of PSVT is often delayed by inappropriate rhythm detection techniques (Holter instead of event monitoring) and failure to recognize ventricular preexcitation on the sinus electrocardiogram; symptoms due to unrecognized PSVT are often ascribed to psychiatric conditions.

PMID 9066458  Arch Intern Med. 1997 Mar 10;157(5):537-43.

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