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Palpitations

Definition -Disagreeable sensation of pulsation or movement in the chest and / or
 adjacent areas

How common -One of the most common complains for which patients seek help in primary care
Studies quote different numbers – which vary from 15-20 % of presentations Account for significant cardiology out-patients work load
Up to 30-40 %
2nd to chest pain
No significant organic pathology in most cases Investigations can be expensive , time consuming and yet fail to establish a cause In patients presenting to a university medical center with palpitations 41 % has arrhythmic cause , 31 % had psychological disorder as anxiety and 16 % no cause was identified

Causes

Cardiac aetiologies can be

ventricular as premature ventricular contractions VT ventricular fibrillation

Atrial –Atrial fibrillation, flutter

High output state-Anaemia AV fistula Pagets disease Pregnancy

Structural- Congenital heart disease Cardiomegaly Aortic anurysm / stenosis Acute LVF

Miscellaneous -POTS ( postural orthostatic tachycardia synd ) Brugada syndrome Sinus tachycardia Ectopics

Psychosomatic -Anxiety and panic attacks Depression Somatization disorders
Systemic causes-Hyperthyroidism Hypoglycaemia Menopause Pregnancy Fever Anaemia Hypovolaemia Orthostatic hypotension Phaecochromocytoma

Drugs -Sympathomimetic agents 
Recent withdrawal of beta blockers Drugs that prolong the QT interval-
Antifungals – eg itraconazole Alcohol , caffeine , nicotine , cocaine , amphetamines , ecstasy and cannabis

History

What does the patient mean
○ explore heart rate at the time of palpitation- ask to tap the heartbeat
○ onset and offset
○ circumstances- when it happens , sudden , provoked ( Triggers )
○ how do they end ? sudden termination suggests paroxysmal SVT
○ duration – momentary or sustained
○ frequency
○ impact on life- severity Associated symptoms ○ breathlessness ○ chest pain ○ syncope or near syncope History of heart dis → predispose to a serious arrhythmia Contributing factors
○ anxiety- h/o mental health problems ?
○ lifestyle factors eg caffeine , illicit drug use Drug history including OTC medications Mental health problems Occupation for e.g sportsmen- imp to get an accurate diagnosis Alcohol history ( ↑ ed risk AF )

Examination

Patient often asymptomatic when examined and 
examination is normal ( unhelpful )

 Heart rate and rhythm Blood pressure Auscultation HS Signs of heart failure Signs of thyrotoxicosis , anaemia , sepsis Blood tests
○ FBC ○ TFT ○ Us and Es ○ Lipids ○ Hba1c ○ LFTs 12 lead ECG ( in all ) BNP – if heart failure suspected Echo – if structural / Failure suspected Mental state

Check for

Pre-existing congential HD, IHD or heart failure Pre-syncope or syncope Family h/o sudden cardiac death or unexplained death < 40 yrs age exertional symptoms – may indicate an underlying heart muscle disease or angina pectoris chest pain associated with palpitations Is it related to a drug for e.g sympathomimetics

Clues to possible diagnosis

Most important aim of initial history taking / examination is to distinguish between patients whose symptoms are related to anxiety from a genuine arrhythmia
patients with anxiety may describe a lump in the throat , tingling in hands and face or ↑ ed RR or hyperventilation Syncope and pre-syncope should always be taken seriously – they may indicate ventricular tachycardia , SVT or other cardiac arrhythmias Episodes that start and end abruptly indicate atrial or ventricular tachyarrhythmia If SVT suspected- AVRT ( atrioventricular re-entrant tachycardia ) WPW becomes less likely with increasing age whereas AV re-entrant tachycardia ( AVNRT ) , AF and atrial tachycardia becomes more likely

Ongoing palpitations with below mentioned – Admit

Ventricular tachycardia ( VT ) Persistent SVT
○ if trained and competent attempt to terminate SVT by
 ♦ Valsalva manoeuvre
 ♦ Carotid sinus massage Haemodynamic instability ( hypotension or bradycardia ) Feature suggesting serious underlying cardiac cause or complication
○ sig breathlessness
○ chest pain
○ syncope or near syncope
○ family hx of sudden cardiac death < 40 yrs
○ onset of palpitations precipitated by exercise Systemic cause- eg
○ thyrotoxicosis
○ severe anaemia or
○ sepsis

Referral not mandatory– Isolated palpitations ( skipped beats , pounding or short sluttering ) that are
○ not provoked by exercise
○ not associated with symptoms such as light headedness , syncope , persistent breathlessness or chest pain
 No history or signs of structural heart disease , heart failure , or hypertension and no family h/o sudden cardiac death
 Normal ECG Palpitations are generally due to extrasystoles or sinus tachycardia

Refer -Palpitations associated with symptoms such as chest pain or light headedness H/O recurrent sustained tachyarrythmia , AF or flutter History or physical signs of structural heart disease ,hypertension or heart failure Clear h/o palpitations consistent with paroxysmal SVT 
○ sudden onset and offset of a fast irregular heartbeat
○ multiple non-diagnostic ambulatory arrhythmia monitor recordings Abnormal ECG
○ 2nd and 3rd degree HBl require urgent referral Heart murmur / Aortic stenosis

Palpitations during exercise Palpitations associated with syncope or pre-syncope Family h/o sudden cardiac death or inheritable cardiac conditions Short PR interval – may suggest pre-excitation syndromes like WPW and Lown-Ganong-Levine 
( short PR but no delta waves ) 2nd degree or 3rd degree AV block Atrial fibrillation Second and third degree AV block Signs of previous MI LVH and left ventricular strain patterns LBBB or RBBB – suggests underlying structural heart disease Abnormal T wave inversion and ST segment changes Abnormal QTc interval and T wave morphology Abnormal repolarization ( Brugada syndrome )

Risk Factors arrhythmia -Age > 60 Regular palpitations Palpitations affected by sleep Regular pounding sensation in neck ( atrial contraction against a closed triscuspid valve as in AVNRT ) Visible neck pulsations Vasovagal symptoms

Further testing

Holter monitoring – best if palpitations happen on a near-daily basis 
( expensive and usually 24-48 hrs ) Transtelephonic Electrocardiographic Monitoring– also known as event monitor or recorder , a hand held device applied to a patients precordium. Newer devices more cost effective and have memory loops that record rhythm data 2 minutes before the device is activated Mobile Cardiac Outpatient Telemetry System ( MCOT ) for episodes which do not last long enough- a continuous loop or real time continuous device Implantable Cardiac Monitors – for long term and continuous analysis Echocardiogram -to assess ventricular function and check for valvular heart disease Exercise tolerance test ( ETT ) if associated with effort Handheld ECG for e.g AliveCor ( see external link £ can be purchased by pts ) Electrophysiological studies ( see under link EPS leaflet ) electrophysiologists map out the pathway of the arrhythmia with intracardiac electrodes before ablating part of it. Diagnosis and cure can be achieved during the same procedure Cardiac MRI 

Management 

Reassurance Advice about caffeine / alcohol / smoking If hypertensive – optimise management
( if needed ) Psychological cause- offer help Treatment can include
○ vagal manoeuveres ( carotid sinus massage or Valsalva )
○ pharmacological e.g amiodarone 
○ DC cardioversion
○ Catheter ablation ( particularly for re-entrant tachycardia )
○ Beta blockers for symptomatic ventricular ectopy
○ implantable cardiac defibrillators

LINKS AND RESOURCES

PATIENT INFORMATION

British Heart Foundation information for patients on palpitations https://www.bhf.org.uk/informationsupport/conditions/palpitations

Arrhythmia Alliance has several useful printable information – particularly checklists . Consider printing one and ask the patient to fill https://www.heartrhythmalliance.org/aa/uk/checklists

Holter monitor– information for patients from Heart Org https://www.heart.org/en/health-topics/heart-attack/diagnosing-a-heart-attack/holter-monitor

Several ECG/ recording  devices are now available to buy -read a review Mobile Self-Monitoring ECG Devices to Diagnose Arrhythmia that Coincides with Palpitations: A Scooping Review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6787597/

Health Navigator New Zealand on palpitations https://www.healthnavigator.org.nz/health-a-z/p/palpitations/

When to go to the emergency department for heart palpitations from MedStar Washington Hospital Centre https://blog.medstarwashington.org/2017/05/29/heart-palpitations-emergency-care/

INFORMATION FOR CLINICIANS

Management of patients with palpitations: a position paper from the European Heart Rhythm Association https://academic.oup.com/europace/article/13/7/920/447426

Management of palpitations in urgent care from The Journal of Urgent Care Medicine 2012 https://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf

Sana M. Al-Khatib, MD, MHS, FACC, FAHA, FHRS, Chair, William G. Stevenson, MD, FACC, FAHA, FHRS, Vice Chair, Michael J. Ackerman, MD, PhD, William J. Bryant, JD, LLM, David J. Callans, MD, FACC, FHRS, Anne B. Curtis, MD, FACC, FAHA, FHRS, Barbara J. Deal, MD, FACC, FAHA, Timm Dickfeld, MD, PhD, FHRS, Michael E. Field, MD, FACC, FAHA, FHRS, Gregg C. Fonarow, MD, FACC, FAHA, FHFSA, Anne M. Gillis, MD, FHRS, Christopher B. Granger, MD, FACC, FAHA, Stephen C. Hammill, MD, FACC, FHRS, Mark A. Hlatky, MD, FACC, FAHA, José A. Joglar, MD, FACC, FAHA, FHRS, G. Neal Kay, MD, Daniel D. Matlock, MD, MPH, Robert J. Myerburg, MD, FACC, and Richard L. Page, MD, FACC, FAHA, FHRS

 

 

 

 

References

  1. Management of patients with palpitations: a position paper from the European Heart Rhythm Antonnio Raviele et al Association Europace (2011 ) 13 (7) : 920-934
  2. Guidance on the management of Palpitations in Primary Care Westcliffe Cardiology Service Dr Matthew Fay and Dr Andreas Wolff
  3. Assessment of palpitations Professor Chris P Gale BMJ 2016 ; 352:h5649
  4. Ten steps before you refer for palpitations Br J Cardiology 2009;16:182-6
  5. Outpatients approach to palpitations. American Family Physician 84(1),63-69
  6. CKS NHS Palpitations
  7. Diagnostic Approach to Palpitations Am Fam Physician .2005 Feb 15;71(4):743-750
  8. Evidence-based Recommendations for the Evaluation of Palpitations in the Primary Care Setting Joel Wilken Med Clin N Am 100 ( 2016 ) 981-989 2016
  9. Palpitations by Upasana Tayal and Mark Dancy Medicine , Volume 41 , Issue 2 , February 2013 , Pages 118-124
  10. Approach to Palpitations by Alex JA McLellan , Jonathan M Kalman RCGP AJGP Vol 48 , No 4 , April 2019
  11. Palpitations StatPearls Amandeep Goyal et al July 2019
  12. Pedrinazzi C, Durin O, Bonara D, Inama L, Inama G. II cardiopalmo: epidemiologia, classificazione e prognosi [Epidemiology, classification and prognosis of palpitations]. G Ital Cardiol (Rome). 2010;11(10 Suppl 1):5S‐8S.
  13. Management of Palpitations Dr Julian Collinson Consultant Cardiologist October 2015 https://www.chelwest.nhs.uk/professionals/gplinks/1-julian-collinson-cardiology-update-palps.pdf

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