The basics - Palpitations

Many patients with palpitations have no serious defect. By Dr Raj Thakkar

Two-thirds of patients who present with palpitations, that is an awareness of one's own heart beating, will have no identifiable or sinister pathology.

Nevertheless, many of these patients are referred to secondary care, accounting for a third of all referrals.

Referrals cause anxiety to patients, clog up cardiac clinics and cost the NHS a lot of money. Of course, there will be many patients who do have serious cardiac disease.

History
Patients' medical history and family must be considered when discussing palpitations. Explore whether the patient has a history of heart, lung or thyroid disease, and whether they have features of angina.

Check whether they are taking any pro-arrhythmic drugs or whether there is a family history of sudden cardiac death.

A careful history often provides the diagnosis. If the patient is currently experiencing palpitations, examine their heart and, if possible, obtain an ECG immediately.

If they are compromised (e.g. are experiencing chest pain/dizziness/breathlessness, have a low BP or have a malignant ECG), immediate transfer to secondary care may be required.

Symptoms
Important features to consider include what the patient means by 'palpitations'. Some patients actually mean breathlessness, chest pain, dizziness or dys-pepsia.

Find out when they first experienced palpitations. If patients have experienced palpitations for many years, why are they presenting now? Anxiety, worsening palpitations or symptoms such as chest pain, dizziness or breathlessness may all trigger a visit to the GP.

Cardiac defects
Palpitations that have gone on for years may be suggestive of congenital or structural cardiac defects or syndromes; this should particularly be borne in mind in younger patients.

Of course, ostium secundum atrial septal defects, for example, may present with breathlessness or palpitations, often in middle-aged women. Recent-onset palpitations may be indicative of an acute cardiac or pulmonary insult, infection, anaemia, thyroid disease or a change in medication (such as reflex tachycardia secondary to amlodipine, or digoxin triggering arrhythmia in Wolff-Parkinson-White syndrome - see ECG above).

Check whether the palpitation feels regular or irregular. Perhaps ask the patient to tap out on the desk what they experience.

An irregular heartbeat may be indicative of paroxysms of AF whereas a fast regular heartbeat may be suggestive of atrial flutter, supraventricular or even ventricular tachycardia.

A slow palpitation may of course be normal or suggest heart block.

The length of time the palpitation is experienced may also offer clues to the diagnosis.

A short-lived thump in the chest with no associated breathlessness, dizziness or chest pain is likely to indicate benign ectopics.

Sudden-onset regular pal-pitations with an abrupt end suggest paroxysms of AF, supraventricular or even ventricular tachycardia. Ill-defined start and end points may suggest longer standing AF.

Ask the patient when the palpitations occur. Those occurring at night, particularly when patients are lying on their left side, often reflect the cardiac apex beating against the thoracic structures.

While exercise triggers sinus tachycardia, arrhythmias experienced during exertion may also indicate more sinister pathology (such as ventricular tachyarrhythmias).

Some patients can offer a clear history of palpitations occurring soon after taking prescribed medication, caffeine, alcohol or drugs such as cocaine.

Alcohol consumption should be assessed accurately (units = ml consumed/1,000 x % alcohol) and a smoking history taken.

Examination
A general examination is required to look for features of poor health, infection, anaemia, respiratory and thyroid disease.

A cardiac examination is obviously essential, looking for evidence of rhythm disturbance, valvular disease, congenital heart disease, cardiac failure and endocarditis.

BP should be measured. A normal cardiac examination does not exclude a sinister cause of palpitations but an abnormal examination may increase its likelihood.

Investigations
If you have access, an ECG should be performed. Of course, it is crucial that the reading is interpreted correctly. There is evidence that many GPs are not able to accurately diagnose rhythm disturbances such as AF on an ECG.

Wolff-Parkinson-White syndrome is often missed on ECGs. Paediatric ECGs always require specialist interpretation.

Many GP practices have access to 24-hour ambulatory ECG monitors, which may prove invaluable to diagnosing patients complaining of intermittent palpitations.

Bloods such as a FBC and TFTs should be checked. Electrolytes should be monitored and, if the patient is on digoxin, levels should be established at the outset and monitored if appropriate.

If you have access to echocardiography and are concerned there may be structural heart disease, it is reasonable to organise a scan as long as the patient is stable and you are confident you can interpret an echo report.

Referral
Referral to secondary care should be immediate if the patient is compromised, otherwise referral should be considered if sinister features are exhibited.

These include prolonged palpitations, exercise-induced symptoms, tachy- or brady- arrhythmias, palpitations associated with breathlessness, dizziness (or collapse) or chest discomfort, structural heart disease on examination including cardiac failure, family history of cardiac death (<40 years of age) or an abnormal ECG.

Patients should be advised on the latest DVLA guidelines.

  • Dr Thakkar is a GP in Wooburn Green, Buckinghamshire

Learning points

  • Most palpitations are benign.
  • Associated chest pain, dizziness/collapse, breathlessness and exercise-induced palpitations are serious features.
  • If performing ECGs, ensure they are properly interpreted.

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