Palpitations are 'an (abnormal) awareness of one's own heartbeat'. They are extremely common, and often benign.
Clarification of exactly what a patient means by a palpitation is crucial. Some may mean chest pain, dizziness, shortness of breath or be experiencing indigestion, among other examples. The history is vital in assessing the cause and severity of the problem. Well over half of all patients presenting with palpitations will have no sinister underlying pathology.1 A history or family history of MI, angina, arrhythmias, thyroid disease, infection, anaemia, lung disease, anxiety, cardiomyopathy or unexplained death is relevant.
|Red flag symptoms|
Consider whether the patient is symptomatic or compromised when seen. Drug history may offer a clue to past medical history, or the drugs may cause arryhthmias - amlodipine (reflex tachycardia), thyroxine (excess may cause tachycardias and AF) and tricyclic antidepressants, to name a few. Smoking, caffeine and alcohol could contribute.
Enquire about the duration and frequency of symptoms, and when they occur. Ask the patient to 'tap out' the rhythm.
Palpitations in addition to any of these red flag symptoms are likely to indicate the need for further urgent investigation and/or an acute admission.
Chest pain could be an indicator of an acute coronary syndrome (ACS). Acute dizziness could signify a serious arrhythmia, profound bradycardia, or AV heart block.
Shortness of breath might be present if the patient suffers from anxiety, ACS or structural defects (such as atrial septal defect) but this is rare.
Hypotension may be due to ACS, infection, anaemia or acute cardiac/pulmonary insult. Focal neurology may indicate CVA secondary to an arrhythmia.
Pulse rate, along with features suggested in the history, may point to the types of palpitation:
- Irregular pulse may indicate AF, ectopics or variable block. May be fast or rate controlled.
- Fast regular pulse may indicate supraventricular tachycardia, or more rarely ventricular tachycardia (VT). VT is a medical emergency.
- Slow pulse, heart block/normal. Mobitz II and third degree blocks require cardiological intervention.
- Infrequent 'thump' palpitations are likely to indicate benign ectopic beats. Reassure the patient.
- Increasing frequency palpitations, but normal pulse felt may indicate paroxysmal AF. Ambulatory ECG monitoring may be most suitable.
Look for signs of thyroid disease, infection, anaemia, and cardiac and respiratory disease.
Compromised patients should be managed in secondary care. Blood tests should include FBC and TFTs. Others such as U&Es, calcium, magnesium, LFTs, cholesterol, ferritin and inflammatory markers may be useful, depending on other factors elicited in the history.
A 12-lead ECG may reveal the diagnosis but not always, in which case ambulatory monitoring should be considered.
1. Thakkar R. The basics: palpitations GP 20 Feb 2009.