Palpitations - red flag symptoms

What are the red flag symptoms to look out for when patients present with palpitations? Refresh your knowledge with a quick guide updated by Dr Anish Kotecha.

(Photo: Dean Mitchell/Getty Images)
(Photo: Dean Mitchell/Getty Images)

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.

A history or family history of myocardial infarction, angina, arrhythmias, thyroid disease, infection, anaemia, lung disease, anxiety, cardiomyopathy or unexplained death is relevant.

History

Enquire about the duration and frequency of symptoms, and when they occur. Ask the patient to 'tap out' the rhythm. Consider whether the patient is symptomatic or compromised when seen.

Medication history may offer a clue to past medical history, or specific drugs may cause arrhythmias - amlodipine (reflex tachycardia), thyroxine (excess may cause tachycardia and atrial fibrillation) and tricyclic antidepressants, to name a few.

Smoking, caffeine and alcohol could also contribute to the symptom.

Red flags in palpitations

  • Chest pain
  • Acute dizziness or syncope
  • Shortness of breath
  • Hypotension
  • Focal neurological symptoms

Palpitations in addition to any of the red flag symptoms listed in the box above 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 atrioventricular (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 an acute cardiac/pulmonary insult.
Focal neurology may indicate a cerebrovascular accident or event secondary to an arrhythmia.

Examination

Pulse rate, along with features suggested in the history, may point to the cause of the palpitations.

Irregular pulse: May indicate atrial fibrillation, ectopics or variable heart block – this may be fast or rate-controlled.

Fast regular pulse: May indicate a supra-ventricular tachycardia, or more rarely ventricular tachycardia, which is a medical emergency.

Slow pulse: May suggest heart block or be normal. Note that a Mobitz II and third degree block require cardiological intervention.

Infrequent `thump’ palpitations: Likely to indicate benign ectopic beats - the patient can be reassured.

Increasing frequent palpitations with a normal pulse: May indicate paroxysmal atrial fibrillation and ambulatory electrocardiogram monitoring may be suitable.

Look for signs of thyroid disease, infection or anaemia as well as cardiac and respiratory disease.

Investigations and possible causes

Compromised patients should be managed in secondary care.

Blood tests should include full blood count and thyroid function. Others such as renal function, calcium, magnesium, liver function, cholesterol, ferritin and inflammatory markers may be useful, depending on other factors elicited in the history.

A 12-lead electrocardiogram may reveal the diagnosis but not always, in which case ambulatory monitoring should be considered.

Possible causes

  • Acute coronary syndrome
  • Acute arrhythmia
  • Profound bradycardia
  • Wolff-Parkinson-White syndrome
  • Anxiety
  • Thyroid dysfunction
  • Acute infection
  • Anaemia
  • Medication side effects

This article, originally by Dr Barney Tinsley, was first published on 11 September 2009 and was updated by Dr Anish Kotecha, GP in Gwent.

Further reading

Visit MIMS Learning for an interactive version of this article and a CPD certificate.

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