Red flag symptoms: Palpitations

The patient's pulse, medical or drug history may point to a diagnosis.

Pulse can be a clue in palpitation
Pulse can be a clue in palpitation

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

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.

Examination
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.

Possible causes

  • Acute coronary syndrome
  • Acute arrhythmia
  • Profound bradycardia
  • Wolff-Parkinson-White syndrome
  • Anxiety

 

Reference

1. Thakkar R. The basics: palpitations GP 20 Feb 2009.

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Just published

What do plans for 50% contributions mean for your NHS pension?

What do plans for 50% contributions mean for your NHS pension?

The government is planning to consult on a proposal that would allow GPs to reduce...

50:50 pension option 'will fail' says BMA as government consults on proposal

50:50 pension option 'will fail' says BMA as government consults on proposal

The BMA has said that a plan to allow doctors to halve their pension contributions...

GPs urged to be vigilant year-round as fraud cases rock practices

GPs urged to be vigilant year-round as fraud cases rock practices

GP partners should ensure they are on top of their practice finances throughout the...

Digital-first approach in underdoctored areas risks short changing patients

Digital-first approach in underdoctored areas risks short changing patients

Plans to tackle GP shortages by allowing digital-first providers to expand in underdoctored...

GP Job of the Week: Lead GP, urgent care centre, east London

GP Job of the Week: Lead GP, urgent care centre, east London

Greenbrook Healthcare is looking to appoint a lead GP to its clinical leadership...

NHS England says it will avoid top-down approach to PCNs

NHS England says it will avoid top-down approach to PCNs

NHS England will not issue national guidance to primary care networks (PCNs) about...