Clinical Notes : Cardiovascular Disease

119. Palpitations

Palpitations

 

Definitions

 

Palpitation is an uncomfortable awareness of the heart rhythm. ​

Tereminology used in this guideline

  • Palpitation

    • the uncomfortable awareness of the heart rhythm:

      • normal palpitations occur with exercise, emotion, and stress or, after taking substances that increase adrenergic activity or decrease vagal activity 

      • abnormal palpitations may occur for no reason and may be fast or strong-and-slow. Palpitations may point to cardiac arrhythmia; however, many people who have rhythm disturbances will not have palpitations, instead they will experience syncope, shock, and chest pain 

      • the symptom can cause distress to the patient

        • despite this anxiety the majority of palpitations are not associated with dysrhythmia, and of the ones found to be arrhythmias, many of these are benign in nature. Less than 1 in 2 cases of palpitations are cardiac in nature 

      • Identifying the difference between a benign and significant dysrhythmia presenting as palpitations is achievable through careful history-taking and assessment of the 12-lead electrocardiography (ECG)

  • Syncope

    • a sudden but brief loss of consciousness that is caused by inadequate blood supply to the brain.

      • recovery is spontaneous and rapidly complete

      • ayncope is common, disabling, and possibly associated with sudden cardiac death

  • Vertigo

    • a hallucination of movement of the environment about the patient, or of the patient with respect to the environment.

      • is not synonymous with dizziness

      • may be central (due to a disorder of the brainstem or the cerebellum) or peripheral (due to a disorder in the inner ear or the 8th cranial nerve).

      • ear, nose, and throat review prior to cardiac review is recommended,unless associated with palpitations or chest pain 

 
 

History

  • What does the patient mean? 

    • Patient's own definition

      • ’Palpitations’ does not necessarily indicate cardiac dysrhythmia but an unusual pounding sensation.

      • hence people presenting in primary care generally use this term correctly but in its broadest sense, and the clinician must ascertain exactly what they mean.

      • palpitations are a symptom and are not necessarily arrhythmia—sometimes the patient could be referring to a different issue, such as chest discomfort 

    • The heart rate at the time of palpitations

      • asking the patient to tap the heartbeat with their hands can help further clarify the rate and also give an idea about regularity:

        • regular palpitations are more likely to be an arrhythmia than irregular ones.

        • brief irregularities such as missed beats, fluttering sensations, or extra beats, are often caused by ectopy

 

  • Exact description

    • duration and frequency of palpitations

    • impact on the patient’s life 

    • circumstances during which palpitations occur: 

      • does it happen when the patient is at rest or does it happen during activity? 

      • can it be brought on by swallowing cold food or drinks? 

      • can it be stopped by coughing or breath holding?

        • coughing can sometimes be found in atrial flutter

        • breath holding could suggest an Atrioventricular Nodal Re-entrant Tachycardia

 

  • Associated features 

    • Syncope

      • syncope can be the only symptom of arrhythmia.

      • associated pre-syncopal symptoms or loss of consciousness 

      • recurrent unexplained syncope

      • syncope occurring during exercise/exertion

      • injury due to syncope 

    • Dyspnoea

      • can be a sign of tachydysrhythmia

      • can be a sign of cardiac decompensation such as in atrial fibrillation with a rapid ventricular release

    • Chest pain

      • can be the due to underlying coronary disease

      • a rapid heart rate can cause chest discomfort even when the heart is structurally normal 

 

  • Contributing factors

    • Anxiety

      • often associated with palpitations and fluttering in the chest.

      • a full history is still required as someone can be suffering from anxiety and be taking pro-arrhythmic medication 

    • Lifestyle factors

      • excessive caffeine intake

      • alcohol abuse

      • illicit drug use 

    • Medication

      • thyroxine replacement

      • beta-agonists

      • calcium channel receptor blockers

      • initiation of anti-arrhythmics may cause increased severity of palpitations

      • summative effect of medication that prolong the corrected QT interval (QTc)  A non-exhaustive list is included in the appendix

 

  • Family history 

    • cardiac muscle problems

    • early onset coronary disease

    • atrial fibrillation

    • implantable cardioverter defibrillators (ICDs) or pacemakers

    • young unexplained deaths

      • may indicate the presence of Sudden Arrhythmic Death Syndromes (SADS)

      • may be explained as cardiac issues but they may be concealed as drownings, road traffic accidents, or suicides

Drugs Causing QT Prolongation

​Type IA antiarrhythmics

  • Quinidine

  • Procainamide

  • Disopyramide

 

Type IC antiarrhythmics

  • Flecainide

  • Encainide

 

Class III antiarrhythmics

  • Sotalol

  • Amiodarone

Antipsychotics

  • Chlorpromazine

  • Haloperidol

  • Droperidol

  • Quetiapine

  • Olanzapine

  • Amisulpride

  • Thioridazine

 

Tricyclic antidepressants

  • Amitriptyline

  • Doxepin

  • Imipramine

  • Nortriptyline

  • Desipramine

 

Other antidepressants

  • Mianserin

  • Citalopram

  • Escitalopram

  • Venlafaxine

  • Bupropion

  • Moclobemide​

Antihistamines

  • Diphenhydramine

  • Astemizole

  • Loratidine

  • Terfanadine

 

Other

  • Chloroquine

  • Hydroxychloroquine

  • Quinine

  • Macrolides: Erythromycin; Clarithromycin

 
 

Diagnosis

  • Often asymptomatic on presentation

    • cardiovascular assessment

      • rate

      • rhythm

      • character of the pulse

      • manual blood pressure assessment

      • signs of heart failure syndrome or murmurs may point to underlying structural heart disease 

    • EC​G

      • significant changes :

        • Atrial fibrillation 

        • Second- and third-degree atrioventricular block 

        • Signs of previous myocardial infarction 

        • Left ventricular hypertrophy and left ventricular strain patterns 

        • Left bundle branch block 

        • Abnormal T-wave inversion and ST-segment changes 

        • Signs of pre-excitation (short PR interval and delta waves) 

        • Abnormal QTc interval and T-wave morphology

Risk stratification

 

Management :

 

Refer all cases at risk  to A+E for further investigation and management (amber and red risk statification)

Refer all cases A+E which the OOH physician feels unable to confidently manage

  • unable to obtain detailed history

  • fear of patient non compliance

Refer low risk cases ( green risk stratification) back to own GP for further investigation

  • Blood tests​

    • full blood count to exclude anaemia

    • electrolytes

    • liver function tests 

    • glucose assessment 

    • thyroid function tests

    • cholesterol and lipid assessment for those over 35 years of age who have not had a recent cardiovascular risk assessment 

  • Ambulatory rhythm monitoring

    • of value if the symptoms are frequent

    • the duration of recording should reflect the frequency of symptoms

    • a normal recording during an asymptomatic period does not exclude arrhythmic problems

    • a 24-hour period of recording gives a positive result in less than 1 in 10 cases

 

Driving and palpitations

  • regulations state that if a person suffers incapacity or may suffer incapacity from an arrhythmia they must cease driving.

  • inform patient

  • inform patient's GP so that appropriate action may be taken

  • document actions in clinical notes

 
 
journals.png

Matthew Fay, Andreas Wolf

Guidance on the Management of Palpitations in Primary care

Westcliffe Cardiology Service

Guidelines, March 2018

View/Access

Ireland notes.png
 

CPD Quiz and Certificate

This activity attracts 1,0 CPD point

Scroll down the box above to view its entire content

All users who successfully complete the quiz are e-mailed a copy of their personalised CPD certificate.