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

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