Approach to palpitations - RACGP

Approach to palpitations - RACGP

Approach to palpitations

Alex JA McLellan, Jonathan M Kalman                       PALPITATIONS are one of the most common         be a normal response to stress, including
                                                          presentations to general practice, and          episodes of anxiety, and it is important
                                                          while they are usually benign, they may         to elucidate cause and effect. Age of
Palpitations are one of the most
                                                          also have life-threatening significance.        the patient may give some indication
common presentations to general                           Palpitations have been estimated to             regarding the arrhythmia mechanism if
practice. While they are usually benign,                  account for 16% of general practice             supraventricular tachycardia is suspected;
they may be associated with an adverse                    presentations and are the second most           atrioventricular re-entrant tachycardia
prognosis.                                                common presentation to cardiologists            (AVRT; Wolf-Parkinson-White syndrome)
                                                          after chest pain.1 Although the vast            becomes less likely with increasing age,
This article presents a systematic                        majority are benign, there are some             whereas atrioventricular nodal re-entrant
approach to the patient with palpitations                 clinical and electrocardiographic               tachycardia (AVNRT), atrial fibrillation
and addresses considerations of                           signs that determine when further               and atrial tachycardia become more likely
aetiology, history and examination;                       investigations may be necessary. Only           (Figure 1).5
appropriate diagnostic work-up;                           rarely will palpitations be associated with
cardiology/electrophysiology referral
                                                          risk of serious cardiac events.2 This article
and management strategies.                                                                                History and physical examination
                                                          presents a systematic approach to the
Discussion                                                patient with palpitations and addresses         History
Not all palpitations are due to                           consideration of the aetiology, history         A thorough history is essential given
arrhythmia, and because of the
                                                          and examination; appropriate diagnostic         the overwhelming majority of patients
transitory nature of palpitations, the
                                                          workup; cardiology/electrophysiology            will present in sinus rhythm, between
work-up will usually be performed
between episodes. Direction from                          referral and management strategies.             episodes of arrhythmia.1 Palpitations are
history, examination and 12-lead                                                                          subjective and have been defined as ‘a
electrocardiography will guide further                                                                    disagreeable sensation of pulsation or
investigations and will often include                     Aetiology                                       movement in the chest and/or adjacent
an echocardiogram and ambulatory                          Not all patients with palpitations will         areas’;4 it is important to clarify whether
electrocardiographic monitoring.
                                                          have a cardiac or arrhythmic cause.             the patient’s symptom is palpitations
The intensity of ambulatory
electrocardiographic monitoring and
                                                          In patients presenting to a university          rather than a non-arrhythmic cardiac
diagnostic work-up will be dictated by                    medical centre with palpitations, 41%           symptom (eg chest pain, shortness of
the frequency, nature and severity of                     had an arrhythmic aetiology, 31%                breath, pre-syncope) or a non-cardiac
symptoms, and will sometimes require                      had palpitations in the context of              symptom. Sometimes it is useful to get
incorporation of new technologies and                     psychological disorder such as anxiety,         the patient to tap or clap out the heart
electrophysiology referral. Ultimately,                   and in 16% no cause was identified.2 In         rhythm during their typical episode.
management must be tailored on a
                                                          an emergency population, a cardiac cause        Once clarified, the history should focus
case-by-case basis depending on
the cause of palpitations and                             of palpitations was identified in 34%           on the nature of the symptoms and
symptom severity.                                         of patients.3 It is important to caution        circumstances around the time of the
                                                          labelling a patient’s palpitations as being     palpitations (Box 1).
                                                          due to anxiety/panic disorder or stress,
                                                          as 54% of this group will eventually be         Subjective awareness of a
                                                          diagnosed with an arrhythmic cause, and         normal heartbeat
                                                          the time delay until arrhythmia diagnosis       One of the causes of palpitations is simply
                                                          is 3.3 years.4 Sinus tachycardia may also       an increased awareness of normal sinus

204   | REPRINTED FROM AJGP VOL. 4 8, NO. 4, APRIL 2019                                                    © The Royal Australian College of General Practitioners 2019
APPROACH TO PALPITATIONS                                                                                                                                   CLINICAL

rhythm.6 The patient may describe a                            increased under conditions of anxiety,           be an abnormal heart rate on a heart
forceful beating in the chest or neck that                     fatigue and inter-current illness. Although      rate device such as a fitness tracker or
is not particularly fast; they may be able                     doctors frequently recommend patients            exercise monitor worn around the chest.
to hear their own heartbeat, particularly                      with ectopic beats to avoid caffeine, there is   Patients may be concerned that their
at night in bed. Although there may                            very little evidence that this is beneficial.8   resting heart rate is higher than a friend’s
occasionally be secondary causes, in the                       When asked how long their palpitations           or relative’s and wonder whether this
vast majority of cases this is benign. It may                  last, patients with repetitive ectopy may say    signifies a problem. It is important to be
often occur at times of heightened anxiety.                    that they occur over a period of minutes         able to reassure patients that a wide range
                                                               to many hours. It is important to establish      of resting heart rates can be within the
Momentary palpitations: Ectopic beats                          that this is a recurrent, intermittent event     normal spectrum. These different devices
Another frequent cause of palpitations is                      rather than continuous rapid palpitations.       are also prone to error, particularly during
benign ectopic beats, which can be atrial                      Previous studies suggest that up to 100          exercise, and can erroneously give very
or ventricular.7 Patients describe these                       ventricular ectopic beats in a 24-hour           high or very low readings.10 The key clue
as a momentary skipped or missed beat.                         period (24-hour Holter monitor) are within       as to whether the heart rate recorded
They are frequently associated with an                         normal limits.9 More frequent ectopic beats      indicates a genuine health problem is the
unusual, momentary sensation in the                            require further investigation; however,          presence of associated symptoms.
patient’s throat or chest. Patients usually                    even when a patient has thousands of
become aware of ventricular ectopic beats                      ectopic beats per 24-hour period, these will     Sustained palpitations
because of a compensatory pause after the                      most usually be benign and not signify an        Sustained rapid palpitations of gradual
ectopic beat, with an associated increase                      increased risk of adverse cardiovascular         onset and offset over minutes or longer
in diastolic filling and supra-normal stroke                   outcomes.                                        periods of time may represent sinus
volume of the post-ectopic sinus beat.                                                                          tachycardia. This is also usually benign,
Ectopic beats may occur repetitively in                        Heart rate devices                               particularly at times of anxiety or stress.
patterns (bigeminal, trigeminal, etc) or                       It is also common for patients to seek           Less often, sinus tachycardia may
may be isolated. The frequency of ectopic                      medical attention for ‘palpitations’ when        signify an underlying disorder such as
beats will vary day to day and may be                          they have recorded what they think may           thyrotoxicosis or anaemia.
                                                                                                                   Sustained rapid palpitations of sudden
                                                                                                                onset may be regular or irregular.
                                                                                                                Patients describe a sudden onset of rapid
                                                                                                                palpitations that may last from minutes to
                                                                                                                hours continuously. In the case of atrial
                                                                                                                fibrillation, this may continue for days or
                                                                                                                be continuous until treated.

                                                                                                                Rapid regular palpitations
                                                                                                                In the vast majority of patients, presenting
                                                                                                                with sudden-onset regular sustained
                                                                                                                rapid palpitations will signify episodes
                                                                                                                of supraventricular tachycardia (SVT); in
                                                                                                                contrast, patients with sinus tachycardia

                                                                                                                Box 1. Palpitations: Key questions in

                                                                                                                Onset and offset: sudden or gradual
                                                                                                                Duration: momentary or sustained
                                                                                                                (how long?)

Figure 1. Common types of SVT and representative circuits                                                       Triggers (frequently may not be obvious)
The small circuit in dots represents typical AVNRT, short dashes represent (orthodromic) AVRT                   Associated symptoms
(via a right free wall pathway represented by the red dashes), and long dashes represent atrial                 • Pre-syncope/syncope
flutter. The yellow arc represents the AV node.                                                                 • Breathlessness
AVNRT, atrioventricular nodal re-entrant tachycardia; AVRT, atrioventricular re-entrant tachycardia;            • Chest pain (possibly ischaemic in nature)
RA, right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle
                                                                                                                Existing cardiac conditions

© The Royal Australian College of General Practitioners 2019                                                    REPRINTED FROM AJGP VOL. 48, NO. 4, APRIL 2019 |   205
CLINICAL                                                                                                                         APPROACH TO PALPITATIONS

may have a more gradual onset.11 SVT                      cardiac function in patients presenting         with the development of cardiomyopathy
may classically be induced by sudden                      with palpitations, as abnormalities can         and cardiac arrhythmia such as atrial
movements, particularly bending. Many                     significantly affect management and             fibrillation.14 Family history should be
younger patients, including athletes, may                 prognosis.                                      explored, particularly regarding genetic
describe a sudden onset of excessive heart                                                                arrhythmia syndromes and history of
rate during exertion that may interfere                   Rapid irregular palpitations:                   sudden cardiac death.
with their ability to compete. However,                   Atrial fibrillation                                A systematic review identified
many patients find no particular trigger,                 Patients with paroxysmal or persistent atrial   only six factors from the history that
and events can occur at rest. While SVT                   fibrillation may present with sustained         significantly correlated with arrhythmia:
may cause sudden light-headedness at                      palpitations. These are usually described       age of >60 years, regular palpitations,
onset, syncope is unusual. Patients may                   as heartbeats that are very irregular or ‘all   palpitations affected by sleep, regular
also complain of chest discomfort or                      over the place’. Patients frequently have       pounding sensation in neck (atrial
breathlessness during the event.                          associated exertional breathlessness.           contraction against a closed tricuspid
   Patients with sustained palpitations                   Syncope due to a rapid ventricular rate         valve as in atrioventricular nodal re-entry
and significant associated symptoms                       in atrial fibrillation is unusual. When         tachycardia), visible neck pulsations,
(eg pre-syncope, breathlessness or                        patients with paroxysmal atrial fibrillation    and vasovagal symptoms (pallor or
chest pain) require early referral for                    have syncope, this is frequently due to         diaphoresis).12
evaluation. Patients presenting with                      a significant sinus pause at the time of
syncope or ongoing chest pain should be                   spontaneous reversion (ie tachycardia-          Examination
transferred to an emergency department                    bradycardia syndrome). While chest pain         Examination will also usually be performed
by ambulance.                                             during atrial fibrillation may be solely        in between episodes of arrhythmia, and
   Young patients with rapid palpitations,                secondary to a rapid ventricular response       it should address any cardiac or systemic
particularly young women, may be                          rate, if the pain is ischaemic in nature it     illness that might be implicated in the
misdiagnosed as having panic attacks.                     may reflect underlying coronary artery          development of arrhythmia including
Anxiety and distress may be a normal                      disease. Polyuria may be associated with        weight (obesity may contribute to
response to an episode of SVT, and the                    paroxysmal atrial fibrillation because of       atrial fibrillation), resting heart rate,
history will clarify whether the SVT or                   the associated release of atrial natriuretic    hypertension, signs of heart failure,
anxiety occurred first.                                   peptide.12 Atrial fibrillation onset during     cardiac murmurs (valvular heart disease),
   Patients with SVT can frequently (but                  the night may suggest a vagal mechanism         thyroid examination and signs of anaemia.
not universally) terminate an event with                  or be a sign of associated sleep-disordered     Fluid status and postural blood pressure/
vagal manoeuvres. These include the                       breathing (eg obstructive sleep apnoea).        heart rate should also be measured, given
Valsalva technique or cold stimulus to                    An understanding of the frequency and           the association of hypovolaemia with
the face.                                                 duration of palpitations over the patient’s     sinus tachycardia and the possibility of
                                                          life is required, as the symptomatic burden     autonomic dysfunction when there is
Does ventricular tachycardia                              will often define the management strategy       an inappropriate sinus tachycardia with
present as recurrent palpitations?                        (eg conservative management versus              postural change. In a systematic review,
Patients with ventricular tachycardia                     medications or electrophysiology study).        the only clinical sign that significantly
infrequently present with palpitations                        The history should include review           correlated with arrhythmia was abnormal
as an isolated presenting symptom. The                    of background medical issues that               resting heart rate (100 beats per minute).12
uncommon idiopathic ventricular                           cardiovascular disease, thyroid illness),
tachycardia, particularly when it is                      psychiatric history, medication history
recurrent and non-sustained. In most                      and illicit substances that may contribute      Diagnostic work-up
cases, ventricular tachycardia occurs in                  to arrhythmia (eg stimulant, weight             The gold standard diagnostic technique
the context of underlying structural heart                loss medication). Alcohol history is            for a patient with palpitations is
disease (most commonly prior myocardial                   important given the association of alcohol      to be monitored using a 12-lead
infarction), and patients present with                    consumption with the risk of atrial             electrocardiogram (ECG) at the time of
features of haemodynamic compromise.                      fibrillation.13 Although some patients          symptoms. However, due to the transitory
This may include syncope, diaphoresis,                    describe palpitations associated with           nature of arrhythmia, this method tends
chest pain and breathlessness. Such                       caffeine intake, a recent study identified      to be the exception rather than the rule.
patients would usually be transferred                     no increased risk of any arrhythmia with        All patients presenting between symptoms
directly to an emergency department                       caffeine intake, even after adjustment          should have a 12-lead ECG, because the
when sustained events occur. As structural                for confounders.8 An exercise history           sinus rhythm ECG can sometimes infer
heart disease may cause palpitations                      could be helpful given that extreme             an arrhythmic mechanism (Table 1).
(and vice versa), it is important to assess               endurance exercise can be associated            Ambulatory electrocardiographic

206   | REPRINTED FROM AJGP VOL. 4 8, NO. 4, APRIL 2019                                                    © The Royal Australian College of General Practitioners 2019
APPROACH TO PALPITATIONS                                                                                                                                   CLINICAL

monitoring (eg Holter monitor, external                         the arrhythmia, though can often be             recorder can be considered for patients
loop recorder, implantable loop recorder,                       performed following specialist referral.        with sporadic palpitations (
CLINICAL                                                                                                                                        APPROACH TO PALPITATIONS

Table 2. Ambulatory ECG monitoring: Choice of investigation
                                    Investigation of choice:
Investigation                       symptom frequency                    Advantages                              Disadvantages

12-lead ECG                         -                                    Readily available                       Rarely performed during arrhythmia

24–48 hour Holter                   Daily to every second day            Usually available                       Low yield other than for daily arrhythmias
monitor                                                                  Does not require activation:
                                                                         asymptomatic arrhythmia
                                                                         can be detected

Loop/event recorder                 Weekly–monthly                       Increased yield and cost                Most units only record ECG if patient triggered;
(range of 1–4 weeks)                                                     effectiveness (versus Holter)           not useful for asymptomatic arrhythmia or
Loop/event recorder for
                                                                                                                 Generally only one-week recorders available
one week
                                                                                                                 Patient discomfort for longer-term monitoring

Implantable loop                    Months to year/s                     High yield                              Cost
recorder                                                                 Long-term monitoring                    Not available in all centres
                                                                         approximately three years               Currently only approved for diagnosis of syncope
                                                                         Automatic bradycardia/                  or cryptogenic stroke
                                                                         tachycardia storage plus
                                                                         patient-triggered episodes

Handheld ECG                        Months to year                       High yield                              Cost to patient
                                                                         Permanently available                   Time for activation of device before arrhythmia
                                                                         to patient                              termination
                                                                                                                 Potential large volume of data to interpret, no
                                                                                                                 Medicare rebate
                                                                                                                 Data ownership with some systems, sometimes
                                                                                                                 requiring subscription

ECG, electrocardiography

Authors                                                    2. Weber BE, Kapoor WN. Evaluation and outcomes              9. Ng GA. Treating patients with ventricular ectopic
Alex JA McLellan MBBS, PhD, Cardiology                        of patients with palpitations. Am J Med                      beats. Heart 2006;92(11): 1707–12. doi: 10.1136/
Department, Royal Melbourne Hospital, Vic;                    1996;100(2):138–48.                                          hrt.2005.067843
Cardiology Department, St Vincent’s Hospital               3. Probst MA, Mower WR, Kanzaria HK, Hoffman JR,             10. Reddy RK, Pooni R, Zaharieva DP, et al. Accuracy
Melbourne, Vic; Baker Heart & Diabetes Institute, Vic         Buch EF, Sun BC. Analysis of emergency                        of wrist-worn activity monitors during common
                                                              department visits for palpitations (from the
Jonathan M Kalman MBBS, PhD, Cardiology                                                                                     daily physical activities and types of structured
                                                              National Hospital Ambulatory Medical Care
Department, Royal Melbourne Hospital, Vic;                                                                                  exercise: Evaluation study. JMIR Mhealth Uhealth
                                                              Survey). Am J Cardiol 2014;113(10):1685–90.
Cardiology Department, St Vincent’s Hospital                                                                                2018;6(12):e10338. doi: 10.2196/10338.
                                                              doi: 10.1016/j.amjcard.2014.02.020.
Melbourne, Vic; Baker Heart & Diabetes Institute, Vic;
                                                           4. Lessmeier TJ, Gamperling D, Johnson-Liddon V,             11. Raviele A, Giada F, Bergfeldt L, et al. Management
Faculty of Medicine, Dentistry, and Health Sciences,
                                                              et al. Unrecognized paroxysmal supraventricular               of patients with palpitations: A position paper
University of Melbourne, Vic.
                                                              tachycardia. Potential for misdiagnosis as panic              from the European Heart Rhythm Association.
Competing interests: None.
                                                              disorder. Arch Intern Med 1997;157(5):537–43.                 Europace 2011;13(7):920–34. doi: 10.1093/
Funding: Dr McLellan is supported by an Australian                                                                          europace/eur130.
                                                           5. Porter MJ, Morton JB, Denman R, et al.
National Heart Foundation postdoctoral fellowship.            Influence of age and gender on the mechanism              12. Thavendiranathan P, Bagai A, Khoo C,
Professor Kalman is supported by a practitioner               of supraventricular tachycardia. Heart                        Dorian P, Choudhry NK. Does this patient
fellowship from the National Health and Medical               Rhythm 2004;1(4):393–96. doi: 10.1016/j.
Research Council. This research is supported in                                                                             with palpitations have a cardiac arrhythmia?
part by the Victorian Government’s Operational                                                                              JAMA 2009;302(19):2135–43. doi: 10.1001/
                                                           6. Thavendiranathan P, Bagai A, Khoo C,                          jama.2009.1673.
                                                              Dorian P, Choudhry NK. Does this patient
Provenance and peer review: Commissioned,                                                                               13. Voskoboinik A, Prabhu S, Ling LH,
                                                              with palpitations have a cardiac arrhythmia?
externally peer reviewed.                                     JAMA 2009;302(19):2135–43. doi: 10.1001/                      Kalman JM, Kistler PM. Alcohol and atrial
                                                              jama.2009.1673.                                               fibrillation: A sobering review. J Am Coll
References                                                                                                                  Cardiol 2016;68(23):2567–76. doi: 10.1016/j.
                                                           7.   Gale CP, Camm AJ. Assessment of palpitations.
                                                                BMJ 2016;352:h5649 doi: 10.1136/bmj.h5649.                  jacc.2016.08.074.
1.   Raviele A, Giada F, Bergfeldt L, et al. Management
     of patients with palpitations: A position paper       8. Dixit S, Stein PK, Dewland TA, et al. Consumption         14. Flannery MD, Kalman JM, Sanders P, La Gerche A.
     from the European Heart Rhythm Association.              of caffeinated products and cardiac ectopy. J Am              State of the art review: Atrial fibrillation in athletes.
     Europace 2011;13(7):920–34. doi: 10.1093/                Heart Assoc 2016;5(1). pii: e002503. doi: 10.1161/            Heart Lung Circ 2017;26(9):983–89. doi: 10.1016/j.
     europace/eur130.                                         JAHA.115.002503.                                              hlc.2017.05.132.

208    | REPRINTED FROM AJGP VOL. 4 8, NO. 4, APRIL 2019                                                                  © The Royal Australian College of General Practitioners 2019
APPROACH TO PALPITATIONS                                                                                                                                 CLINICAL

                                                                     History, examination, ECG

                                                      Echocardiogram if cardiovascular symptoms/risk factors
                                                                 Holter monitor for frequent palpitations

                          Diagnosis confirmed, structurally
                                                                                                    Unexplained palpitations
                             normal heart, normal ECG

                                                                                         Structural heart
                                                                                                                              Structurally normal
                          Yes                                      No                   disease/abnormal

           Manage as appropriate,                                                                                                             No further
         consider referral if sustained                  Consider cardiology/EP       Cardiology/EP                                        management if
                                                                                                             referral if frequent
           palpitations or warning                              referral                 referral                                        infrequent and not
                                                                                                               and distressing
                    signs*                                                                                                                   distressing

    Figure 2. Approach to the patient with palpitations1
    ECG, electrocardiogram; EP, electrophysiology
    *Refer to Box 2

Box 2. Which patients to refer or ‘When to worry’

Patients with frequent or persistent palpitations
Sustained rapid palpitations
Significant associated symptoms:
• Pre-syncope/syncope (consider situational context)
• Breathlessness
• Chest pain
Family history of recurrent syncope or of sudden death
Significant resting 12-lead electrocardiography or echocardiographic
• Wolff–Parkinson–White syndrome (pre-excitation including short PR
  interval and delta wave)
• Signs of structural or electrical abnormalities:
   –– T wave abnormalities
   –– Prior myocardial infarction (Q waves)
   –– Long or short QT interval, Brugada pattern, early
      repolarisation pattern

© The Royal Australian College of General Practitioners 2019                                                  REPRINTED FROM AJGP VOL. 48, NO. 4, APRIL 2019 |   209
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