Palpitations are a common, subjective symptom resulting in frequent presentations in the primary health care setting. Although generally benign, they can occasionally be a manifestation of a potentially life-threatening arrhythmia. Appropriate evaluation is therefore required.
Cardiac or arrhythmic causes are the most common aetiology. Other causes include medical conditions (e.g. endocrine and metabolic abnormalities), psychiatric disorders, medication effects, and drug or other substances. It is important not to label a patient’s palpitations as secondary to panic/anxiety without a proper evaluation, as around 50% of this group will be diagnosed with an arrhythmic cause.
A targeted and thorough history is required given the majority of patients present in sinus rhythm, between episodes of palpitation. The description of skips, jumps and thumps may represent ectopic beats (atrial or ventricular); rapid onset/onset of racing heart may be consistent with a supraventricular tachycardia.
Ask about onset and offset (sudden or gradual), duration (momentary or sustained), frequency of episodes, triggers, any associated symptoms (e.g. syncope, breathlessness or chest pain), pre-existing cardiac issues and any family history of sudden cardiac death or cardiac conditions.
This depends on the history, frequency and duration of episodes. A 12-lead ECG (if symptomatic at the time) is the gold standard. Ambulatory (Holter) monitoring is useful if frequent symptoms, whilst an event monitor is useful in less frequent symptoms. Loop recording (for recurrent syncope), echocardiography to evaluate heart structure and stress testing (if exercise induced or suspected IHD) can be helpful. Smart phone monitoring/apps may be the future.
Correlation of the rhythm at the time of symptoms is the key to the diagnosis (arrhythmic or not).
Thyroid function and full blood count as a baseline are recommended with further tests dependent on the history/findings.
Blood pressure and palpation of the pulse at each consultation is highly recommended as an irregularly, irregular pulse may be indicative of Atrial Fibrillation (AF). This needs confirmation with a 12-lead ECG. The diagnosis is important as AF is associated with a high morbidity and mortality, can be asymptomatic, and effective treatment including oral anticoagulation is available.
The management of palpitations depends on the cause and associated prognosis. Simple reassurance in many cases is appropriate, although medical therapy and referral to cardiac electrophysiologist may be required in some cases.
Red flags include frequent, persistent and sustained episodes and significant associated symptoms (e.g. syncope, chest pain), abnormalities on resting ECG such as T-wave abnormalities, long or short QT interval and evidence of prior AMI (Q waves) or short PR interval (possible Wolff-Parkinson White syndrome).
- Palpitations are frequent in the community
- History, examination and basic investigations can determine cause in many patients
- Case finding and management of AF is critical as is awareness of red flags.
References available on request.
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Author competing interests: nil
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