Palpitations

Contributors

  • Alex Bush

Palpitations

Palpitation refers to "an unpleasant awareness of the heart beating in the chest".  This is when sudden awareness of the heart beating interrupts unrelated thoughts.  Patients often describe the feeling as "thumping", "pounding", "fluttering" or "racing". Palpitations are commonly experienced on an occasional basis by people in all age groups.  They are usually harmless; however frequent palpitations or palpitations with associated symptoms such as pre syncope or syncope can be an indication of an underlying condition.

 

Pathophysiology

Three general pathophysiological mechanisms cause palpitations.  These are:

 

  1. Abnormally fast, slow or irregular contraction of the heart.
  2. Abnormally forceful contraction of the heart.
  3. Altered perception of heartbeat.

 

 

    Causes

    Diagram to show some common causes of palpitations

    History and Examination

    History

    Patients will usually not be experiencing palpitations at the time that they are seen by a doctor. Taking a good history is therefore an important first step towards forming a diagnosis. There are several key areas to explore in the history aimed at distinguishing the nature of the pathophysiological mechanism involved.

     

    • First, confirm that what the patient is experiencing are indeed palpitations.

     

      Next, the history of the presenting complaint should be taken including a systematic description of the episodes from start to finish.

       

      • Precipitating factors.

                  -  What was the patient doing when the episode came on? (e.g. exercising, drinking alcohol

                     or coffee, taking medical or other drugs, experiencing emotional or physical stress, was the

                     patient standing or sitting?)

       

        • Onset

                    -  Was the onset sudden or gradual?

                    -  Did the patient experience any other symptoms directly preceding the event? e.g.Chest

                       pain, dizziness, lightheadedness, 

                       shortness of breath, or syncope

         

        • Duration

                    -  Assess the character of the rhythm.  Was the rhythm regular or irregular, rapid or slow?  It

                       can be helpful to ask the patient to tap out the rhythm for you.

                    -  Did the patient experience any other symptoms during the episode? e.g.Chest pain,

                       dizziness, lightheadedness, shortness of

                       breath, or syncope

                      -  How long did the episode last?

           

          • Termination

                      -  Did the symptoms subside suddenly or gradually?

                      -  Did the patient do anything to stop the symptoms?

           

          • Past history of the presenting symptoms.

                      -  Has the patient experienced these symptoms before? How many times, or how often? 

                      -  When was the first time that they experienced them?

           

          The remainder of the history is the same as for other medical histories, including a systems review, past medical history, drug and allergies history, family history and social history.  There are however some key areas to focus on.

           

          • Past medical history.

                      -  Previous cardiovascular disease, particularly coronary heart disease or valvular heart disease.

                      -  Previous psychosomatic, thyroid or systemic disease.

           

          • Family history.

                      -  Cardiovascular disease (tachycardia) or sudden cardiac death.

           

          • Drug history.

                       -  A thorough drug history is important as many drugs can cause palpitations as a side

                          effect.

           

          • Social history.

                       -  Drug and alcohol abuse.

           

            Examination

            More often than not, a physical examination will take place at a time when the patient is not experiencing symptoms.  Signs may still be present however that could reveal the underlying cause of the palpitations and help to establish a diagnosis. 

             

            The examination follows standard procedures: Observe, inspect, palpate and auscultate.  It is important to do a thorough cardiovascular exam, checking for signs of disease (hypertension, murmur, oedema, etc) and also to examine for other systemic diseases. 

             

            If a patient does experience palpitations during a consultation, the rate and rhythm of the pulse should be examined, followed by an assessment of the patient's cardiovascular state during the episode.

             

            When examining a patient, important ALARM signs to look out for are:

            -Reduced consciousness level

            -Chest pain

            -Systolic BP <90 mmHg

            -Heart failure

             

            For all patients an ECG should be performed whether or not they are experiencing symptoms, as signs of an underlying condition can still be present on the ECG and the results will influence the need for further investigation. 

             

            The findings of the history and examination will indicate the aetiology of the palpitations in about half of patients, and can rule out, with some certainty, a sinister cause.

             

            Characteristic Presentations

            Some characteristic descriptions of types of palpitations are listed below:

             

            • Extrasystole - Sudden onset, irregular 'skipping' pulse triggered by rest.

             

              • Atrial Fibrillation - Variable rate, irregular pulse triggered by effort, cooling, meal, or alcohol.  May be accompanied by polyuria.

               

              • Other tachycardias (atrial flutter, ventricular tacchycardias) - Sudden onset, fast, regular pulse triggered by effort.  May be accompanied by syncope, shortness of breath or chest pain.

               

              • Anxiety - Gradual onset, slightly fast, regular pulse triggered by stress.  May be accompanied by tingling, dyspnoea, or sensation of a 'lump in the throat'.

               

                Investigations

                Palpitations are usually benign, and common arrhythmias such as extra systole or sinus tachycardia have a very good outcome if no structural heart disease is present. Therefore patients with a  low probability of an arrhythmic cause and no history of cardiovascular disease often do not require further investigation. In other cases, specialist assessment should be considered.  Investigations

                 

                • All patients should recieve an ECG whether symptoms are present or not.

                 

                • Stress testing should be carried out where palpitations are associated with exercise or coronary heart disease.

                 

                • Echocardiography should be carried out where a structural cause is suspected based on the history and examination.

                 

                • An Ambulatory ECG should be carried out for recurrent palpitations of unknown origin. 

                 

                • Electrophysiology can be considered for recurrent palpitations of unknown origin that remain undiagnosed with ambulatory ECG.

                 

                   

                  See the diagram below for the diagnostic approach.

                    Diagnostic Strategy



                    Management

                    Management is aimed at treating the underlying cause of the palpitations. The main treatment strategies are outlined below.

                     

                    • Benign arrhythmia with no underlying heart disease:  Reassure the patient and arrange follow up.

                     

                    • Anxiety: Reassure the patient, discuss stress reduction and refer for psychiatric assessment/treatment if required.

                     

                    • Caffeine, alcohol, drugs: Reassure the patient, encourage cessation of use of the responsible substance. Refer for  specialist care if necessary.

                     

                    • Systemic conditions:  Treat the systemic condition where possible.

                     

                    • Structural abnormalities: Assess the patient's clinical picture.  If appropriate, surgery can be offered to repair abnormalities.

                     

                    • Arrhythmias:  Anti-arrhythmic drugs, implantable cardiac defibrillators, and endocardial or surgical ablations could be considered.

                     

                      Prognosis

                      Most causes of palpitations are benign, and mortality is low.   They are not without morbidity however as recurrent episodes can cause anxiety and reduce quality of life.  When managing palpitations it is important to consider the effect on the patient's quality of life as well as managing the underlying condition.

                      Summary

                      D-Definition, A-Aetiology, P-Pathophysiology, H+E-History and Examination, C-Characteristic Presentations, I-Investigations, T-Treatment, P-Prognosis



                      References

                      • Douglas G, Nicol F, Robertson C. Macleod's Clinical Examination. Churchill Livingston. 12th Edition.2009
                      • http://www.medscape.com/viewarticle/745651_3