PEER REVIEWED FEATURE 2 CPD POINTS

CLINICAL INVESTIGATIONS FROM THE RACP The patient with palpitations Cardiac, systemic or psychosomatic?

LIANG-HAN LING MB BS, PhD, FRACP PETER KISTLER MB BS, PhD, FRACP In this series, we present authoritative advice on the investigation of a common clinical problem, especially commissioned for family doctors and written by members of the Royal Australasian College of Physicians.

alpitations are one of the most commonly encountered KEY POINTS presenting complaints in general practice.1 A definitive • During the initial consultation, careful history taking, diagnosis depends on electrocardiographic recording physical examination and a baseline ECG often reveal the of the heart rhythm at the time of spontaneous symp- likely cause of palpitations to be cardiac, systemic or Ptoms.2 Management should address the underlying cause of psychosomatic. the palpitations, which may fall broadly into cardiac or • Concerted attempts should be made by both doctor and ­noncardiac categories (Box 1). Determining the underlying patient to obtain an electrocardiographic recording during cause requires careful history taking, physical examination palpitations, as this provides the basis for a definitive and the judicious use of investigations.3,4 diagnosis. • Echocardiography is essential to evaluate for the presence of MedicineToday 2015; 16(10): 43-47 structural heart disease. Dr Ling is a Cardiologist and Electrophysiologist at the Heart Centre, • Specific investigations should be performed if there is clinical The Alfred Hospital, Melbourne; Collaborating Researcher at the Baker IDI suspicion of an underlying systemic condition. Heart and Diabetes Institute, Melbourne; and National Heart Foundation • Referral of patients with documented arrhythmias to a Postdoctoral Research Fellow in the Faculty of Medicine, Dentistry and Health cardiac electrophysiologist is warranted, as many may be Sciences, University of Melbourne, Melbourne. Professor Kistler is Head of treated effectively with catheter ablation; however, other Electrophysiology at the Heart Centre, The Alfred Hospital, Melbourne; Head of patients may be managed by their GP or referred to a general Electrophysiology at the Baker IDI Heart and Diabetes Institute, Melbourne and cardiologist for further evaluation. Professor in the Faculty of Medicine, Dentistry and Health Sciences, University • Patients with benign palpitations due to isolated ectopy, of Melbourne, Melbourne, Vic. He is also a Practitioner Fellow of the National anxiety or psychosomatic conditions should be treated with Health and Medical Research Council.

reassurance and counselling. SERIES EDITOR: Christopher S. Pokorny, mb bs, fracp, frcp, facg, is Conjoint Copyright _Layout 1 17/01/12 1:43 PM Page 4 Associate Professor of Medicine at the University of New South Wales, and SUMNERSGRAPHICSINC/ISTOCKPHOTO

© Visiting Gastroenterologist, Sydney and Liverpool Hospitals, Sydney, NSW.

MedicineToday ❙ OCTOBER 2015, VOLUME 16, NUMBER 10 43 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. patient with palpitations continued

be normal, slow or rapid, and the rhythm report that bed rest reliably terminates 1. CAUSES OF PALPITATIONS regular or irregular. Irregular palpitations their palpitations, although this helps little may be caused by atrial fibrillation, in establishing a diagnosis. Cardiac causes supraventricular tachycardia with variable Cardiac arrhythmias atrioventricular conduction or frequent Determine whether associated Supraventricular ectopy, ventricular ectopy of atrial or ­ventricular origin.1 symptoms are present ectopy, supraventricular tachycardia, atrial fibrillation, atrial flutter, ventricular Missed or skipped beats occurring at rest The presence of associated symptoms will tachycardia, pacemaker-mediated are extremely common complaints and help in reaching a diagnosis. Syncope tachycardia usually signify benign isolated ectopy. warrants urgent evaluation to differentiate Structural heart disease benign causes such as vasovagal events Mitral valve prolapse, severe valvular Characterise the pattern of from more serious causes, including dysfunction, mechanical heart valves, palpitations ­potentially lethal cardiac arrhythmias or intracardiac shunts, dilated The pattern of palpitations can be char- decompensated heart failure. If the pal­ cardiomyopathies, hypertrophic cardiomyopathies acterised by determining how often the pitations are accompanied by breath­ palpitations occur and how long the epi- lessness or faintness, this may reflect a Noncardiac causes sodes last. Palpitations may be short-lived degree of haemodynamic compromise or Systemic disorders or persistent and may occur once to several anxiety. Patients with palpitations and Pyrexia, anaemia, hypovolaemia, times daily, weekly, monthly or yearly. The chest pain suggestive of angina should be hypoglycaemia, pregnancy, postmenopausal syndrome, postural patient should be asked to describe one or evaluated for underlying coronary artery orthostatic tachycardia syndrome, two of the most severe e­pisodes, as not disease. hyperthyroidism, phaeochromocytoma, infrequently there is more than one pat- arteriovenous fistula tern of palpitations. The more prominent Relevant background history Effects of medications and recreational and distressing pattern should be identi- It is important to collect details of the drugs fied by the patient. patient’s background history. Relevant Sympathomimetic agents, beta-blocker withdrawal, benzodiazepine withdrawal, There may be specific factors that trig- details to ask about include: weight loss medications, alcohol, ger the palpitations. Palpitations may • occupation caffeine, energy drinks, cannabis, ­normally follow intense exercise, emotional • involvement in sport amphetamines, cocaine stress or postural change, and in this • previous cardiac disease Psychosomatic disorders ­setting are generally brief and disregarded • previous thyroid disease Anxiety, panic attacks, depression, by healthy individuals. If the patient • other medical conditions somatisation decides to bring these palpitations to the • previous depression, anxiety or Physiological palpitations attention of their doctor then they may be ­psychosomatic conditions Exercise, emotional stress – consider a hidden patient agenda* experiencing exaggerated symptoms, • family history of cardiac conditions, ­signalling the presence of an underlying unexplained fainting spells and * Desire to discuss interpersonal or psychosocial problems. organic pathology, a psychosomatic unexpected death ­disorder or a hidden patient agenda, such • medical and recreational drug use as the need to discuss issues of inter­ around the time of episodes. History taking personal conflicts or psychosocial stress- Establish that the patient is ors. Triggers associated with adrenergic Physical examination describing palpitations activation may induce palpitations by Patients are normally asymptomatic at When taking a history from the patient, causing cardiac arrhythmias, by increas- the time of clinical e­ valua­tion. Physical it is first important to establish that the ing cardiac contractility and/or through examination is directed at finding symptoms the patient is describing are psychological mechanisms. ­Medications evidence­ of: ­palpitations. The patient should be asked and drugs are frequently reported triggers • ongoing arrhythmia what the feeling is like. ‘Palpitations’ of palpitations. • cardiomyopathy/heart failure describes the uncomfortable awareness of Palpitations that start and stop abruptly • vascular disease and risk factors the heart’s pulsations. The term is some- are more frequently due to cardiac • structural heart disease, including times used loosely by patients to refer to arrhythmia. Episodes of palpitations may valvular disease chest pain or pulsatile tinnitus. end spontaneously. Vagal manoeuvres or • prior cardiac surgery or device It is helpful for Copyrightthe patient _Layout to tap 1 out 17/01/12 drug 1:43 administration PM Page 4 may slow or termi- implantation the beat of the palpitations. The rate may nate some arrhythmias. Patients often • signs of systemic disease.

44 MedicineToday ❙ OCTOBER 2015, VOLUME 16, NUMBER 10 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. Initial investigations Interrogation of implanted cardiac Ectopic beats Establishing the patient’s heart rhythm devices An important and common cause of during palpitations is crucial to dif­ Patients with implantable pacemakers, ­palpitations is a heightened awareness of ferentiating between cardiac arrhythmias cardioverter defibrillators and loop one’s own heart beat – either the normal and other potential causes and is therefore recorders who are experiencing palpita- beat or atrial or ventricular ectopic beats. central to definitive diagnosis.2 Unless tions should be referred to their treating Although this is often considered by the patient clearly describes i­nfrequent cardiologist for device interrogation, ­clinicians to be a ‘psychosomatic’ condi- ­isolated ectopy in their history (i.e. skipped which may provide documentary evidence tion, patients often have no other psycho- beats, missed beats or intermittent slow of an arrhythmia. logical issues except maybe some anxiety. heavy beats with no associated symptoms), Implantable loop records, typically The key management strategy is to listen reasonable efforts should be made to used in the investigation of syncope, may carefully to the patient, exclude another acquire electro­cardiographic ­evidence of be useful in selected patients with severe, cause, exclude underlying heart disease isolated ectopy using one of the methods sporadic palpitations, where other inves- and then to explain the phenomenon to below. Other investigations including tigations have failed to identify their cause. the patient. echocardiography are ­important adjuncts Several devices are available, some the size An ectopic beat can be described as an to diagnosis. of a USB memory stick or smaller. They early inefficient beat often followed by a are implanted in the left pectoral region pause and then a stronger beat as the Electrocardiography and continuously monitor the patient’s rhythm resets itself. Some people feel the Electrocardiography (ECG) is an essential cardiac rhythm, recording episodes either missed beat, some feel the f­ollowing element of the initial evaluation. A 12-lead when automatically detected or patient stronger beat and many feel nothing at all. ECG should be performed for every activated (using a remote controller). Just this explanation is often enough to patient presenting with palpitations. The reassure the patient and stop the sensation recording must be identified, dated and whereas a simple ‘they’re only ectopics – time stamped, and the presence or absence The patient should be provided don’t worry’ is usually not sufficient. If of symptoms at the time of the recording frequent symptoms persist despite reassur- with a copy of the ECG for future documented. ance, or if Holter monitoring reveals very The patient should be provided with a reference by other healthcare frequent ventricular ectopy (>10,000 beats copy of the ECG for future reference by professionals. per 24 hours), or if the left ventricle is other healthcare professionals. If prior ­structurally or functionally abnormal, then ECGs and ambulatory monitoring have referral of the patient to a cardiologist is failed to capture symptomatic ­episodes, warranted. then patients should be advised to report Cardiac imaging to an emergency department or medical Echocardiography is essential to evaluate Other documented arrhythmias practice immediately for a 12-lead ECG for the presence of structural heart Patients with documented arrhythmias, when they experience prolonged or severe disease. except for infrequent ectopy, should be palpitations that have not yet been diag- referred to a cardiac electrophysiologist nosed, and retain a copy of the ECG for Other initial investigations for appropriate counselling and review future reference. Specific tests should be performed if there of their treatment options, as many can is clinical suspicion of an underlying potentially be treated effectively with Holter monitoring, event monitoring ­systemic condition. These may include a catheter ablation.6,7 Accurate diagnosis and exercise stress testing full blood count, thyroid function test, of the culprit arrhythmia is assisted Patients with daily or weekly symptoms measurement of plasma and urinary meta- greatly by providing the specialist with warrant 24-hour or seven-day Holter nephrine and electrolyte levels, and urine copies of all relevant ECG and Holter ­monitoring. Mobile ECG monitoring drug screening for illicit substances. monitor recordings for review. As devices may be fitted to smart phones and Patients with chest pain should be evalu- described above, one of the most common allow the recording of a single-lead ECG.5 ated for coronary ischaemia. ECG findings in patients reporting pal- A symptom diary is required for correlation pitations is isolated atrial ectopy. Depend- with recordings. Exercise stress testing may Management ing on clinical experience, this benign be required to reproduce exercise-induced A suggested algorithm for the manage- finding can often be managed at a primary palpitations and is generallyCopyright organised_Layout 1 17/01/12by ment 1:43 of patientsPM Page with 4 palpitations is shown care level. Avoidance of adrenergic sub- a cardiologist. in the flowchart. stances and reassurance of the patient

MedicineToday ❙ OCTOBER 2015, VOLUME 16, NUMBER 10 45 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. patient with palpitations continued

SUGGESTED ALGORITHM FOR THE MANAGEMENT OF A PATIENT WITH PALPITATIONS

A patient presents with palpitations

Initial consultation • History, examination, ECG • Systemic causes suspected: appropriate initial investigations

Obtain echocardiogram and electrocardiographic recording of palpitations For palpitations that are: • ongoing – immediate 12-lead ECG • daily to weekly – 24-hour or 7-day Holter monitoring • infrequent to sporadic – emergent 12-lead ECG. Device interrogation where appropriate

Arrhythmic palpitations Nonarrhythmic palpitations Failure to record cardiac confirmed or strongly confirmed: normal cardiac rhythm during suspected* rhythm during clinical palpitations despite symptoms reasonable attempts

Refer to cardiac electrophysiologist Heart Systemic Psychosomatic Intrusive Non-intrusive disease causes, causes or palpitations palpitations documented medications psychological or abnormal with normal or strongly and drugs concerns cardiac ECG and suspected investigations echocardiogram

Refer to Investigate Reassure and Refer to cardiac Reassure and general or and treat address electrophysiologist advise relevant underlying psychological re-evaluation subspecialty cause concerns if symptoms cardiologist escalate

Abbreviation: ECG = electrocardiogram. * Arrhythmic palpitations are strongly suspected if: • palpitations are consistently of sudden onset and offset • palpitations are rapid and reliably terminated by vagal manoeuvres • palpitations are exercise induced • palpitations are rapid and associated with syncope or severe breathlessness • ventricular pre-excitation is present on ECG that the condition is benign may be noncardiac cause should be sought. as thyrotoxicosis should be investigated ­sufficient to control symptoms. Patients showing objective evidence of and managed accordingly. Palpitations For patients in whom normal sinus cardiac disease require specialist evalua- due to the effects of medications and rhythm is recordedCopyright during spontaneous_Layout 1 17/01/12 tion 1:43 by a PM general Page or 4 subspecialty cardiolo­ ­recreational drugs are generally self-­ symptoms, an underlying cardiac or gist. Those with systemic disorders such limiting and readily reversible with the

46 MedicineToday ❙ OCTOBER 2015, VOLUME 16, NUMBER 10 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. palpitations, the possibility of a hidden the atrial fibrillation ablation procedure: the 2. INDICATIONS FOR INPATIENT iTransmit study. Heart Rhythm 2015; 12: 554-559. MANAGEMENT OF PATIENTS WITH patient agenda should be explored using PALPITATIONS an empathic and nonconfrontational 6. Stevenson WG. Current treatment of ventricular approach. Hidden agendas may include arrhythmias: state of the art. Heart Rhythm 2013; • Incessant supraventricular or the need to discuss issues of interpersonal 10: 1919-1926. ventricular tachyarrhythmias conflicts or psychosocial stressors. 7. Lee G, Sanders P, Kalman JM. Catheter requiring termination or catheter Finally, although most patients with ablation of atrial arrhythmias: state of the art. ablation palpitations may be managed on an out- Lancet 2012; 380: 1509-1519. • Suspected or confirmed potentially patient basis, hospitalisation may be lethal ventricular arrhythmias required for those requiring inpatient COMPETING INTERESTS: None. requiring further investigation or cardiac device implantation investigations and/or emergent treatment. Indications for inpatient management are ONLINE CPD JOURNAL PROGRAM • Bradycardia requiring pacemaker listed in Box 2. implantation • Severe structural heart disease What associated symptoms may be present with heart palpitations? • Haemodynamic compromise Definitive diagnosis often • Decompensated heart failure requires patience, and management • Social or psychological proceeds on the basis of a decompensation probable diagnosis. appropriate medication or lifestyle changes. Often, the infrequency of symptoms makes electrocardiographic documenta- Conclusion tion during palpitations challenging. Defin- Palpitations are a common complaint that itive diagnosis often requires patience, and requires careful clinical assessment and management proceeds on the basis of a the judicious use of investigations to © SENTELLO/DOLLAR PHOTO CLUB 1 probable diagnosis. For most patients with ­distinguish benign and serious causes. Review your knowledge of this topic nonintrusive symptoms and normal results Although many patients can be managed and earn CPD points by taking part on cardiac investigations, no specific ther- at the primary care level, those in whom in MedicineToday’s Online CPD Journal apy for the palpitations is warranted beyond underlying cardiac or systemic conditions Program. Log in to reassurance and re-evaluation should the are demonstrated or strongly suspected www.medicinetoday.com.au/cpd symptoms escalate. For those with probable should be referred to the appropriate supraventricular tachycardia, instruction ­specialist for further ­evaluation. MT on the use of Valsalva techniques is most useful, although specialist referral of the References patient would also be warranted. Here, the 1. Raviele A, Giada F, Bergfeldt L, et al; European potential frustration for both patients and Heart Rhythm Association. Management of Share your anecdotes patients with palpitations: a position paper from physicians can be avoided through the use Tell us your own personal anecdote in the European Heart Rhythm Association. Europace of clear communication and of appropriate 1000 words or less and share the 2011; 13: 920-934. counselling regarding the benign nature lessons you learned. You can use a 2. Abbott AV. Diagnostic approach to palpitations. of the palpitations. nom de plume if you wish and there Am Fam Physician 2005; 71: 743-750. In patients with intrusive palpitations or is a small reward if we publish your 3. Giada F, Raviele A. Diagnostic management of abnormal results on cardiac investigations, article in ‘Innocence revisited’. patients with palpitations of unknown origin. Ital referral to a cardiac electrophysiologist is Write to: Heart J 2004; 5: 581-586. warranted for further investigations, such Medicine Today 4. Brugada P, Gürsoy S, Brugada J, Andries E. as loop recorder implantation, electro­ PO Box 1473 Investigation of palpitations. Lancet 1993; 341: physiological studies and cardiac ­magnetic Neutral Bay NSW 2089 1254-1258. resonance­ imaging. or [email protected] Where clinical Copyrightevaluation _Layout reveals 1 no17/01/12 5. T1:43arakji PMKG, WazniPage OM, 4 Callahan T, et al. Using a cardiac explanation for the symptom of novel wireless system for monitoring patients after

MedicineToday ❙ OCTOBER 2015, VOLUME 16, NUMBER 10 47 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015.