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The Patient with Palpitations Cardiac, Systemic Or Psychosomatic?

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The Patient with Palpitations Cardiac, Systemic Or Psychosomatic? 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 e pisodes, 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 evalua tion. 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 i nfrequent 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
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