Approach to Palpitations

CLINICAL

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 Background 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) 1 Objectives after chest pain. 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. presents a systematic approach to the History and physical examination 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 work-up will usually be performed workup; cardiology/electrophysiology will present in sinus rhythm, between 1 between episodes. Direction from referral and management strategies. episodes of arrhythmia. 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 3 symptom severity. of patients. 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

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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 history-taking

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

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

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 (<60 beats per minute or exception to this may be the relatively may predispose to arrhythmia (eg >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

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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 (<1 per month), hand-held ECG) can be performed In rare cases, cardiac magnetic resonance often when there is associated syncope. with the goal of correlating a transitory imaging may be considered, again usually symptom with arrhythmia, and the following specialist referral. choice of monitoring should be guided The initial diagnostic work-up will often Referral by the yield of the investigation (Table 2). be normal; however, if clinical suspicion Specialist referral should be considered The critical component of interpreting remains high (such as with a classic when there may be a substrate for the ambulatory ECG is the rhythm at history of SVT), specialist referral should significant arrhythmia, particularly atrial time of symptoms, and it should ideally be considered for electrophysiology study fibrillation and ventricular arrhythmia, also document the arrhythmia onset with or without ablation or implantable given the adverse prognostic implications and/or offset. New technologies such loop recorder (ILR). The advantages associated with these arrhythmia. This as hand-held ECG (iECG) devices (eg of electrophysiology studies include may be suggested by: AliveCor Kardia, Semacare Remon) can identifying the arrhythmia mechanism, • a history of structural heart disease; be considered for the identification of potentially curing the arrhythmia during abnormal ECG or echocardiogram arrhythmia, though these are limited by the same procedure, avoiding chronic • palpitations associated with syncope, the cost for the patient to purchase, the medication to suppress arrhythmia, and presyncope or chest pain time taken to activate the device before avoiding the delay required to document • family history of sudden cardiac death arrhythmia termination, and the large arrhythmia (eg on serial ambulatory ECG • high clinical suspicion in a patient with amount of data that may be created with monitoring or ILR); this is especially sustained palpitations. no Medicare Benefits Schedule rebate pertinent if palpitations are associated Specialist referral will often be required for analysis. with syncope or if there is structural after the initial diagnostic work-up has In patients with symptoms, risk factors heart disease. The risks of performing been completed for consideration of, or concern of cardiovascular disease, an electrophysiology study include the and access to, longer-term monitoring or echocardiogram should be performed invasive nature of the procedure electrophysiology study with or without (Figure 2). Where symptoms occur on (including vascular access complication) ablation. exertion, an exercise stress test can be and the rare risk of damage to the AV considered to both induce and document node during ablation. An implantable loop Management The management of palpitations will Table 1. Sinus rhythm ECG markers of arrhythmia1 depend on the arrhythmia mechanism and implicated prognosis. Many patients Electrocardiographic sign Implication/consideration with a subjective awareness of their own heartbeat or infrequent palpitations Pre-excitation/delta wave WPW – AVRT consistent with ectopic beats can be Left atrial enlargement, frequent PACs, Atrial fibrillation treated with reassurance and support. sinus bradycardia Box 2 includes a list of which patients should be considered for referral. Patients Left ventricular hypertrophy Atrial fibrillation, ventricular tachycardia with certain occupations (eg pilots, Frequent PVCs Ventricular tachycardia commercial truck drivers) will require specialist referral for consideration of Q waves Ischaemic heart disease – atrial fibrillation, occupational implication, diagnostic ventricular tachycardia and treatment strategies. Patients with Widespread T wave inversion across Hypertrophic cardiomyopathy – risk of atrial suspected or documented SVT should be precordial leads, LVH, Q waves and ST- fibrillation, ventricular tachycardia educated regarding the Valsalva manoeuvre, segment changes which can often terminate arrhythmia. Long or short QT interval, Brugada pattern, Genetic arrhythmia syndromes – risk of early repolarisation pattern sudden cardiac death Conclusion Inverted T waves or Epsilon waves across ARVC – risk of sudden cardiac death Palpitations are common and, while usually right precordial leads (V1–V3)* benign, may rarely be associated with ARVC arrhythmogenic right ventricular cardiomyopathy; AVRT, atrio-ventricular reciprocating tachycardia; adverse prognosis. A structured approach ECG, electrogardiogram; LVH, left ventricular hypertrophy; PACs, premature atrial contractions; PVCs, will often identify the arrhythmia; however, premature ventricular contractions; WPW, Wolff–Parkinson–White specialist referral will be sometimes *In patients without right bundle branch block required for both diagnosis and treatment.

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 Inexpensive

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 syncope 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 doi: 10.1016/j.amjcard.2014.02.020. 2018;6(12):e10338. doi: 10.2196/10338. Melbourne, Vic; Baker Heart & Diabetes Institute, Vic; 11. Raviele A, Giada F, Bergfeldt L, et al. Management Faculty of Medicine, Dentistry, and Health Sciences, 4. Lessmeier TJ, Gamperling D, Johnson-Liddon V, of patients with palpitations: A position paper University of Melbourne, Vic. [email protected] et al. Unrecognized paroxysmal supraventricular 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 5. Porter MJ, Morton JB, Denman R, et al. europace/eur130. 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. with palpitations have a cardiac arrhythmia? Research Council. This research is supported in hrthm.2004.05.007. part by the Victorian Government’s Operational JAMA 2009;302(19):2135–43. doi: 10.1001/ 6. Thavendiranathan P, Bagai A, Khoo C, Infrastructure. jama.2009.1673. Dorian P, Choudhry NK. Does this patient 13. Voskoboinik A, Prabhu S, Ling LH, Provenance and peer review: Commissioned, 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 Cardiol 2016;68(23):2567–76. doi: 10.1016/j. References 7. Gale CP, Camm AJ. Assessment of palpitations. jacc.2016.08.074. 1. Raviele A, Giada F, Bergfeldt L, et al. Management BMJ 2016;352:h5649 doi: 10.1136/bmj.h5649. 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.

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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 disease/abnormal Yes No heart/ECG ECG

Manage as appropriate, No further Cardiology/EP 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 abnormalities • 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 correspondence [email protected]