Palpitations in General Practice

Dr Jess Fletcher MBChB (Hons) MRCP MRCGP

What are ?

• Palpitations are a symptom characterised by awareness of the heartbeat, often described as a strong, skipping, fluttering, racing, pounding, thudding, or jumping sensation in the chest. • Some patients describe a sensation of having to cough or their breath being taken away.

• However, patients occasionally mean something other than palpitations (eg. chest discomfort) which may need a different line of investigation.

Causes of palpitations

• List the common causes of palpitations you see in general practice • Can you group the causes?

Evaluation and outcomes of patients with palpitations Weber BE Kapoor WN Am J Med 1997 • Prospective cohort study presenting with palpitations • 197 consecutive patients • At Student medical centre

Outcomes

• Cardiac (43%) • Psychiatric (31%) • Miscellaneous (10%) • Unknown (16%) etiology of papitations

cardiac psychiatric miscellaneous unknown But please note….

• A large proportion of patients with palpitations are diagnosed as having panic, stress, or anxiety when, instead, they have an underlying arrhythmia Unrecognised Paroxysmal Supraventricular . Potential for misdiagnosis as panic disorder Lessmeier et al Arch Inter Med 1997

• Retrospective study • 107 consecutive pts with re-entrant pSVT • pSVT missed after initial medical evaluation in 55% • Remained unrecognised for median of 3.3 yrs • Ablation therapy 81% pts • Symptom resolution 86% • Post ablation, 4% met DSM-IV criteria of panic disorder Cardiac Causes

• List Cardiac Causes

SVT AF/Aflutter

tacharrhymias

Cardiac cause of VT palpitations (Related to exercise) Extrasystoles “skipped/missed beat” Commonest cause Extrasystoles

• Generally not associated with significant structural disease • Common • Frequent ventricular extrasystoles in >55 yr old more concerning (>30 per hr) might suggest underlying myocardial ischaemia Paroxysmal supraventricular tachycardia

• Conduction abnormalities in atrio-ventricular node or bypass tracts Atrial Fibrillation Atrial Flutter • 5 commonest underlying causes? Atrial Fibrillation Atrial Flutter • Hypertension • IHD • Valvular heart disease • DM • • Chronic alcohol misuse • Obesity

AF

• Classification, pathophysiology, and mechanisms of AF: key points • Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia

• AF is usually classified as paroxysmal, persistent, or permanent. • AF adversely affects cardiac haemodynamics because of loss of atrial contraction and the rapidity and irregularity of the ventricular rate • AF causes significant symptoms in approximately two thirds of patients • AF is associated with a 1.5- to 2-fold increase in mortality • AF is associated with a 6-fold increase in risk of stroke • AF is initiated by rapid electrical activity, often arising from arrhythmogenic foci located in the muscular sleeves of pulmonary . • After a period of continuous AF, electrical remodelling occurs, further facilitating AF maintenance Non cardiac causes

• Metabolic disorders (thyrotoxicosis, hypoglycaemia, pheochromocytoma) • Medication induced (vasodilators, anticholinergic drugs) • Central nervous system stimulants (caffeine, cocaine, amphetamines) • Psychiatric disease (panic attacks, generalised anxiety disorder, depression)

History

• 7 key questions History

1. What does the patient mean by palpitations? 2. Tap out rhythm on table 3. Duration/ Frequency 4. Severity ?have to sit down?collapse. If syncope urgent referral 5. Associated or breathlessness (IHD associated ?fast AF)(“breath taken away” - extrasystoles 6. Exercise related? (urgent referral – ?cardiomyopthy/ischaemia/channelopathy) 7. How do they end? Can you stop them? (Valsalva/diving reflex suggests SVT)

History continued

• Drug History –thoughts?

What does this ECG show?

Drugs that prolong the QT interval

• Erythromycin • Moxifloxacin • Haloperidol • Amiodarone • Amphetamines

Drugs associated with tachyarrhthymias

Drugs that are associated with tachyarrhythmias • β agonists (salbutamol), • antimuscarinics (amitriptyline), • theophylline (phylocontin), • dihydropyridine calcium channel blockers (nifedipine), • class 1 anti-arrhythmics (flecainide, disopyramide), Drugs

• Caffeine ( ) • Alcohol (AF) • Illicit drugs

History continued

• Fever or underlying infection (AF) • History of Anaemia (sinus tachycardia) • Family history sudden cardiac death <40 yrs

Brugada Syndrome

• Video BHF Examination

• What do you look for? Raised JVP Ankle oedema

Signs of

Gallop rhythm Bi-basal crackles Tremor Goitre

Thyrotoxicosis signs

Eye signs Thin Examination continued

• Listen for murmur • Check for pallor • Check BP for underlying hypertension

Tests

FBC

U+E

TFT Case

• 40 yr old man • Walk in -Asking for urgent GP appointment • “Rapid fast palpitations and light headed” • Told in past to see GP urgently if reoccurs for assessment while symptomatic

• What do you do?

• History: • 3 previous episodes • Self limiting after 10-15mins • No chest pain • No other significant history

• Examination • P160bpm regular • BP 98/50 • No sign of heart failure

SVT

• Vagal manouvres, diving reflex • Sinus rhythm restored

• Copy of ECG to patient to keep • For patients with infrequent palpitations, asking them to attend your practice or the emergency department to have an electrocardiogram recorded during symptoms is not unreasonable.

ECG

• What are you looking for on ECG to give clues as to underlying cause? 12 lead electrocardiogram practice pointers for palpitations—when to consider specialist referral • Atrial fibrillation or atrial flutter • Second degree atrioventricular block • Third degree atrioventricular block • Myocardial infarction • Left ventricular hypertrophy (with or without strain pattern) • Left bundle branch block • Abnormal T waves and ST segments • Pre-excitation (Wolff-Parkinson-White pattern of a slow rise in the initial portion of the QRS (delta wave)) • Abnormal QT/QTc interval If ECG normal

• Guidelines from the American College of • Recommend Holter monitoring in patients with palpitations and syncope , near syncope (episodic dizziness or lightheadedness in patients with known cardiac disease), and recurrent palpitations if the resting ECG is normal.

Ambulatory Rhythm Monitors

• 24 hour Holter monitor to patients who have at least daily symptoms, • a 48 hour Holter monitor to those with symptoms on most days, • and a seven day monitor to those with weekly symptoms, even if the 12 lead electrocardiogram is normal. • Inappropriate use of short periods of ambulatory monitoring for infrequent symptoms is cumbersome for patients, delays the diagnosis, and is costly. Urgency of referral

• Low risk features for which referral is not mandatory • Isolated palpitations (described as skipped beats, pounding, or short fluttering) that are not provoked by exercise and not associated with symptoms such as lightheadedness, syncope, persistent breathlessness, or chest pain; • No history or signs of , heart failure, or hypertension and no family history of sudden cardiac death; and • A normal 12 lead electrocardiogram. • In these cases, palpitations are generally due to extrasystoles or sinus tachycardia. Urgency of Referral

• Urgent cardiology referral • Palpitations during exercise; • Palpitations associated with syncope or pre- syncope; • Family history of sudden cardiac death or inheritable cardiac conditions; or • Second degree or third degree atrioventricular block on the 12 lead electrocardiogram.

Driving

• In the United Kingdom, the Driver and Vehicle Licensing Agency (DVLA) regulations state that if an arrhythmia has caused incapacity or is likely to cause incapacity, the patient must not drive. • It is the clinician’s responsibility to notify the patient of this, document it in the case records, and advise the patient to contact the DVLA, who will make the final recommendation. Citations

• Assessment of palpitations • BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.h5649 (Publishe d 06 January 2016)Cite this as: BMJ 2016;352:h5649 • Markides V, Schilling RJ • Atrial fibrillation: classification, pathophysiology, mechanisms and drug treatment • Heart 2003;89:939-943