Does This Patient With Palpitations Have a Cardiac Arrhythmia? Paaladinesh Thavendiranathan; Akshay Bagai; Clarence Khoo; et al. Online article and related content current as of November 17, 2009. JAMA. 2009;302(19):2135-2143 (doi:10.1001/jama.2009.1673) http://jama.ama-assn.org/cgi/content/full/302/19/2135 Supplementary material eFigures and eTables http://jama.ama-assn.org/cgi/content/full/302/19/2135/DC1 Correction Contact me if this article is corrected. Citations Contact me when this article is cited. Topic collections Physical Examination; Cardiovascular System; Radiologic Imaging; Diagnosis; Echocardiography; Arrhythmias; Cardiac Diagnostic Tests Contact me when new articles are published in these topic areas. CME course Online CME course available. CME course Online CME course available. Subscribe Email Alerts http://jama.com/subscribe http://jamaarchives.com/alerts Permissions Reprints/E-prints [email protected] [email protected] http://pubs.ama-assn.org/misc/permissions.dtl Downloaded from www.jama.com by guest on November 17, 2009 THE RATIONAL CLINICIAN’S CORNER CLINICAL EXAMINATION Does This Patient With Palpitations Have a Cardiac Arrhythmia? Paaladinesh Thavendiranathan, MD Context Many patients have palpitations and seek advice from general practitioners. Akshay Bagai, MD Differentiating benign causes from those resulting from clinically significant cardiac ar- Clarence Khoo, MD rhythmia can be challenging and the clinical examination may aid in this process. Objective To systematically review the accuracy of historical features, physical ex- Paul Dorian, MD amination, and cardiac testing for the diagnosis of cardiac arrhythmia in patients with Niteesh K. Choudhry, MD, PhD palpitations. Data Source, Study Selection, and Data Extraction MEDLINE (1950 to Au- CLINICAL SCENARIO gust 25, 2009) and EMBASE (1947 to August 2009) searches of English-language ar- A 58-year-old woman presents to the ticles that compared clinical features and diagnostic tests in patients with palpitations emergency department with intermit- with a reference standard for cardiac arrhythmia. Of the 277 studies identified by the tent episodes of palpitations. She search strategy, 7 studies were used for accuracy analysis and 16 studies for diagnos- describes “heart fluttering” that usu- tic yield analysis. Two authors independently reviewed articles for study data and qual- ity and a third author resolved disagreements. ally lasts less than 5 minutes, which is associated with a sense of “impending Data Synthesis Most data were obtained from single studies with small sample sizes. doom,” sweating, and paresthesia in A known history of cardiac disease (likelihood ratio [LR], 2.03; 95% confidence inter- both hands. She is unable to tell val [CI], 1.33-3.11), having palpitations affected by sleeping (LR, 2.29; 95% CI, 1.33- 3.94), or while the patient is at work (LR, 2.17; 95% CI, 1.19-3.96) slightly increase whether the rhythm is regular or the likelihood of a cardiac arrhythmia. A known history of panic disorder (LR, 0.26; irregular and denies a regular rapid- 95% CI, 0.07-1.01) or having palpitations lasting less than 5 minutes (LR, 0.38; 95% pounding sensation in the neck. CI, 0.22-0.63) makes the diagnosis of cardiac arrhythmia slightly less likely. The pres- There is no associated presyncope or ence of a regular rapid-pounding sensation in the neck (LR, 177; 95% CI, 25-1251) syncope. She has a history of panic or visible neck pulsations (LR, 2.68; 95% CI, 1.25-5.78) in association with palpita- disorder but is otherwise healthy and tions increases the likelihood of a specific type of arrhythmia (atrioventricular nodal takes no medications. Her pulse rate reentry tachycardia). The absence of a regular rapid-pounding sensation in the neck and rhythm are palpably normal and makes detecting the same arrhythmia less likely (LR, 0.07; 95% CI, 0.03-0.19). No other features significantly alter the probability of clinically significant arrhythmia. Di- the rest of her physical examination agnostic tests for prolonged periods of electrocardiographic monitoring vary in their along with a 12-lead electrocardio- yield depending on the modality used, duration of monitoring, and occurrence of typi- gram is normal. cal symptoms during monitoring. Loop monitors have the highest diagnostic yield (34%- 84%) for identifying an arrhythmia. WHY IS THE CLINICAL Conclusions While the presence of a regular rapid-pounding sensation in the neck EXAMINATION FOR or visible neck pulsations associated with palpitations makes the diagnosis of atrio- PALPITATIONS IMPORTANT? ventricular nodal reentry tachycardia likely, the reviewed studies suggest that the clini- Palpitations are a common, unpleas- cal examination is not sufficiently accurate to exclude clinically significant arrhythmias ant, and often alarming awareness of in most patients. Thus, prolonged electrocardiographic monitoring with demonstra- heartbeats,1 with a prevalence as high tion of symptom-rhythm correlation is required to make the diagnosis of a cardiac ar- as 16% in medical outpatients.2 They rhythmia for most patients with recurrent palpitations. often pose a clinical challenge3 JAMA. 2009;302(19):2135-2143 www.jama.com because of the wide differential diag- Author Affiliations: Division of Cardiology, Depart- Corresponding Author: Niteesh K. Choudhry, nosis (BOX). Palpitations may occur due ment of Medicine (Dr Thavendiranathan) and Divi- MD, PhD, Brigham and Women’s Hospital, Har- to a change or abnormality in heart sion of Cardiology, St Michael’s Hospital (Drs Bagai vard Medical School, 1620 Tremont St, Ste and Dorian), University of Toronto, Toronto, Ontario, 3030, Boston, MA 02120 (nchoudhry@partners Canada; Division of Cardiology, Department of Medi- .org). cine, University of British Columbia, Vancouver, Canada The Rational Clinical Examination Section Editors: CME available online at (Dr Khoo); and Division of Pharmacoepidemiology and David L. Simel, MD, MHS, Durham Veterans Affairs www.jamaarchivescme.com Pharmacoeconomics, Department of Medicine, Medical Center and Duke University Medical Center, and questions on p 2160. Brigham and Women’s Hospital and Harvard Medi- Durham, NC; Drummond Rennie, MD, Deputy cal School, Boston, Massachusetts (Dr Choudhry). Editor. ©2009 American Medical Association. All rights reserved. (Reprinted) JAMA, November 18, 2009—Vol 302, No. 19 2135 Downloaded from www.jama.com by guest on November 17, 2009 PALPITATIONS AND CARDIAC ARRHYTHMIA Because a minority of patients have tant to consider clinically significant ar- Box. Differential Diagnosis palpitations while being examined by rhythmias associated with sudden car- of Palpitations their physician, the challenge is to cap- diac death. Atrial fibrillation, flutter, Arrhythmia ture a recording of the cardiac rhythm atrial tachycardia, and ventricular during symptoms. While event moni- tachycardia (eFigure 1A, B, I) tend to Defined as atrial fibrillation or flut- ter, atrioventricular node reentry tors have been designed to facilitate this occur later in life and are often associ- tachycardia or atrioventricular re- process, the diagnostic yield varies with ated with structural heart disease. Some entry tachycardia, atrial tachycar- the frequency of symptoms and dura- arrhythmias such as atrioventricular dia, ventricular tachycardia, pre- tion of the monitored period. Arrhyth- node reentry tachycardia (eFigure 1C) mature ventricular contractions or mias also may occur in individuals who may be more common in women than premature atrial contractions, or have no symptoms at all.7 Therefore, the men.9-11 multifocal atrial tachycardia presence of an arrhythmia on diagnos- A history of panic disorder should be The causes are primary electrical tic testing does not confirm that it is the explored.12 The details of a family his- abnormality or electrical abnor- cause of a patient’s symptoms.7 To be tory of palpitations should be re- mality secondary to structural car- certain, their symptoms must be cor- corded, especially if family members diac disease or comorbid medical related with an electrocardiographi- have established diagnoses such as ar- conditions. cally documented rhythm distur- rhythmogenic right ventricular cardi- Sinus tachycardia bance. Similarly, if the patient repeatedly omyopathy13 or atrial fibrillation.14 Any The causes include hyperthyroid- has a normal cardiac rate and rhythm history of previous cardiac disease may ism, anxiety or panic disorder, fe- during typical symptoms, one can reas- predispose patients to more clinically ver, hypovolemia, stimulants (caf- sure the patient that the cause is likely significant arrhythmias4,6 and suggest feine, alcohol), medications, blood nonarrhythmic. the need for a more aggressive search loss, pheochromocytoma, hypo- While palpitations are usually be- for a cardiac cause. glycemia, and idiopathic. nign, they may be a manifestation of Patients should be asked to tap out Normal sinus rhythm life-threatening conditions. More im- the rhythm of their palpitations, or to The cause is heightened cardiac portantly, recurrent palpitations can be choose from cadences tapped by the perception for an unclear reason. associated with significant disability, in- physician, to identify the regularity and cluding impaired work performance speed of the palpitations. Single skipped and the inability to perform house- beats or a sensation of the heart stop- hold duties.4,8 However, using diagnos- ping and then starting with a pound- rhythm, such as an arrhythmia