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 204 | REPRINTED FROM AJGP VOL. 48, NO. 4, APRIL 2019 © The Royal Australian College of General Practitioners 2019 APPROACH TO PALPITATIONS CLINICAL 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 © The Royal Australian College of General Practitioners 2019 REPRINTED FROM AJGP VOL. 48, NO. 4, APRIL 2019 | 205 CLINICAL APPROACH TO PALPITATIONS 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