The sensation of the heart beating in the chest.
- Define what the patient means by palpitation.
- What does it feel like?
- Make sure it is a palpatation
- Patients may describe feeling a skipped beat (followed by a strong beat- classic of ectopic beats)
- May describe a rapid pounding in their chest
- Can you tap it out? (this can be very useful, particularly if the patient has a tachycardia, bradycardia or arrhythmia)
- When does it come on? Are there any exacerbating or relieving factors?
- How often does it happen? How long does it last?
- Does it come on at rest or on exertion? Are there any feelings of stress, anxiety, not being able to cope etc that would suggest a psychosomatic cause? Does it come on during particular situations (e.g. at work)
- Is it made worse by anything e.g. cold food/drink (e.g. Atrial flutter)? Caffeine? Alcohol (e.g. ectopic beats)
- Is it made better with anything? e.g. breath-holding, coughing (valsava manoeuvres typically relieve an AVNRT arrhythmia); Rest
- It is important to ask about any
- chest pain (particularly anginal i.e. crushing);
- any loss of consciousness/collapse (and define whether this is syncope/pre-syncope or not- suggestive by feeling ‘faint’, dizzy, perhaps nauseous, claustrophobic)
- any shortness of breath or sweatiness (may be organic cause but can also be psychosomatic)
- any rapid increase in heartbeat
- Also ask about any heat intolerance, shaking, weight loss (/gain), any eye symptoms, change in appetite, weakness/fatigue, oligomenorrhoea/amenorrhoea etc to include/exclude hyperthyroidism
- What does it feel like?
- Take a thorough cardiovascular as well as general past medical history
- Any history of angina, any MIs, any known arrhythmias, any hypertension, etc
- Any other medical problems (respiratory, anxiety, epilepsy, thyroid problems, etc)
- Is the patient on any drugs?
- Ask about family history of palpitations, cardiovascular conditions, causes of death
- Ask about smoking, alcohol and illicit drug use. Also ask about occupation.
Before even starting- do a Mental State Examination. Does the patient appear anxious/stressed? (Increased pressure of speech, fidgeting)
- Look at the hands for any signs of thyrotoxicosis e.g. palmar erythema, thyroid acropachy, hot/sweaty. Also look for any signs such as nicotine stains
- You may also want to look for fine tremor by asking the patient to hold their hands/arms outstretched
- Feel the pulse
- Assess rate (if irregular, take time to do this), rhythm, volume, strength
- Do a brief examination of the neck to assess the thyroid (NB depending on your differential from history taking, this may or may not be required- the same is true for examination of the eyes e.g. exophthalmos, lid lag/retraction, abnormal movements)
- Feel the carotid pulse
- This may be done with the radial pulse to check for any differences
- If there was a history of collapse/syncope, you might also want to test neurological function of the limbs (tone, power, reflexes) as well as the cranial nerves
- Check the blood pressure
- Look for any chest signs e.g. any scars suggestive of previous cardiac surgery, any obvious pulsations of the chest wall etc
- Feel for the apex beat, noting its location, rhythm, rate, character. Feel for any parasternal heaves or thrills
- Listen to the heart sounds, noting any extra sounds
- A 12-lead ECG is easy to do and can be extremely helpful at identifying underlying electrical abnormalities of the heart.
- Note that patients who are not experiencing symptoms may have a normal ECG. However, they may have abnormal findings. I.e. the presence or absence of symptoms at present should not contraindicate ECG.
- Blood tests may be useful to
- FBC (anaemia can increase the risk of cardiac arrhythmia if there is already underlying predisposition)
- U&Es (in particular, potassium levels- as both hyperkalaemia and hypokalaemia can affect cardiac electrophysiology
- LFTs, TFTs and glucose may be useful.
- Other ECG based tests e.g. 24-hour Holter monitoring or exercise ECG may be useful if palpitations
- Anxiety disorder
- Ectopic beats
- Atrial Fibrillation
- Atrial Flutter
- Supraventricular tachycardias
- Ventricular tachycardia
- Sick sinus syndrome
- Valvular heart disease (particularly mitral disease)
- Hyperthyroidism, hypoglycaemia
- Alcohol use, caffeine, illicit drug use
- Other medications e.g. beta-agonist inhalers, calcium channel blocker,
- Others e.g. Atrial/ventricular septal defects, cardiomyopathy, congenital heart disease, congestive heart failure,
Management of the acutely unwell patient with palpitations caused by tachycardia