Palpitations

The sensation of the heart beating in the chest.

History

• 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
• 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.

Examination

Before even starting- do a Mental State Examination.  Does the patient appear anxious/stressed?  (Increased pressure of speech, fidgeting)

General Examination

•  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

Examination of the chest (see also CV Examination; CV Examination)

• 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

Investigations

• 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

Differential Diagnosis

• Anxiety disorder
• Ectopic beats
• Atrial Fibrillation
• Atrial Flutter
• Supraventricular tachycardias
• Ventricular tachycardia
• Sick sinus syndrome
• Valvular heart disease (particularly mitral disease)
• Hyperthyroidism, hypoglycaemia
• Fever
• Phaeochromocytoma
• 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