Approach to Palpitations

Differential diagnosis

• Cardiovascular
  • Benign palpitations
  • Ectopics
  • Arrhythmia
    • Atrial fibrillation / flutter
      • Underlying valvular heart disease
    • Wolff-Parkinson-White syndrome
    • Multi-focal atrial tachycardia
    • Tachy-brady syndrome (sick sinus syndrome)
    • Ventricular tachyarrhythmia (especially if there is a focus, e.g. ischaemic scar)
  • Hypertrophic obstructive cardiomyopathy
• Respiratory
  • Pulmonary embolism
• Endocrine
  • Hyperthyroidism
  • Hypoglycaemia
  • Phaeochromocytoma
    • MEN-2A: medullary thyroid carcinoma, phaeochromocytoma, parathyroid adenoma
    • MEN-2B: medullary thyroid carcinoma, phaeochromocytoma, marfanoid habitus
• Drugs
  • Caffeine
  • Nicotine
  • Salbutamol
  • Theophylline
  • Illicit drugs
    • Amphetamine
    • Cocaine
    • Ecstasy
• Pregnancy
• Infection (fever)
• Symptomatic anaemia
• Electrolyte imbalance
• Psychosocial
  • Anxiety disorder
  • Panic attacks

Relevant points in the history

• Palpitations
  • What were you doing when you first noticed the palpitations?
  • Have you had them before?
  • Have they been getting more frequent?
  • Irregular or regular
  • Forceful beats or sensation of fast heart rate?
  • Does anything bring the attacks on or stop them?
  • Do you feel dizzy when the attacks happen?
  • Have you every fainted because of the palpitations?
  • What do you think is causing the palpitations?
  • What effect have they had on your life?
• Underlying cause
  • Cardiac
    • Do you have any chest pain?
    • Do you feel breathless when you have these palpitations?
    • Are the palpitations worsened by exercise?
    • Do you have any heart problems?
    • Has anyone in your family ever died suddenly or unexpectedly?
  • Pulmonary embolism
    • Have you had any recent long-haul flights?
    • Have you injured yourself or been relatively immobile recently?
  • Endocrine
    • Do you feel like it is abnormally hot?
    • Have your periods become heavier?
    • Do you have tremors in your hands?
    • Have you had problems with your bowels? Any diarrhoea?
    • Have you noticed that you are sweating more than usual?
    • Have you been having headaches more frequently than usual?
    • Do you have diabetes?
    • Have you ever experienced episodes where your blood sugar is too low?
    • Did you have any symptoms similar to that episode with the palpitations?
  • Do you have any fever?
  • Have you ever experienced brief periods of overwhelming panic or terror accompanied by palpitations, difficulty in breathing, dizziness or tingling in your hands?
  • When was the first day of your last menstrual period?
  • Drugs
    • Are you allergic to any medication?
    • Do you take any regular medications?
    • Have you ever used a puffer for asthma or shortness of breath?
    • Do you drink coffee or tea?
    • Have you ever used any illicit drugs?
  • Do you have any medical conditions?

Examination

• Vitals
  • Fever
  • Heart rate
  • Blood pressure – if low and arrhythmia present, requires urgent cardioversion
• Pulse
  • Rate
  • Rhythm
• Eyes for conjunctival pallor
• Cardiovascular
  • Mitral facies
  • Presence of implantable cardiac device
  • Right ventricular heave – pulmonary hypertension
  • Apex beat (character and location)
  • Heart sounds for any murmurs (e.g. systolic click of mitral valve prolapse, ESM of HOCM)
• Endocrine
  • Observe for proptosis, lid lag
  • Look for tremor
  • Look and palpate for goitre
  • Check for thyroid surgery scars
  • Look for pre-tibial myxedema
• Neurological
  • Pronator drift as a screen for cardioembolic disease if in AF

Investigations

• FBC to look for anaemia, signs of infection
• Electrolytes as electrolyte imbalance may precipitate palpitations
• Thyroid function tests
• 24 hours urine metanephrines if phaeochromocytoma suspected
• Electrocardiogram
  • Wolff-Parkinson-White
  • May capture arrhythmia
  • Look for signs of ischaemic heart disease, which may precipitate scar VT
• Holter or Reka monitoring if no abnormalities seen on ECG
  • Longer duration of recording increases chance of capturing arrhythmia
• Echocardiogram to look for structural heart disease
• May require electrophysiological studies if the above are non-diagnostic

Management

• Can usually be managed outpatient, unless index of suspicion of malignant arrhythmia is very high
• Treat the underlying cause
• Beta blockers if symptomatic
• If in AF, will need anticoagulation if CHADSVASC score ≥2
  • Congestive heart failure – 1
  • Hypertension – 1
  • Age 65 – 74  – 1
  • Age ≥ 75 – 2
  • Diabetes – 1
  • Previous stroke / TIA – 2
  • Vascular disease (MI/PVD) – 1
  • Female sex – 1
• If hyperthyroid, will require carbimazole to control thyroid function
  • Will need to warn patient about the risk of neutropaenia
  • Repeat FBC after starting carbimazole
• May need AICD if arrhythmia is malignant
• May need accessory pathway ablation if SVT is confirmed on EPS