Abstract
Palpitations, the abnormal perception of a heart beating, are a common cause for presentation to a GP and have a prevalence of up to 16% in primary care consultations. They are associated with long-term morbidity with a substantial proportion of patients reporting concern and anxiety despite the exclusion of a significant underlying cause. Palpitations are the second most common reason for a GP to refer to specialist cardiology. The challenge for GPs is to be able to differentiate palpitations of a benign aetiology, from those related to a significant underlying arrhythmia that requires prompt investigation and referral. This article aims to highlight the factors involved in making an assessment and stratifying risk in patients presenting with palpitations in a primary care setting.
The GP curriculum and palpitations
Specific relevant problem-solving skills that GPs should have are to be able to intervene urgently when patients present with a cardiovascular emergency, demonstrate an understanding of the importance of risk factors in the diagnosis and management of cardiovascular problems and demonstrate a reasoned approach to the diagnosis of cardiovascular symptoms using history, examination, incremental investigations and referral.
Causes of palpitations
The causes of palpitations are diverse. Initial concern is usually related to the possibility of a significant underlying cause and the subsequent risk of cardiac-related mortality. However, a significant aetiology is found in less than 50% of patients presenting with palpitations and non-cardiac causes must also be considered. Furthermore, of the patients who have an identifiable disorder of the cardiac rhythm, the majority have an aetiology that conveys a good prognosis. The underlying causes for palpitations may be considered as arrhythmia and non-arrhythmia related (Tables 1 and 2). The remainder of the article will focus on the assessment of palpitations with a view to identifying cardiovascular features.
Arrhythmia-related causes of palpitations
Non-arrhythmia-related causes of palpitations
The assessment of a patient with palpitations
History
Taking a thorough history is a crucial and often the most important part of the assessment of any patient with palpitations. As with all history taking, applying a structure is important. Ask about
The history of the palpitations Associated symptoms Past medical history Medication history Family history Social history
In the first instance, it is important to clarify what the patient means by ‘palpitations’. Is it the abnormal sensation of their heartbeat or is it chest discomfort that they are describing?
Once it has been ascertained that the patient is experiencing palpitations, it is then necessary to gain an understanding of the features of the palpitations. This involves identifying the rate and rhythm of symptoms. Asking simple questions such as ‘are they fast, slow or normal?’ and ‘are they regular or irregular?’ can sometimes be useful. Next, specifically ask about the feeling of skipped, missed or extra beats as these can be strongly suggestive of ventricular ectopics. In circumstances where patients find it difficult to describe their palpitations, it is also useful to ask patients to tap out their symptoms on the desk as this makes it easier to appreciate their characteristics. It is interesting to note that most, but not all, patients will present with fast palpitations, and surprisingly, the description of regular palpitations more frequently correlates with an arrhythmia than those perceived as irregular.
Asking how long the episodes last for and how often they occur enables the physician to appreciate both the impact on the patients' life as well as helping to decide what further investigations may be suitable. Furthermore, palpitations that occur with both a rapid onset and a termination are more likely to be associated with an underlying arrhythmia.
It is also important to consider exacerbating and relieving factors associated with the palpitations. Symptoms that are precipitated by exertion are an important red flag, and palpitations relieved by coughing or breath holding can be suggestive of an underlying atrioventricular re-entrant tachycardia.
Having ascertained the nature of the palpitations themselves, the next step is to determine whether there are any associated features, such as presyncope, breathlessness or chest pain. Presyncope is described as the feeling of impending loss of consciousness and is a definite red flag in the history. Syncope is less commonly reported as the loss of consciousness is normally immediately after the onset of an underlying arrhythmia and palpitations are either not sensed or quickly forgotten.
Shortness of breath can also be a red flag as it can be a sign of cardiac decompensation associated with arrhythmias, such as atrial fibrillation with rapid ventricular response or ventricular tachycardia. True breathlessness should be differentiated from the sensation of having your breath taken away which is more benign and commonly felt with a missed or skipped beat. In a similar fashion, chest discomfort from the presence of palpitations should be differentiated from cardiac-type chest pain resulting from myocardial ischaemia, and this may be either as a cause or as a result of an arrhythmia.
Reviewing past medical history and recent attendances is also an important part of history taking. The recognition of underlying anxiety, depression or somatization disorders is useful as these conditions can all be associated with benign palpitations. Part of the assessment should screen for potential psychological influences on the current presentation.
Medication history is equally important as coexisting prescription of palpitation-inducing drugs may be responsible for the reported symptoms. Common medications implicated in the development of palpitations or arrhythmias include beta-agonists, theophyllines, levothyroxine and anti-arrhythmic agents (all of which have the potential for proarrhythmic effects). It should also be remembered that medications used for psychiatric disorders such as antidepressants and antipsychotics can also interfere with cardiac electrical conduction (particularly QT interval prolongation), thereby increasing the risk of arrhythmia precipitation.
Family history is an often an overlooked part of the history and specific enquiry should be made into sudden death at a young age or the onset of premature coronary disease in first-degree relatives. A relative with an implantable cardiac-defibrillator placed at a young age can also be a significant revelation.
A social history should be sought and this should include an enquiry into lifestyle factors, which relate to the increased perception of palpitations, such as high caffeine intake and smoking. Alcohol intake is also very important to ask about as excessive consumption (long term or binge drinking) is related not only to the perception of palpitations but also to the development of arrhythmias (such as atrial fibrillation) and cardiomyopathy. Interestingly, extreme levels of exercise have been shown to be associated with the development of arrhythmias, and atrial fibrillation has been reported to have a prevalence of around 9% in athletes.
If the patient is young, then consider making a sensitive and non-judgemental enquiry into any recreational drug use. Almost all can cause palpitations but the main culprits are cocaine, ecstasy and amphetamines. Finally, it is fruitful to enquire about driving and occupation as the patient may require advice on these issues depending upon symptoms and underlying aetiology.
Examination
The vast majority of patients presenting with palpitations are asymptomatic at the time of assessment. In the unlikely scenario of a patient having typical symptoms during assessment, it is important to ensure patient safety by making an assessment for signs of cardiovascular decompensation. In addition to red flag symptoms, signs of deterioration can be considered in the context of a bradycardic (heart rate less than 60 beats/minute) or tachycardic presentation (heart rate greater than 100 beats/minute) as it is unlikely a patient will have any significant haemodynamic compromise in the presence of a normal rate (Table 3). Patients with adverse features need urgent transfer to the emergency department for further assessment and management.
Otherwise, a thorough but focused cardiovascular examination should be undertaken ensuring pulse, blood pressure, heart sounds and signs of cardiac failure are noted. In addition, it is important to look for signs of coexisting pathology (such as thyrotoxicosis and anaemia), although this may be guided in part by the clinical history. Often, physical examination is normal, but the presence of abnormalities is more suggestive of an underlying cardiac aetiology and should warrant further investigation.
Adverse features of patients with palpitations
Investigations
All patients with a history of palpitations should have a 12-lead electrocardiogram (ECG) in the first instance. Often, this test fails to identify a dysrhythmia as patients tend to be asymptomatic during assessment. However, an ECG is still very important as it provides useful information about any underlying conduction or structural abnormality, and if an ECG is entirely normal, this is usually a good prognostic indicator as a ventricular arrhythmia is much less likely. Table 4 summarizes the key features that should be identified on an ECG that are more suggestive of an underlying cardiac aetiology. Other important investigations include blood tests and all patients with palpitations should have a full blood count, thyroid function and electrolytes (urea and electrolytes, calcium and magnesium) checked. This is to exclude anaemia, hyperthyroidism and electrolyte abnormalities, respectively.
ECG abnormalities that may be present in a patient presenting with palpitations
The remainder of investigations should be tailored to patient symptoms and can be subdivided as:
investigations of an underlying arrhythmia investigations of underlying structural heart disease
The investigation of rhythm abnormalities is usually in the form of ambulatory ECG monitoring, which is an umbrella term for a variety of tests that monitor the patients' cardiac rhythm during day to day life. The aim of ambulatory ECG monitoring is to capture a period of rhythm analysis during a typical episode of patient symptoms, thereby correlating symptoms with rhythm abnormality.
In recent years, there have been an increasing number of practices investing in ambulatory rhythm monitoring as a practice-led investigation, which has had a positive impact on patient assessment and referrals to secondary care. However, it must be remembered that not all patients with palpitations need ambulatory ECG monitoring (such as those with a history strongly suggestive of ectopy and no associated risk factors) and for other patients ambulatory monitoring should not delay urgent cardiology referral (such as those with palpitations associated with red flag features).
The most common forms of ambulatory monitoring at a GP's disposal are 24 hour ECG monitors (where a patient wears a lightweight cardiac monitor and has continuous ECG monitoring over a 24 hour period) and 7 day event recorders (where a patient wears a similar device over 7 days, but activates it to record the rhythm only when symptoms occur). It is crucial to ascertain the frequency of patient symptoms before deciding on the appropriate investigation and it has been suggested that patients should be experiencing symptoms at least three to four times a week for these investigations to be fruitful.
Another easily available investigation used for patients with palpitations is transthoracic echocardiography. This imaging modality is usually reserved to evaluate the possibility of an underlying structural cardiac abnormality prompted by clinical assessment (such as the presence of a murmur or abnormal ECG findings). However, the availability of echocardiography is dependent upon local resources, and GPs without access to a community echocardiography or rapid access palpitations service would have to refer to a cardiology specialist for further evaluation before investigation.
Assessment of risk and further management
Having taken a careful history, examination and organized the relevant investigations, a physician has the information available to be able to risk stratify patients and thereby decide on the best course of action. Figure 1 is a traffic light representation of key features of the assessments described and classifies patients as high, moderate and low risk within each domain of assessment. Once the level of risk has been decided, one has to decide on the appropriate management strategy.
The risk assessment of patients presenting with palpitations
In the acute setting where a patient is experiencing an arrhythmia associated with adverse features, immediate transfer to the emergency department is necessary. The further management of the majority of patients depends upon whether or not a specific aetiology is identified (such as an arrhythmia) and the level of risk. It is beyond the scope of this article to discuss the management of all the various arrhythmias as the treatment options and referral pathways would differ for each rhythm abnormality. Once the aetiology is identified, the treatment options may range from lifestyle advice, reassurance and the avoidance of precipitants to the initiation of pharmacotherapy and referral to a cardiologist for further investigation, treatment and even complex electrophysiological procedures.
A schematic representation of the management of patients presenting with palpitations is provided in Fig. 2 and is an approach to guide the decision-making process and referral pathway between primary and secondary care services when trying to identify an arrhythmia as a cause of symptoms. It initially differentiates high-risk patients from other patients and highlights the importance of early referral in this cohort. The remaining patients are further assessed based on symptoms and risk factors and if they are deemed to be low risk can be reassured and observed. Those at moderate risk require further investigation and may warrant a secondary care opinion if there remains doubt about the underlying cause or if a diagnosis is made that requires specialist input.
Management and referral pathway for patients presenting with palpitations.
Further considerations
Opportunistic health promotion
It is also worth remembering that when making an assessment of patients with palpitations, the physician has a unique opportunity to intervene with opportunistic health promotion. Part of the process of identifying the cause for symptoms may lead to the recognition of lifestyle factors that although maybe unrelated to the presenting complaint will still need to be discussed. Clinical enquiry may enable cardiovascular risk assessment and modification, including smoking, alcohol, dietary and exercise advice.
Driving and occupation
Arrhythmias can have a variable impact upon a patients' life and special consideration needs to be applied to driving and occupation (particularly operating machinery or working at heights). Current regulation from The Driver and Vehicle Licensing Agency (DVLA) stipulates that “Driving must cease if an arrhythmia has caused or is likely to cause incapacity and that driving may be permitted when the underlying cause has been identified and controlled for at least four weeks.” However, in such circumstances the DVLA need not be notified unless the symptoms are distracting or disabling. It is difficult to advise patients presenting with palpitations what the correct course of action is without knowing the underlying cause, but it would be prudent to advise against driving should there be a high index of suspicion of an underlying dysrhythmia that associates with a greater risk of incapacity (such as ventricular tachycardia), or if the symptoms experienced are associated with features of cardiovascular decompensation (such as presyncope, syncope, chest pain or breathlessness). Indeed, once an arrhythmia is identified, the DVLA regulations can be reconsidered and patients advised accordingly in the context of the correct diagnosis.
Genetic and familial screening
Consideration also needs to be made to patients who have an identified inherited cardiovascular aetiology [such as hypertrophic obstructive cardiomyopathy (HOCM)] as genetic counselling and the screening of relatives will need to be discussed. Often, this will be initiated from secondary or tertiary care services, but patients may present to a GP to discuss the further implications of their diagnosis and process of screening.
Patient and doctor support
Over the last decade, there has been the development of a number of societies and patient groups, which provide invaluable support to patients and information for doctors. Certainly, the use of these societies helps facilitate the GP consultation and consolidate the vast quantities of information that can be passed on to patients during such encounters. Examples of these societies and groups include:
Heart Rhythm UK [www.hruk.org.uk/] Arrhythmia Alliance [www.heartrhythmcharity.org.uk/] Sudden Adult Death Trust [www.sadsuk.org/] Cardiac risk in the young [www.c-r-y.org.uk/]
Key points
Palpitations are a common reason for attendance in general practice and are associated with considerable patient anxiety The natural presumption of a cardiac dysrhythmia usually leads to further investigation, but other causes should also be considered, including lifestyle, psychological and other systemic medical conditions The assessment of a patient with palpitations involves taking a careful history, physical examination and instigating the correct investigations After initial assessment, patients should be stratified according to risk if a cardiac arrhythmia is considered. Depending on risk, patients should be investigated and referred to secondary care services appropriately Consideration should also be directed towards other aspects of patient care such as opportunistic health promotion and the impact of symptoms should be explored in the context of patient lifestyle, particularly driving and occupation, with the provision of appropriate advice For the minority of patients, there may be a diagnosis of an inherited cardiac condition and a sensitive and empathic approach is required as the impact on patient and relatives may be substantial from the implications of genetic counselling and screening investigations