Approach to Palpitations

Question 1

History taking of palpitations

Answer 1

1. Nature of palpitation - “how does it feel like?”
   - Racing or tapping: fast arrhythmia
   - Missed or extra beat, pounding/forceful beat: ectopics
   - Pounding in neck: cannon A wave from atrial contraction against closed valve
   - Sudden pause for a moment: AV dissociation, severe bradycardia
2. Rate and rhythm
   - Fast or slow?
   - Timing of pulse? smart watch? Regular or irregular?
   > Regular: SVT, VT, ST
   > Irregular: AF, extrasystoles
3. Onset, frequency, duration
   - When did it occur? gradual or sudden onset?
   - How long is each episode?
   - How frequent do you experience symptoms?
4. Age of onset
   - Younger patients: SVT, long QT syndrome, VT
   - Middle or older age: AF
5. Precipitating factor
   - Triggers: exercise, stress, alcohol, coffee, emotions
   - Substance abuse: cocaine, amphetamine
   - Recent illness
6. Relieving factor
   - Spontaneous? or manoeuvers/straining?
7. Associated symptoms
   - Dyspnoea
   - Syncope/presyncope
   - Chest pain, SOB, diaphoresis, nausea: ischaemia
   - Exertional SOB, orthopnoea, PND, LL swelling: heart failure

Question 2

Relevant medical history in palpitations

Answer 2

1. Thyroid disease
   - Hyperthyroidism - weight loss, heart intolerance, tremor, sweating
   - Hypothyroidism - weight gain, cold intolerance, fatigue, constipation
2. Hypoglycaemia - hunger, headache, irritability, confusion, cold sweats
3. Phaeochromocytoma - headache, flushing, tremor, sweating
4. Cardiac disease - angina, valvular, structural
5. Cerebrovascular - previous stroke (consequence of AF)
6. Risk factors: hypertension, hyperlipidaemia, DM
7. Psychiatry - anxiety
8. Asthma treatment - beta agonist resultant ST

Question 3

Family history of palpitations

Answer 3

1. Cardiac disease
2. Sudden death

(Think HOCM, LQTS)

Question 3

Medications precipitating palpitations

Answer 3

1. Beta agonists - salbutamol
2. Theophylline
3. Levothyroxine
4. Sympathomimetics - MAOI
5. Prolonging QT drugs - metoclopramide, macrolides, SSRI, TCAs, quinidine, amiodarone, sotalol
6. Recreational/illicit - cocaine, amphetamine

Question 4

Social history for palpitations

Answer 4

1. Smoking, alcohol
2. Caffeine
3. Illicit drug use
4. QOL impact of palpitation
5. Hazardous occupation, driving

Question 5

Ideas, concerns, expectations

Answer 5

1. What are your concerns about this symptom?
2. Offer: blood tests and ECG
3. Reassurance if benign, admit if high risk
4. Offer: further evaluation for arrhythmias, structural heart disease (if suspected)
5. Offer: treatment - medication, non-invasive or invasive intervention

Question 6

Investigations (plan of action) for patient with palpitation

Answer 6

1. FBC - anaemia, infection
2. RP, CMP - electrolyte imbalance
3. TFT - hypo/hyperthyroidism
4. Troponins and ECG
5. CXR - cardiomegaly, congestion, infection, LA enlargement (double apical border) in AF
6. Holter monitoring
7. Echocardiography - structural, valvular disease
8. Treadmill stress ECG - if palpitation on exercise
9. Electrophysiological study
10. Cardiac MRI - HOCM, cardiac amyloid, other cardiomyopathies
11. Implantable loop recorder

Others:
12. D-dimer and CT PA - tachycardia, desat, unilateral LL swelling
13. Urinary catecholamines - suspected phaeochromocytoma

Question 7

Differential diagnoses of palpitations

Answer 7

Cardiac causes: AF, WPW, SVT, VT, bradycardia, tachycardia, sick sinus syndrome, etc

Non-cardiac causes: anaemia, thyrotoxicosis, metabolic, drugs, anxiety, physiological, pregnancy