Palpitations/Arrhythmia

Question 1

72 yo man. “I’ve been feeling a bit dizzy, I think my heart is beating a little fast”. He is otherwise well.

Initial considerations?

Answer 1

In this non-specific presentation, I would want to initiate a targeted history and examination to more clearly define the problem.

Important red-flags diagnoses to consider include;

• ventricular fibrillation
• cardiac arrest
• heart failure

More commonly, this could be due to arrhythmias such as AF or other SVTs including A Flutter, but could also be a sinus tachycardia, or related to other medical conditions such as hyperthyroidism/anxiety, or related to medications or substance use such as alcohol.

Question 2

Palpitations: Goals/Aims

Answer 2

Aims of this consultation would be to identify the underlying aetiology of this presentation, and to mitigate any underlying cardiovascular risk factors or potential complications.

Question 3

Palpitations: History + Exam

Answer 3

History:

• HPC: nature, onset, complications (headache, syncope/ pre-syncope, dizziness, etc), chest pain, dyspnoea,
• Risk factors for AF: age, HTN, OSA, diabetes, fam Hx. symptoms pertaining to
• past Hx/medical conditions: heart attacks, HTN,
• medications: TCAs, anti-psychotics (long-qt syndrome)
• social: alcohol, smoking, recreational substances, caffeine

Exam:

• General health: BP, HR, radial pulse,
• cardiovascular examination: murmurs, signs of heart failure, peripheral oedema

Question 4

Palpitations: Investigations

Answer 4

Investigations:

• bedside: BP, SP02, ECG**
• bloods: BNP (heart failure), FBC (infection), UEC (kidney failure in fluid overload), TFT (thyroid disease)
• Imaging: Echo (rule out structural heart disease), cMRI
• Stress testing, coronary angiogram

Question 5

Management

Answer 5

Management depends on the type of arrhythmia, and whether patient harm-dynamically stable or not

Mx for AF
pharm
 - AF: 
    - anticoagulants: warfarin or docs to reduce stroke risk
    - 
 - 
non-harm
 - lifestyle modifications to reduce cardiovascular risk

referral
- cardiology, or to ED/hospital if unstable

safety-net + education
- patient to present to ED if SOB, chest pain, syncope, worsening palpitations

Others:

• VEBs: reassurance, altho may require F/U with cardiologist and further testing
• sinus tachycardia: reassurance
• SVT: revert to normal rhythm (vagus manoeuvres, adenosine, cardioversion (if haemodynamically unstable)