Approach to palpitations

• Not all palpitations are due to arrhythmia, and because of the transitory nature of palpitations, the work-up will usually be performed between episodes. 
• Direction from history, examination and 12-lead electrocardiography will guide further investigations and will often include an echocardiogram and ambulatory electrocardiographic monitoring. 
• The intensity of ambulatory electrocardiographic monitoring and diagnostic work-up will be dictated by the frequency, nature and severity of symptoms, and will sometimes require incorporation of new technologies and electrophysiology referral. 
• Ultimately, management must be tailored on a case-by-case basis depending on the cause of palpitations and symptom severity.

Aetiology

• 41% had an arrhythmic aetiology
• 31% had palpitations in the context of psychological disorder such as anxiety
• 16% no cause was identified

Palpitations: Associated Symptoms and Causes

Cardiac:Arrhythmias

• Atrial fibrillation/flutter
• Bradycardia caused by advanced arteriovenous
• block or sinus node dysfunction
• Bradycardia-tachycardia syndrome (sick sinus syndrome)
• Multifocal atrial tachycardia
• Premature supraventricular or ventricular contractions
• Sinus tachycardia or arrhythmia
• Supraventricular tachycardia
• Ventricular tachycardia
• Wolff-Parkinson-White syndrome

Cardiac: Nonarrhythmic cardiac causes 

• Atrial or ventricular septal defect
• Cardiomyopathy
• Congenital heart disease
• Congestive heart failure
• Mitral valve prolapse
• Pacemaker-mediated tachycardia
• Pericarditis
• Valvular disease (e.g., aortic insufficiency, stenosis)

Serious Indicators:

• Dizziness, Near-Syncope, or Syncope:
  • Suggests tachyarrhythmia.
  • Potentially more serious.

Symptom Characteristics:

• “Pounding” or “Jumping” Palpitations:
  • Noticed when sitting or lying down quietly.
  • Often result from premature contractions, especially premature ventricular contractions (PVCs).

Orthostatic Intolerance:

• Symptoms:
  • Palpitations.
  • Tachycardia.
  • Altered mentation.
  • Headache.
  • Nausea.
  • Pre-syncope.
  • Occasionally, syncope.
• Common Population:
  • Most common in women of childbearing age.
• Cause:
  • Inadequate cerebral perfusion on upright posture.

Psychiatric causes

• Anxiety disorder
• Panic attacks
• Panic Disorder and Palpitations
• Prevalence:: The prevalence of panic disorder in patients with palpitations is 15-31%.
• Characteristics:: Characterized by recurrent unexpected panic attacks.
• Symptoms:
  • Racing heartbeats.
  • Shortness of breath.
  • Dizziness.
• Persistence of Palpitations:
  • Palpitations are most persistent in individuals who:
    • Experience many minor daily irritants.
    • Are highly sensitive to bodily sensations.
• Coexisting Psychiatric Illness:
  • Psychiatric illness may coexist in patients with another etiology of palpitations.
• Screening Question:
  • Question to Ask Patients:
    • “Have you experienced brief periods, for seconds or minutes, of an overwhelming panic or terror that was accompanied by racing heartbeats, shortness of breath, or dizziness?”

Drugs and medications

• Alcohol
• Caffeine
• Certain prescription and over-the-counter agents (e.g., digitalis, phenothiazine, theophylline, beta agonists)
• Street drugs (e.g., cocaine)
• Tobacco

Extracardiac causes

• Anemia
• Electrolyte imbalance
• Fever
• Hyperthyroidism
• Hypoglycemia
• Hypovolemia
• Pheochromocytoma
• Pulmonary disease
• Vasovagal syndrome

History Taking

1. Detailed Symptom Description:
   • Onset and offset: sudden or gradual
   • Duration: momentary or sustained (how long?)
   • Frequency
   • Associated symptoms – higher arrhythmia risks
     • Pre-syncope/syncope
     • Breathlessness
     • Chest pain
     • palpitations that disrupt sleep
     • regular pounding sensations in the neck
     • visible neck pulsations
     • vasovagal symptoms like pallor or sweating
2. Precipitating Factors: Identify any triggers such as exercise, stress, or caffeine intake.
3. Previous Cardiac History: Determine if there is a history of heart disease, prior episodes of similar symptoms, or family history of cardiac issues.
4. Exercise and Alcohol: Excessive endurance sports and alcohol intake are risk factors for developing cardiomyopathies and arrhythmias.
5. Medication and Substance Use: substance use, particularly stimulants and weight loss drugs

Key Clinical Findings with Palpitations and Suggested Diagnoses

Finding	Suggested diagnosis
Single “Skipped” Beats	Benign ectopy
Feeling Of Being Unable To Catch One’s Breath	Ventricular premature contractions
Single Pounding Sensations	Ventricular premature contractions
Rapid, Regular Pounding In Neck	Supraventricular arrhythmias
Palpitations That Are Worse At Night	Benign ectopy or atrial fibrillation
Palpitations Associated With Emotional Distress	Psychiatric etiology or catecholamine-sensitive arrhythmia
Palpitations Associated With Activity	Coronary heart disease
Relationship to an emotional upset should be sought, General Anxiety	Panic attacks
Medication Or Recreational Drug Use	Drug-induced palpitations
Rapid Palpitations With Exercise	Supraventricular arrhythmia, atrial fibrillation
Positional Palpitations	Atrioventricular nodal tachycardia, pericarditis
Heat Intolerance, Tremor, Thyromegaly	Hyperthyroidism
Palpitations Since Childhood	Supraventricular tachycardia
Rapid, Irregular Rhythm	Atrial fibrillation, tachycardia with variable block
Palpitations Terminated By Vagal Maneuvers	Supraventricular tachycardia
Heart Murmur	Heart valve disease
Midsystolic Click	Mitral valve prolapse
Friction Rub	Pericarditis
Symptoms proceeded by postural change or micturition	orthostatic hypotension or micturition syncope
Exercise induced symptoms	aortic stenosis or supraventricular tachycardia (SVT)
Syncope experienced during exercise and high emotions (50% of the genetic variant)	prolonged QT syndrome
Syncope during swimming, including immediately after diving into the water	prolonged QT syndrome

Existing cardiac conditions:

Subjective Awareness of Normal Heartbeat:

• Increased awareness of normal sinus rhythm.
• Describes forceful heartbeat in chest or neck, sometimes heard at night.
• Although there may occasionally be secondary causes, in the vast majority of cases this is benign. It may often occur at times of heightened anxiety.

Momentary Palpitations: Ectopic Beats:

• Common cause: benign ectopic beats (atrial or ventricular).
• Described as skipped or missed beats with momentary throat or chest sensation.
• Ventricular ectopic beats:
  • compensatory pause, increased diastolic filling, supra-normal stroke volume.
• Ectopic beats can be
  • repetitive
    • bigeminal
    • trigeminal or
  • isolated
• Influenced by
  • anxiety
  • fatigue
  • inter-current illness.
• Avoidance of caffeine is commonly recommended but not strongly supported by evidence.
• Recurrent, intermittent events rather than continuous rapid palpitations.
• Up to 100 ventricular ectopic beats in 24 hours are within normal limits; more frequent beats may need further investigation.

Sustained Palpitations:

Sinus Tachycardia:	Gradual onset and offset over minutes or longer. Usually benign, related to anxiety or stress. May indicate underlying disorders like thyrotoxicosis or anemia.
Sudden Onset Rapid Palpitations:	Regular or irregular, lasting minutes to hours. May represent atrial fibrillation, continuing until treated.

Rapid Regular Palpitations:

Supraventricular Tachycardia (SVT):

Often triggered by – sudden movements like bending – in athletes, may manifest as a rapid increase in heart rate during exercise. Symptoms: light-headedness, chest discomfort, breathlessness. Requires early referral for significant symptoms (pre-syncope, breathlessness, chest pain). Syncope or ongoing chest pain needs emergency department transfer. Response to Vagal Maneuvers: Many patients can stop an SVT episode through techniques like the Valsalva maneuver or applying a cold stimulus to the face. Young patients, especially women, may be misdiagnosed with panic attacks.

Ventricular Tachycardia (VT):

arely presents solely with palpitations typically accompanied by signs of hemodynamic instability such as fainting, sweating, chest pain, or severe breathlessness. Infrequent isolated palpitations. Typically occurs with underlying structural heart disease (e.g., prior myocardial infarction). Patients present with haemodynamic compromise features.

Rapid Irregular Palpitations:

Atrial Fibrillation:

Paroxysmal or persistent, described as very irregular heartbeats. Characterized by extremely irregular and quick heartbeats, frequently accompanied by difficulties during exertion and potential breathlessness. Syncope due to rapid ventricular rate is unusual; often due to sinus pause at spontaneous reversion. Chest pain may indicate rapid ventricular response or underlying coronary artery disease. Polyuria associated due to atrial natriuretic peptide release. Nocturnal onset suggests vagal mechanism or sleep-disordered breathing (e.g., obstructive sleep apnea). Frequency and duration of palpitations over patient’s life guide management (conservative vs. medications or electrophysiology study).

Examination

1. General Assessment:
   • Check for signs of distress, anxiety, or physical discomfort
   • weight (obesity may contribute to atrial fibrillation)
2. Cardiovascular Examination:
   • abnormal resting heart rate (<60 beats per minute or >100 beats per minute)
   • Listen for irregular heartbeats/murmurs
     • mitral prolapse – mid systolic click murmur
     • aortic stenosis – ejection systolic murmur
     • hypertrophic obstructive cardiomyopathy (HOCM) – systolic murmur at lower left sternal edge, louder on Valsalva
   • signs of heart failure
   • Fluid status and postural blood pressure/heart rate
3. Systemic Examination:
   • abnormal resting heart rate (<60 beats per minute or >100 beats per minute)Look for signs of
   • thyroid disease (goiter, tremor)
   • signs of anemia
   • signs of drug use

Investigations

1. ECG

• All patients with suspected arrhythmia require an ECG to identify any arrhythmic events or other underlying cardiac abnormalities.
• A 12-lead ECG during symptoms remains the most definitive diagnostic tool. However, due to the transient nature of arrhythmias, capturing an event on a standard ECG is often challenging.
• Sinus Rhythm ECG: Should be performed even when patients are between symptoms, as it can provide clues about arrhythmic mechanisms, such as pre-excitation patterns or signs of ischemia.

2. Echocardiogram

• Purpose: To assess cardiac structure and function, particularly in patients with suspected structural heart disease, valvular pathology, or unexplained symptoms.

3. Exercise Stress Test

• Purpose: Evaluates the heart’s response to physical stress, which may induce arrhythmias or reveal ischemic changes suggestive of coronary artery disease. Useful for symptoms that occur with exertion.

4. Blood Tests

• Troponin: Indicated when coronary artery disease is suspected, especially if symptoms are suggestive of myocardial ischemia.
• Urea, Creatinine, and Electrolytes (e.g., Potassium): To rule out electrolyte abnormalities that can contribute to arrhythmias.
• Thyroid Function Tests: Hyperthyroidism or hypothyroidism can provoke or worsen arrhythmias.
• Routine Use of Magnesium, Calcium, and Phosphate: Generally produces a low diagnostic yield unless clinical suspicion of an abnormality exists.

5. Ambulatory Electrocardiographic Monitoring

• Holter Monitor: Suitable for patients with frequent symptoms (e.g., daily), allowing continuous monitoring for 24-48 hours.
• Event Recorder: Appropriate for less frequent symptoms, with monitoring over weeks, activated by the patient during symptoms.
• Implantable Loop Recorder: Recommended for very infrequent symptoms or when other methods fail to capture the arrhythmia, allowing long-term monitoring for months to years.
• External Loop Recorder and Hand-Held ECG Devices: Options for capturing arrhythmias in patients with less frequent or unpredictable symptoms, providing alternative monitoring methods.

from: AuSTrAlIAn FAMIly PhySICIAn Vol. 40, no. 8, AuGuST 2011

Indications:

• Palpitations of unclear cause despite history and ECG.
• Syncope or presyncope where arrhythmia (bradycardia or tachycardia) is suspected.
• Rare indications: Pacemaker malfunction, post-myocardial infarction monitoring, arrhythmia follow-up during drug therapy.

Choice of Investigation:

• Frequent symptoms (e.g., daily palpitations): 24-hour Holter monitor.
• Less frequent symptoms: Event recorder or ILR is more cost-effective.
• Holter monitors can be ordered by GPs; ILRs typically by cardiologists.

Contraindications:

• Delays more appropriate interventions: E.g., AECG is not suitable for initial assessment of stable angina.
• High-risk syncope: Inpatient admission is more appropriate.

Diagnostic Approach:

• History and clinical examination are critical.
• Initial tests: 12-lead ECG, blood tests (FBE, UEC, CMP, TFT).
• Further imaging: Echocardiography, stress test/angiography if structural or coronary heart disease is suspected.

Patient Instructions:

• Holter monitor: Worn for 24 hours, no showering during the test.
• Event recorder: Worn for 1-4 weeks, can be removed for showering.
• ILR: Implanted subcutaneously via a minor procedure.

Working Mechanism:

• Holter monitor: Continuous 3-channel ECG recording for 12-48 hours.
• Event recorder: Activated prospectively or retrospectively to record brief episodes.
• ILR: Continuous monitoring, activated manually or automatically.

Results Interpretation:

• Reports include:
  • Heart rate trends, pauses >2 seconds, premature contractions, SVT or VT episodes.
  • Bradycardia: May indicate the need for pacemaker evaluation.
  • Tachycardia: May require anti-arrhythmic therapy or further testing.
  • Atrial fibrillation (AF): Consider anticoagulation therapy.
  • Nonsustained/sustained VT: Cardiology review warranted.
  • Heart rate variability: May indicate sinus node dysfunction.

Limitations:

• Arrhythmia may not occur during the monitoring period.
• Does not detect ischemia or monitor blood pressure.
• standard methods like Holter monitoring which is performed over a 24 to 48-hour period, has a limited ability to detect paroxysmal atrial fibrillation
• CRYSTAL-AF Trial (2014): Demonstrated that continuous long-term monitoring with an implantable loop recorder (ILR) detected AF in 30% of cryptogenic stroke patients at 36 months

Next Steps After a Negative Test:

• Consider an event recorder for higher diagnostic yield.
• Refer to cardiology if AECG is negative but clinical suspicion is high.

Patient Considerations:

• Costs: Holter and event monitors have rebates
• ILRs typically do not but may be covered by insurance or public hospitals.

Ambulatory ECG monitoring: Choice of investigation
Investigation	Investigation of choice: symptom frequency	Advantages	Disadvantages
12-lead ECG	–	Readily available Inexpensive	Rarely performed during arrhythmia
24–48 hour Holter monitor	Daily to every second day	Usually available Does not require activation: asymptomatic arrhythmia can be detected	Low yield other than for daily arrhythmias
Loop/event recorder (range of 1–4 weeks)	Weekly–monthly	Increased yield and cost effectiveness (versus Holter	Most units only record ECG if patient triggered; not useful for asymptomatic arrhythmia or syncope Generally only one-week recorders available Patient discomfort for longer-term monitoring
Loop/event recorder for one week
Implantable loop recorder	Months to year/s	High yield Long-term monitoring approximately three years Automatic bradycardia/ tachycardia storage plus patient-triggered episodes	Cost Not available in all centres Currently only approved for diagnosis of syncope or cryptogenic stroke
Handheld ECG	Months to year	High yield Permanently available to patient	Cost to patient Time for activation of device before arrhythmia termination Potential large volume of data to interpret, no Medicare rebate Data ownership with some systems, sometimes requiring subscription

Sinus rhythm ECG markers of arrhythmia
Electrocardiographic sign	Implication/consideration
Pre-excitation/delta wave	WPW – AVRT
Left atrial enlargement, frequent PACs, sinus bradycardia	Atrial fibrillation
Left ventricular hypertrophy	Atrial fibrillation, ventricular tachycardia
Frequent PVCs	Ventricular tachycardia
Q waves	Ischaemic heart disease – atrial fibrillation, ventricular tachycardia
Widespread T wave inversion across precordial leads, LVH, Q waves and ST-segment changes	Hypertrophic cardiomyopathy – risk of atrial fibrillation, ventricular tachycardia
Long or short QT interval, Brugada pattern, early repolarisation pattern	Genetic arrhythmia syndromes – risk of sudden cardiac death
Inverted T waves or Epsilon waves across right precordial leads (V1–V3)*	ARVC – risk of sudden cardiac death
ARVC arrhythmogenic right ventricular cardiomyopathy; AVRT, atrio-ventricular reciprocating tachycardia; ECG, electrogardiogram; LVH, left ventricular hypertrophy; PACs, premature atrial contractions; PVCs, premature ventricular contractions; WPW, Wolff–Parkinson–White *In patients without right bundle branch block

Monitoring with Heart Rate Devices

• Usage Concerns: Patients often seek medical advice after noticing an abnormal heart rate on personal monitoring devices.
• Device Accuracy: These devices, particularly during physical activity, are prone to inaccuracies, producing falsely high or low readings.
• Interpretation of Readings: An abnormal reading is concerning only if accompanied by other symptoms like dizziness or chest pain.

Management Strategies

1. Reassurance and Lifestyle Modification: For benign arrhythmias, such as premature atrial or ventricular contractions.
2. Medication: Antiarrhythmic drugs for more persistent or troublesome arrhythmias.
3. Electrophysiology Study and Ablation: Consider for diagnosing complex arrhythmias or treating them through catheter ablation.
4. Management of Underlying Conditions: Address any identified underlying conditions such as thyroid disorders or electrolyte imbalances.

Referral Criteria

1. Persistent or Severe Symptoms: Refer patients with ongoing or severe symptoms that impact quality of life.
2. Structural Heart Disease: Immediate referral for patients with suspected structural heart disease.
3. High-Risk Cases: Patients with family history of sudden cardiac death or known genetic syndromes affecting the heart.

Which patients to refer or ‘When to worry’

Patients with frequent or persistent palpitations Sustained rapid palpitations Significant associated symptoms: – Pre-syncope/syncope (consider situational context) – Breathlessness – Chest pain Family history of recurrent syncope or of sudden death Significant resting 12-lead electrocardiography or echocardiographic abnormalities – Wolff–Parkinson–White syndrome (pre-excitation including short PR interval and delta wave) – Signs of structural or electrical abnormalities: — T wave abnormalities — Prior myocardial infarction (Q waves) — Long or short QT interval — Brugada pattern — early repolarisation pattern

Follow-Up

1. Regular Monitoring: Depending on the initial findings, some patients may require regular follow-up to monitor the progression of symptoms or response to treatment.
2. Adjustments in Therapy: Based on patient feedback and ongoing symptom monitoring.