Palpitations can be described as the sensation of an abnormally received heartbeat. It can be rapid, irregular, forceful or just an unusual awareness. Palpitations are a common presentation with patients of all ages and demographics. Occasionally palpitations can be life-threatening, however, most palpitations are non-urgent, treatable conditions. The key to decision making is a thorough history and focussed tests.

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Common causes of palpitations

• Psychosomatic (anxiety, panic attacks, depression)
• Drugs, Nicotine, Caffeine, Alcohol withdrawal
• Cardiac Arrhythmias: Extrasystoles (supraventricular or ventricular ectopics), Supraventricular Tachycardias including atrial fibrillation or flutter, Ventricular Tachyardia
• Hyperthyroidism
• Anaemia
• Electrolyte imbalances
• Fever or infection
• Menopause
• Structural cardiac disorders (MIs, Cardiomyopathies, Valvular Abnormalities, Heart Failure)

Assessment

If the patient is symptomatic at time of assessment, urgently obtain a manual pulse check & 12 lead ECG. Otherwise you might miss the opportunity.

Like dizziness, palpitations can mean multiple things to different people. It is important to have the patient describe in simple terms what they feel like. Essentially palpitations are the sudden feeling of noticing the heartbeat. They can feel the heart-pounding, fluttering or beating irregularly. The palpitations can last from seconds to minutes, so it is important that the patient is asked how long does it last and how many episodes they have had.

History of Presenting Complaint

Red flag features must be asked & prompt urgent assessment

• Identify the nature & frequency of palpitations
  • What were they doing when they started? Precipitated by exercise?
  • Did they start suddenly or with warning?
  • Are they always the same?
  • How frequently do they occur & how long do they last?
  • How fast did it feel? Can the patient tap out the pattern (regular/irregular)? Did it feel like they were skipping/missing a beat? Has the patient measured their pulse rate during an episode?
• Were there any specific triggers?
  • Exertion, postural, panic/anxiety, changes in sleep pattern, alcohol, drug, caffeine or food intake
  • Can they quantify the amount of alcohol/drug/caffeine
  • Can the patient do anything to improve the symptoms? E.g. vagal manoeuvres such as straining or holding breath is suggestive of paroxysmal SVT
• Any associated symptoms?
  • Syncope (very concerning as could be life-threatening VT)
  • Shortness of breath, lightheadedness or dizziness (could be concerning of the above)
  • Chest pain (can be concerning of underlying cardiac disease)
  • Feeling pressure in the neck (re-entry tachycardia)
  • Sweating, fever, coughing (infection)
  • Weight loss, diarrhoea, sweating, tremor, feeling hot (hyperthyroidism)
  • Diarrhoea or vomiting (electrolyte abnormalities)
  • Mood or emotional stress (Anxiety)
• It is worth asking the patient what they think is going on, what it is that is concerning them and what they are hoping to gain

Past Medical History

• Cardiac disease particularly valvular disease, cardiomyopathies, ischaemic heart disease
• Thyroid disease (overtreated hypothyroidism or untreated hyperthyroidism)
• Any family history of sudden cardiac death under the age of 40?
• Drug history – prescribed, over the counter & recreational drugs. Look for medications that might increase the QT interval. Diet pills can cause dangerous arrhythmias.

Social History

• Smoking and alcohol intake
• Exercise & impact on ADLs
• If they drive it is important that they don’t drive as per the DVLA until the source has been identified

Examination

• General examination (Do they look well? Are they feverish, cachetic or dehydrated?)
• Cardiovascular examination (valvular disease, heart failure, anaemia, tar staining)
• Do they have a tremor potentially in keeping with anxiety or hyperthyroidism?
• If indicated any other relevant examination e.g. Respiratory, Abdominal, Thyroid, Mental State

What to look for on the 12 Lead ECG?

• Most commonly the ECG is normal, shows sinus tachycardia or ocasional extrasystoles (premature atrial complex/premature ventricular complex)
• Features of ischaemic heart disease or cardiomyopathy: pathological Q waves, T wave inversion, poor R wave progression, left bundle branch block
• Features of cardiac hypertrophy (LVH or RVH)
• QT interval (abnormally short or long) ensuring to correct with the heart rate
• Heart block
• Pre-exictation syndromes such as WPW (shortened PR interval & delta wave)
• Tachyarrhythmias
  • SVT: narrow QRS complex tachycardia usually without discernible P waves
  • VT: broad complex tachycardia
  • Atrial fibrillation: irregularly irregular narrow complex tachycardia without P waves
  • Atrial flutter: saw tooth pattern at 300bpm (or 150/100/75 with 2:1, 3:1 or 4:1 block)
• P wave abnormalities
  • Peaked – Right atrial overload (Pulmonary or tricuspid valve stenosis, pulmonary hypertension).
  • Broad and Bifid – Hypertension, Mitral valve disease.
• Brugada syndrome

Further Investigations

• FBC, U&Es, LFTs, CRP, Magnesium, Bone Profile, TFTs, HbA1c
• BNP if heart failure suspected
• Ambulatory ECG (24h or longer depending on how frequently the symptoms occur)
• Echocardiogram (if unclear aetiology, murmur, heart failure suspected or raised BNP)

Management

Indications for urgent admission

• Ventricular tachycardia
• Persistent SVT (not ceasing with vagal manouevres)
• Haemodynamic instability
• Features suggestive of underlying cardiac cause (syncope, presyncope, high degree heart block, chest pain, significant shortness of breath, family history of young sudden cardiac death, palpitations brought on by exercise)
• Severely systemically unwell (severe anaemia, sepsis, thyrotoxicosis)

Indications for referral to cardiology

• Atrial Flutter or paroxysmal AF
• SVT terminated by vagal manoeuvre
• Wolff-Parkinson-White syndrome
• Prolonged QT interval (depending on how prolonged)
• Suspicion of structural cardiac disease

Treatment

• Reassurance if benign cause
• Treat the underlying cause (thyrotoxicosis, anxiety, fever/sepsis, anaemia)
• Review medication & recreational drug use
• Provide lifestyle advice – avoidance of triggers, smoking cessation, exercise
• Cardiovascular disease risk assessment
• B blockers are used if lifestyle measures aren’t sufficient in patients with symptomatic premature atrial/ventricular complexes/ectopics

Further Reading & References

• Geeky Medics: Palpitations OSCE Guide
• NICE CKS: Palpitations
• Patient Info Professional: Palpitations
• BMJ Best Practice: Palpitations

Written by: Craig Jackson (Paramedic, South Central Ambulance Service SE Operations, PA 49873 HCPC)
Reviewed & Edits by Dr Akash Doshi (ST3 in Endocrinology/Diabetes & GIM)

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