Chapter 70

### Introduction

The most important requirement of the art of healing is that no mistakes or neglect occur. There should be no doubt or confusion as to the application of the meaning of complexion and pulse. These are the maxims of the art of healing.

Huang Ti (The Yellow Emperor) (2697–2597 BC)

Palpitations are an unpleasant awareness of the beating of the heart. By definition it does not always imply ‘racing’ of the heart but any sensation in the chest, such as ‘pounding’, ‘flopping’, ‘skipping’, ‘jumping’, ‘thumping’ or ‘fluttering’ of the heart. The problem requires careful attention and reassurance (if appropriate) because heartbeat is regarded as synonymous with life. To the practitioner it may simply represent anxiety or it could be a prelude to a cardiac arrest. In many circumstances prompt referral to a cardiologist is imperative.

Key facts and checkpoints

• The symptom of palpitations is suggestive of cardiac arrhythmia but may have a non-cardiac cause.

• Palpitations not related to emotion, fever or exercise suggest an arrhythmia.

• Perhaps the commonest arrhythmia causing a patient to visit the family doctor is the symptomatic premature ventricular beat/complex (ventricular ectopic).

• The commonest cause of an apparent pause on the ECG is a blocked premature atrial beat/complex (atrial ectopic).

• A 12-lead electrocardiographic diagnosis is mandatory. If the cause is not documented, an ambulatory electrographic monitor (e.g. Holter) may be used.

• Consider myocardial ischaemia as a cause of the arrhythmia.

• Consider drugs as a cause, including prescribed drugs and non-prescribed drugs such as alcohol, caffeine and cigarettes.

• Common triggers of paroxysmal supraventricular tachycardia (PSVT) include anxiety and cigarette smoking.

• The commonest mechanism of any arrhythmia is re-entry.

• Get patients to tap out the rate and rhythm of their abnormal beat.

### A diagnostic approach

A summary of the diagnostic strategy model is presented in Table 70.1, which includes significant causes of palpitations.

Table 70.1

Palpitations: diagnostic strategy model

#### Probability diagnosis

If the palpitations are not caused by anxiety or fever, the common causes ...

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