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Palpitations

Palpitations are defined as an unpleasant awareness of beating of the heart, incl. skipped heartbeat, irregular heartbeat, rapid or slow heartbeat. The symptoms are suggestive of cardiac arrhythmia but may have a non-cardiac cause. The commonest presenting cause is the symptomatic premature ventricular beat (ventricular ectopic).

Management strategies

  • Treat the underlying cause

  • Give appropriate reassurance

  • Provide clear patient education

  • Explain about the problems of fatigue, stress and emotion

  • Advise moderation in consumption of alcohol

  • Advise about cessation of smoking and other drugs

  • Avoid drugs for atrial and ventricular premature beats and sinus tachycardia but give a β-blocker (atenolol or metoprolol) if patient disturbed by symptoms

  • Most arrhythmias require referral

Red flag pointers

  • Chest pain, lightheadedness

  • New onset

  • Heart rate >120 or 45/minute at rest

  • Underlying heart disease

  • Family history of sudden death

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Table P2 Palpitations: diagnostic strategy model (modified)

Probability diagnosis

Anxiety

Premature beats (ectopics)

Sinus tachycardia

Supraventricular tachycardia

Drugs (e.g. stimulants)

Serious disorders not to be missed

Myocardial infarction/angina

Arrhythmias

  • atrial fibrillation/flutter

  • ventricular tachycardia

  • bradycardia

  • sick sinus syndrome

  • torsade de pointes

WPW syndrome

Electrolyte disturbances

  • hypokalaemia

  • hypomagnesaemia

Thyrotoxicosis

Pitfalls (often missed)

Fever/infection

Pregnancy

Menopause (sudden vasodilatation)

Drugs

  • social (e.g. caffeine, cocaine, amphetamines, alcohol, nicotine)

  • prescribed (e.g. sympathomimetics)

Mitral valve prolapse

Aortic incompetence

Hypoxia/hypercapnia

Hypoglycaemia

Phaeochromocytoma

Table P3**Summary of treatment guidelines of arrhythmias
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Table P3 Summary of treatment guidelines of arrhythmias

Arrhythmia

First line

Second line

Sinus tachycardia

Treat cause

Reduce caffeine intake

If no cause:

metoprolol or atenolol or verapamil

Bradycardias

Sick sinus syndrome

Permanent pacing if symptomatic

AV block first degree

No treatment

Second degree:

  • Mobitz I

  • Mobitz II

Third degree:

  • acute (e.g. MI)

  • chronic

No treatment

Consider pacing

Temporary pacing

Adrenaline IV

Permanent pacing

Atrial tachyarrhythmias

PSVT

Valsalva

Adenosine IV or

Carotid sinus massage

verapamil IV

image

β-blocker or verapamil (with care) to control rate

Add digoxin (if necessary)

Rhythm control with cardioversion, electrical or drugs

Consider AF ablation

Atrial premature beats

Treat cause

Check lifestyle

Metoprolol or atenolol or verapamil

Ventricular tachyarrhythmias**

Ventricular premature beats

Treat cause

Check lifestyle

Ventricular tachycardia non-sustained sustained

β-blocker, e.g. sotalol, amiodarone or lignocaine IV if stable

Lignocaine IV

—if not: DC shock

Ventricular fibrillation

DC cardioversion

IV adrenaline if fine

VF, then

DC cardioversion

*Consider anti-coagulation with warfarin or aspirin

**

Third-line treatment may be required, usually DC cardioversion or class III antiarrhythmias (sotalol, flecainide or amiodarone)

Management of PSVT

  1. Attempt vagal stimulation:

    • carotid sinus massage (not recommended, especially in elderly) or

    • blow hard into end of empty 20 mL syringe to move plunger

    • Valsalva manoeuvre or

    • self-induced vomiting

  2. If above fails:

    • adenosine IV 6 mg first over 5–10 secs, then 12 mg after 2 min, then 18 mg in 2 min (if preceding doses unsuccessful)

    • verapamil IV is second-line treatment

    Seek specialist advice to ...

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