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Chapter 59: Palpitations

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 BCE)

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.

  • Symptomatic premature ventricular beats/complexes (ventricular ectopics) are common, and atrial fibrillation is the most common sustained cardiac arrhythmia (1–2% of population), while cardiologists claim that the commonest is the symptomatic ventricular ectopic beat.1

  • 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.

  • Ask 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 59.1, which includes significant causes of palpitations.

Table 59.1Palpitations: diagnostic strategy model
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Table 59.1 Palpitations: diagnostic strategy model

Probability diagnosis

Anxiety

Premature beats (ectopics)

Sinus tachycardia

Drugs (e.g. stimulants)

Supraventricular tachycardia

Serious disorders not to be missed

Myocardial infarction/angina

Arrhythmias:

  • atrial fibrillation/flutter

  • ventricular tachycardia

  • bradycardia

  • sick sinus syndrome

  • torsade de pointes

Long QT syndrome

Wolff–Parkinson–White (WPW) syndrome

Electrolyte disturbances:

  • hypokalaemia

  • hypomagnesaemia

  • hypoglycaemia (type 1 diabetes)

Pitfalls (often missed)

Fever/infection

Pregnancy

Menopause (sudden vasodilatation)

Drugs (e.g. caffeine, cocaine)

Mitral valve disease

Aortic incompetence

Hypoxia/hypercapnia

Rarities:

  • tick bites (T1–5)

  • phaeochromocytoma

Seven masquerades checklist

Depression

Diabetes (indirect)

Drugs

Anaemia

Hyperthyroidism

Spinal dysfunction

UTI (possible)

Is the patient trying to tell me something?

Quite likely. Consider cardiac neurosis, anxiety.

Probability diagnosis

If the palpitations are not caused by anxiety or fever, the common causes are sinus tachycardia and premature complexes/ectopics (atrial ...

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