Station 2: Palpitations
What exactly do you mean by palpitations?
Is this a new problem? Or previous episodes?- if so, how often? When was the first episode? Do you take anything for it?
Have you got palpitations right now?
Site: show me where you feel it
Onset: since when, what were you doing at the time?, how long did it last?, when does it happen eg. at night, on exercise. How often? Becoming more often? Does it come on suddenly/gradually over seconds/mins/hours/days? Does it stop suddenly/gradually?
Character: fast/slow, regular/irregular. Ask patient to tap it out. Did you take your pulse rate?-how fast? Were there any missed beats and if so, did the next beat feel heavier?
Associated features/cardiac systems review: CP, SOB, syncope, presyncope, dizziness, sweating, nausea/vomiting, ankle swelling, orthopnoea, PND, exercise tolerance
Exacerbating factors: tea/coffee/alcohol/food. Any new medications recently? Positional?
Relieving factors: can you stop the palps yourself? Eg. swallow, valsalva
Ask Cardiac Risk factors: cholesterol, hypertension, diabetes, smoking, family history
Ask PMH cardiac: Known heart/cardiovascular problems? MI, TIA/stroke, peripheral vascular disease, valve disease, cardiomyopathy, heart failure. Ever had ECG/ exercise tolerance test/angiogram/echo etc.?
Ask Fx cardiac problems
Thyroid: Sweating, weight loss, appetite, tremor, flushing, loose stool, periods, eye changes, neck swelling, mood, heat intolerance, anxiety
Phaeochromocytoma: headache, sweating, chest pain, hypertension
Infection: fever, cough, dysuria etc.
Anaemia: fatigue, lethargy, blood loss
Panic/Anxiety/depression: ask about sleep, worry etc
Menopause and pregnancy- enquire about periods
Recent surgery?
Diabetes (hypoglycaemia causing palpitations)
PMH: cardiac/resp/thyroid etc.
Fx: cardiac eg. Sudden cardiac death under age 40/thyroid
Dx: new meds including OTCs, illicit. eg. salbutamol inhaler, sympathomimetic agents, vasodilators, anticholinergics, beta-blocker/benzo withdrawal
Sx: alcohol, smoking-nicotine, caffeine (tea and coffee), fizzy drinks, drugs-cocaine/amphetamines/ecstasy/heroin/cannabis, occupation, stress, driving, impact on activities of daily living
Systems review
ICE
Investigations:
12 lead ECG
FBC, CRP, TFTs, U+E, LFT, Ca, P, Mg (electrolyte imbalance), glucose/hba1c, lipid profile, (troponin)
CXR
Urine dip
Echo if concern about structural heart disease
24/48 hour tape
Exercise testing
7 day tape
Reveal device (implantable loop recorder)
EP studies
Causes:
Cardiac arrhythmias
- Extrasystoles (ventricular or supraventricular).
- Tachycardias (ventricular or supraventricular. Includes atrial fibrillation (AF) and atrial flutter).
- Bradyarrhythmias (sinus bradycardia, atrioventricular block. Less commonly perceived as palpitations).
Structural heart disease
- Valvular pathology: mitral valve prolapse, aortic or mitral regurgitation, mechanical valves.
- Congenital heart disease.
- Cardiomyopathy.
- Heart failure.
Psychosomatic causes
- Anxiety.
- Panic disorder.
- Somatisation disorders.
- Depression.
Systemic causes
- Hyperthyroidism.
- Hypoglycaemia.
- Fever.
- Anaemia.
- Pregnancy.
- Menopause.
- Postural orthostatic hypotension syndrome.
- Phaeochromocytoma.
- Hypovolaemia.
Medication, recreational drugs and substances
- Sympathomimetic agents: beta-2 agonists, antimuscarinics, vasodilators.
- Withdrawal of beta-blockers.
- Alcohol.
- Nicotine.
- Recreational drugs: cocaine, ‘ecstasy’ – methylenedioxymethamfetamine (MDMA), heroin, cannabis, amfetamines.
- Caffeine: cola, coffee, tea, Red Bull®.
References:
Resources listed in the ‘reference/credit’ section of this webpage
https://patient.info/doctor/palpitations-pro