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Guidance on the management of palpitations in primary care

What is a palpitation? 

  • Palpitation is an uncomfortable awareness of the heart rhythm. Normal palpitations occur with exercise, emotion, and stress, or after taking substances that increase adrenergic activity or decrease vagal activity 
  • The symptom can cause distress to the patient, but can also cause distress to the reviewing clinician. Despite this anxiety the majority of palpitations are not associated with dysrhythmia, and of the ones found to be arrhythmias, many of these are benign in nature. Less than 1 in 2 cases of palpitations are cardiac in nature 
  • Identifying the difference between a benign and significant dysrhythmia presenting as palpitations is achievable through careful history-taking and assessment of the 12-lead electrocardiography (ECG)  

Definitions used in this guideline  

  • Palpitation  is the uncomfortable awareness of the heart rhythm:
    • normal palpitations occur with exercise, emotion, and stress or, after taking substances that increase adrenergic activity or decrease vagal activity 
    • abnormal palpitations may occur for no reason and may be fast or strong-and-slow. Palpitations may point to cardiac arrhythmia; however, many people who have rhythm disturbances will not have palpitations, instead they will experience syncope, shock, and chest pain 
  • Syncope is a sudden but brief loss of consciousness that is caused by inadequate blood supply to the brain. Recovery is spontaneous and rapidly complete. Syncope is common, disabling, and possibly associated with sudden cardiac death
  • Vertigo is a hallucination of movement of the environment about the patient, or of the patient with respect to the environment. It is not synonymous with dizziness. It may be central (due to a disorder of the brainstem or the cerebellum) or peripheral (due to a disorder in the inner ear or the 8th cranial nerve). This guideline would suggest ear, nose, and throat review prior to cardiac review unless associated with palpitations or chest pain 

High risk factors

  • Pre-existing structural heart disease 
  • History of heart failure 
  • History of syncope or pre-syncope 
  • Family history of sudden cardiac death (<40 years of age) 
  • Exertional cardiac symptoms (including exertional palpitations) 
  • Resting 12-lead ECG abnormality (pre-excitation, old myocardial infarction [MI], Left bundle branch block) 

Vagal manoeuvres techniques include:  

  • Valsalva manoeuvre
  • Carotid sinus massage (if practitioner feels competent and no bruits present)
  • Cold-water face immersion

History 

What does the patient mean? 

  • As stated above ’palpitations’ does not necessarily indicate cardiac dysrhythmia but an unusual pounding sensation. Hence people presenting in primary care generally use this term correctly but in its broadest sense. It is for the clinician to define exactly what they mean. Palpitations are a symptom and are not necessarily arrhythmia—sometimes the patient could be referring to a different issue, such as chest discomfort 
  • The heart rate at the time of palpitations should be explored; asking the patient to tap the heartbeat with their hands can help further clarify the rate and also give an idea about regularity:
    • there is a suggestion that regular palpitations are more likely to be an arrhythmia than irregular ones. The brief irregularities such as missed beats, fluttering sensations, or extra beats, are often caused by ectopy
    • it is valuable to know the duration and frequency of palpitations to understand the impact on the patient’s life 
  • It is important to find out about the circumstances during which palpitations occur: 
    • does it happen when the patient is at rest or does it happen during activity? 
    • can it be brought on by swallowing cold food or drinks? 
    • can it be stopped by coughing or breath holding? (Coughing can sometimes be found in atrial flutter, while breath holding could suggest an atrioventricular nodal reentrant tachycardia)

Associated features 

  • Associated pre-syncopal symptoms or loss of consciousness are high risk factors and suggest detailed assessment is required. Syncope can be the only symptom of arrhythmia. Also, patients with recurrent unexplained syncope, or syncope occurring during exercise/exertion, or injury due to syncope should be referred for further assessment 
  • Dyspnoea can be a sign of tachydysrhythmia—at times it may indicate cardiac decompensation such as in atrial fibrillation with a rapid ventricular release
  • Chest pain can be associated with palpitations. This can be the due to underlying coronary disease but a rapid heart rate can cause chest discomfort even when the heart is structurally normal 

Contributing factors

  • Anxiety is often associated with palpitations and fluttering in the chest. However, a full history is still required as someone can be suffering from anxiety and be taking pro-arrhythmic medication 
  • Lifestyle factors, such as excessive caffeine intake, alcohol abuse, or illicit drug use needs to be discussed 
  • Medication can also be part of the aetiology; thyroxine replacement, beta-agonists, and calcium channel receptor blockers can all cause palpitations. The pro-arrhythmic nature of anti-arrhythmics is also a concern and an increased severity of palpitations in people initiating this therapy should be discussed with the responsible physician. There is a long list of medication that can prolong the corrected QT interval (QTc) and their effects can be summative. A non-exhaustive list is included in the appendix

Family history 

  • Take a careful family history, paying particular attention to cardiac muscle problems, a history of early onset coronary disease or a history of atrial fibrillation (often found through discussing the setting of cardioversion). Ask about relatives with implantable cardioverter defibrillators (ICDs) or pacemakers can also assist in finding complex cardiac disorders 
  • Questions around young unexplained deaths may indicate the presence of Sudden Arrhythmic Death Syndromes (SADS). Sometimes these may be explained as cardiac issues but they may be concealed as drownings, road traffic accidents, or suicides. Questions raised during investigations should extend to cousins and beyond 

Examination and investigations 

Examination 

  • When the patient is assessed in primary care they are often asymptomatic and the examination is normal. If the patient is symptomatic at presentation they should be assessed rapidly for haemodynamic compromise. If marked this may warrant discussion with the secondary care cardiology team or assistance from the paramedics 
  • In the asymptomatic patient, a cardiovascular assessment is essential with particular focus on the rate, rhythm, and character of the pulse, and a manual blood pressure assessment. Signs of heart failure syndrome or murmurs may point to underlying structural heart disease 

Investigations 

Blood tests  

  • These should include full blood count to exclude anaemia, electrolytes, liver function tests, glucose assessment, and thyroid function tests; and a cholesterol and lipid assessment for those over 35 years of age who have not had a recent cardiovascular risk assessment 

ECG

  • The 12-lead ECG is the most useful test in the assessment of palpitations and is mandatory in all patients with palpitations. If the patient is clearly haemodynamically compromised this should not delay the call for assistance as admission may be appropriate. An ECG performed during symptoms is of great value and the patient should be made aware of its value, and be asked to attend to get an ECG performed if they are symptomatic and still without a diagnosis
    • chapter 8 of the National Service Framework for cardiology recommends that if an ECG is performed, a copy should be given to the patient so they are able to give it to their reviewing clinician 
    • if there is uncertainty about the nature of an ECG then a review of the trace should be arranged: 
      • abnormalities shown on the ECG, such as left ventricular hypertrophy or previous MI may suggest underlying structural heart disease. Problems with conduction and repolarisation may point to arrhythmic illness. Issues such as second-degree block or complete heart block should be discussed with a hospital cardiologist promptly 

ECG changes that are significant

  • Atrial fibrillation 
  • Second- and third-degree atrioventricular block 
  • Signs of previous myocardial infarction 
  • Left ventricular hypertrophy and left ventricular strain patterns 
  • Left bundle branch block 
  • Abnormal T-wave inversion and ST-segment changes 
  • Signs of pre-excitation (short PR interval and delta waves) 
  • Abnormal QTc interval and T-wave morphology 

Ambulatory rhythm monitoring

  • This is of value if the symptoms are frequent—the duration of recording should reflect the frequency of symptoms. A normal recording during an asymptomatic period does not exclude arrhythmic problems. A 24-hour period of recording gives a positive result in less than 1 in 10 cases 

Risk stratification and referral

Risk stratification

  • The majority of patients presenting with palpitations do have an arrhythmia, and of these patients, many do not have an arrhythmia of prognostic significance. Risk assessment is a guide for GPs to aid decision-making around further investigation and referral 
  • Dr Michael Cooklin, a cardiologist based in London and the South London Cardiac and Stroke Network, has raised awareness of risk stratification in arrhythmic illness with the ‘Traffic Light’ system (Figure 1, below) 

Risk stratification for heart palpitations

Figure 1: Risk stratification for heart palpitations

Referral

  • When a GP feels that there is a clinical scenario that they are unable to confidently manage, a referral for further advice or review is always appropriate
  • It may be appropriate to refer for a clinical opinion, rhythm monitoring, or for a full review. Figure 2 (below) shows possible pathways

Pathways for the management of palpitations in primary care

Figure 2: Pathways for the management of palpitations in primary care

Driving and palpitations

  • Arrhythmias have consequence on people’s lives in many ways and the ability to hold a driving licence is one. The DVLA regulations state that if a person suffers incapacity or may suffer incapacity from an arrhythmia they must cease driving. It is the clinician’s responsibility to ensure the person is aware of this and documentation of this advice in the notes is of paramount importance 
  • More information can be found at: www.dvla.gov.uk/medical/ataglance.aspx
Useful websites 

www.heartrhythmcharity.org.uk

Arrhythmia Alliance, an umbrella charity of other groups dealing with arrhythmia 

www.stars.org.uk

The syncope trust, for clinician and patient support in the area of syncope 

www.atrialfibrillation.org.uk

The international charity to support patients and clinicians in the area of atrial fibrillation 

www.sadsuk.org

The national charity to support relatives and raise awareness of Sudden Arrhythmic Deaths 

www.c-r-y.org.uk

Cardiac Risk in the Young, supporting research and support for sudden cardiac deaths 

www.dvla.gov.uk/medical/ataglance.aspx

DVLA website for medical advice on driving 

www.Long-QT-Syndrome.com

For lists on drugs that can protract the QT interval 

full guideline available from…

www.bradfordvts.co.uk/wp-content/onlineresources/1501cardiovascular/palpitations%20in%20primary%20care.pdf

Dr Matthew Fay and Dr Andreas Wolff. Westcliffe cardiology service. Guidance on the management of palpitations in primary care 

First included: March 2018