Momentary palpitations: Ectopic beatsĪnother frequent cause of palpitations is benign ectopic beats, which can be atrial or ventricular. It may often occur at times of heightened anxiety. Although there may occasionally be secondary causes, in the vast majority of cases this is benign. 6 The patient may describe a forceful beating in the chest or neck that is not particularly fast they may be able to hear their own heartbeat, particularly at night in bed. One of the causes of palpitations is simply an increased awareness of normal sinus rhythm. Subjective awareness of a normal heartbeat Chest pain (possibly ischaemic in nature).Palpitations: Key questions in history-takingĭuration: momentary or sustained (how long?) Once clarified, the history should focus on the nature of the symptoms and circumstances around the time of the palpitations (Box 1). Sometimes it is useful to get the patient to tap or clap out the heart rhythm during their typical episode. 1 Palpitations are subjective and have been defined as ‘a disagreeable sensation of pulsation or movement in the chest and/or adjacent areas’ 4 it is important to clarify whether the patient’s symptom is palpitations rather than a non-arrhythmic cardiac symptom (eg chest pain, shortness of breath, pre-syncope) or a non-cardiac symptom. The yellow arc represents the AV node.ĪVNRT, atrioventricular nodal re-entrant tachycardia AVRT, atrioventricular re-entrant tachycardia RA, right atrium LA, left atrium RV, right ventricle LV, left ventricleĪ thorough history is essential given the overwhelming majority of patients will present in sinus rhythm, between episodes of arrhythmia. The small circuit in dots represents typical AVNRT, short dashes represent (orthodromic) AVRT (via a right free wall pathway represented by the red dashes), and long dashes represent atrial flutter. Common types of SVT and representative circuits Age of the patient may give some indication regarding the arrhythmia mechanism if supraventricular tachycardia is suspected atrioventricular re-entrant tachycardia (AVRT Wolf-Parkinson-White syndrome) becomes less likely with increasing age, whereas atrioventricular nodal re-entrant tachycardia (AVNRT), atrial fibrillation and atrial tachycardia become more likely (Figure 1). 4 Sinus tachycardia may also be a normal response to stress, including episodes of anxiety, and it is important to elucidate cause and effect. 3 It is important to caution labelling a patient’s palpitations as being due to anxiety/panic disorder or stress, as 54% of this group will eventually be diagnosed with an arrhythmic cause, and the time delay until arrhythmia diagnosis is 3.3 years. 2 In an emergency population, a cardiac cause of palpitations was identified in 34% of patients. In patients presenting to a university medical centre with palpitations, 41% had an arrhythmic aetiology, 31% had palpitations in the context of psychological disorder such as anxiety, and in 16% no cause was identified. Not all patients with palpitations will have a cardiac or arrhythmic cause. 2 This article presents a systematic approach to the patient with palpitations and addresses consideration of the aetiology, history and examination appropriate diagnostic workup cardiology/electrophysiology referral and management strategies. Only rarely will palpitations be associated with risk of serious cardiac events. 1 Although the vast majority are benign, there are some clinical and electrocardiographic signs that determine when further investigations may be necessary. Palpitations have been estimated to account for 16% of general practice presentations and are the second most common presentation to cardiologists after chest pain. Palpitations are one of the most common presentations to general practice, and while they are usually benign, they may also have life-threatening significance.
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