Download Arrhythmia? Does This Patient With Palpitations Have a Cardiac

Does This Patient With Palpitations Have a Cardiac
Arrhythmia?
Paaladinesh Thavendiranathan; Akshay Bagai; Clarence Khoo; et al.
Online article and related content
current as of November 17, 2009.
JAMA. 2009;302(19):2135-2143 (doi:10.1001/jama.2009.1673)
http://jama.ama-assn.org/cgi/content/full/302/19/2135
Supplementary material
eFigures and eTables
http://jama.ama-assn.org/cgi/content/full/302/19/2135/DC1
Correction
Contact me if this article is corrected.
Citations
Contact me when this article is cited.
Topic collections
Physical Examination; Cardiovascular System; Radiologic Imaging; Diagnosis;
Echocardiography; Arrhythmias; Cardiac Diagnostic Tests
Contact me when new articles are published in these topic areas.
CME course
Online CME course available.
CME course
Online CME course available.
Subscribe
Email Alerts
http://jama.com/subscribe
http://jamaarchives.com/alerts
Permissions
Reprints/E-prints
[email protected]
http://pubs.ama-assn.org/misc/permissions.dtl
[email protected]
Downloaded from www.jama.com by guest on November 17, 2009
THE RATIONAL
CLINICAL EXAMINATION
CLINICIAN’S CORNER
Does This Patient With Palpitations
Have a Cardiac Arrhythmia?
Paaladinesh Thavendiranathan, MD
Akshay Bagai, MD
Clarence Khoo, MD
Paul Dorian, MD
Niteesh K. Choudhry, MD, PhD
CLINICAL SCENARIO
A 58-year-old woman presents to the
emergency department with intermittent episodes of palpitations. She
describes “heart fluttering” that usually lasts less than 5 minutes, which is
associated with a sense of “impending
doom,” sweating, and paresthesia in
both hands. She is unable to tell
whether the rhythm is regular or
irregular and denies a regular rapidpounding sensation in the neck.
There is no associated presyncope or
syncope. She has a history of panic
disorder but is otherwise healthy and
takes no medications. Her pulse rate
and rhythm are palpably normal and
the rest of her physical examination
along with a 12-lead electrocardiogram is normal.
WHY IS THE CLINICAL
EXAMINATION FOR
PALPITATIONS IMPORTANT?
Palpitations are a common, unpleasant, and often alarming awareness of
heartbeats,1 with a prevalence as high
as 16% in medical outpatients.2 They
often pose a clinical challenge 3
because of the wide differential diagnosis (BOX). Palpitations may occur due
to a change or abnormality in heart
CME available online at
www.jamaarchivescme.com
and questions on p 2160.
Context Many patients have palpitations and seek advice from general practitioners.
Differentiating benign causes from those resulting from clinically significant cardiac arrhythmia can be challenging and the clinical examination may aid in this process.
Objective To systematically review the accuracy of historical features, physical examination, and cardiac testing for the diagnosis of cardiac arrhythmia in patients with
palpitations.
Data Source, Study Selection, and Data Extraction MEDLINE (1950 to August 25, 2009) and EMBASE (1947 to August 2009) searches of English-language articles that compared clinical features and diagnostic tests in patients with palpitations
with a reference standard for cardiac arrhythmia. Of the 277 studies identified by the
search strategy, 7 studies were used for accuracy analysis and 16 studies for diagnostic yield analysis. Two authors independently reviewed articles for study data and quality and a third author resolved disagreements.
Data Synthesis Most data were obtained from single studies with small sample sizes.
A known history of cardiac disease (likelihood ratio [LR], 2.03; 95% confidence interval [CI], 1.33-3.11), having palpitations affected by sleeping (LR, 2.29; 95% CI, 1.333.94), or while the patient is at work (LR, 2.17; 95% CI, 1.19-3.96) slightly increase
the likelihood of a cardiac arrhythmia. A known history of panic disorder (LR, 0.26;
95% CI, 0.07-1.01) or having palpitations lasting less than 5 minutes (LR, 0.38; 95%
CI, 0.22-0.63) makes the diagnosis of cardiac arrhythmia slightly less likely. The presence of a regular rapid-pounding sensation in the neck (LR, 177; 95% CI, 25-1251)
or visible neck pulsations (LR, 2.68; 95% CI, 1.25-5.78) in association with palpitations increases the likelihood of a specific type of arrhythmia (atrioventricular nodal
reentry tachycardia). The absence of a regular rapid-pounding sensation in the neck
makes detecting the same arrhythmia less likely (LR, 0.07; 95% CI, 0.03-0.19). No
other features significantly alter the probability of clinically significant arrhythmia. Diagnostic tests for prolonged periods of electrocardiographic monitoring vary in their
yield depending on the modality used, duration of monitoring, and occurrence of typical symptoms during monitoring. Loop monitors have the highest diagnostic yield (34%84%) for identifying an arrhythmia.
Conclusions While the presence of a regular rapid-pounding sensation in the neck
or visible neck pulsations associated with palpitations makes the diagnosis of atrioventricular nodal reentry tachycardia likely, the reviewed studies suggest that the clinical examination is not sufficiently accurate to exclude clinically significant arrhythmias
in most patients. Thus, prolonged electrocardiographic monitoring with demonstration of symptom-rhythm correlation is required to make the diagnosis of a cardiac arrhythmia for most patients with recurrent palpitations.
www.jama.com
JAMA. 2009;302(19):2135-2143
Author Affiliations: Division of Cardiology, Department of Medicine (Dr Thavendiranathan) and Division of Cardiology, St Michael’s Hospital (Drs Bagai
and Dorian), University of Toronto, Toronto, Ontario,
Canada; Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
(Dr Khoo); and Division of Pharmacoepidemiology and
Pharmacoeconomics, Department of Medicine,
Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts (Dr Choudhry).
©2009 American Medical Association. All rights reserved.
Corresponding Author: Niteesh K. Choudhry,
MD, PhD, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, Ste
3030, Boston, MA 02120 (nchoudhry@partners
.org).
The Rational Clinical Examination Section Editors:
David L. Simel, MD, MHS, Durham Veterans Affairs
Medical Center and Duke University Medical Center,
Durham, NC; Drummond Rennie, MD, Deputy
Editor.
(Reprinted) JAMA, November 18, 2009—Vol 302, No. 19
Downloaded from www.jama.com by guest on November 17, 2009
2135
PALPITATIONS AND CARDIAC ARRHYTHMIA
Box. Differential Diagnosis
of Palpitations
Arrhythmia
Defined as atrial fibrillation or flutter, atrioventricular node reentry
tachycardia or atrioventricular reentry tachycardia, atrial tachycardia, ventricular tachycardia, premature ventricular contractions or
premature atrial contractions, or
multifocal atrial tachycardia
The causes are primary electrical
abnormality or electrical abnormality secondary to structural cardiac disease or comorbid medical
conditions.
Sinus tachycardia
The causes include hyperthyroidism, anxiety or panic disorder, fever, hypovolemia, stimulants (caffeine, alcohol), medications, blood
loss, pheochromocytoma, hypoglycemia, and idiopathic.
Normal sinus rhythm
The cause is heightened cardiac
perception for an unclear reason.
rhythm, such as an arrhythmia (ie, an
abnormal, disordered, or disorganized heartbeat), due to an appropriate increase in normal sinus rate,
or with a normal sinus rate and rhythm
due to heightened sensitivity and
perception of one’s heartbeats
(eFigure 1 is available at http://www
.jama.com).
In one study, primary cardiac disease (43%) and anxiety or panic disorder (31%) were the most common
causes in patients presenting with
palpitations to the emergency department, admitted to the hospital, or
attending a medical clinic.4 Among
patients with cardiac disease, palpitations were attributable to arrhythmia
in 91% of cases. Thus, the pretest
probability of cardiac arrhythmia in a
similar patient population would be
39%. In 2 other studies, 19% of
patients presenting with palpitations
were found to have a clinically significant arrhythmia.5,6
Because a minority of patients have
palpitations while being examined by
their physician, the challenge is to capture a recording of the cardiac rhythm
during symptoms. While event monitors have been designed to facilitate this
process, the diagnostic yield varies with
the frequency of symptoms and duration of the monitored period. Arrhythmias also may occur in individuals who
have no symptoms at all.7 Therefore, the
presence of an arrhythmia on diagnostic testing does not confirm that it is the
cause of a patient’s symptoms.7 To be
certain, their symptoms must be correlated with an electrocardiographically documented rhythm disturbance. Similarly, if the patient repeatedly
has a normal cardiac rate and rhythm
during typical symptoms, one can reassure the patient that the cause is likely
nonarrhythmic.
While palpitations are usually benign, they may be a manifestation of
life-threatening conditions. More importantly, recurrent palpitations can be
associated with significant disability, including impaired work performance
and the inability to perform household duties.4,8 However, using diagnostic tests such as event monitors and
echocardiograms for every person with
palpitations can be costly and of low diagnostic yield. Therefore, we reviewed the utility of clinical history,
physical examination, and resting routine electrocardiography as screening
tests for identifying patients with palpitations whose symptoms are likely or
unlikely to be due to a cardiac arrhythmia.
HOW TO EVALUATE A PATIENT
WITH PALPITATIONS
Patient History
Most demographic and historical features do not significantly influence the
likelihood of clinically significant arrhythmias.5,6 Patient age may be important because supraventricular tachycardias, particularly ones that use a
bypass tract (atrioventricular reentry
tachycardia) (eFigure 1D), may be first
experienced earlier in life.9,10 In young
athletes with palpitations, it is impor-
2136 JAMA, November 18, 2009—Vol 302, No. 19 (Reprinted)
tant to consider clinically significant arrhythmias associated with sudden cardiac death. Atrial fibrillation, flutter,
atrial tachycardia, and ventricular
tachycardia (eFigure 1A, B, I) tend to
occur later in life and are often associated with structural heart disease. Some
arrhythmias such as atrioventricular
node reentry tachycardia (eFigure 1C)
may be more common in women than
men.9-11
A history of panic disorder should be
explored.12 The details of a family history of palpitations should be recorded, especially if family members
have established diagnoses such as arrhythmogenic right ventricular cardiomyopathy13 or atrial fibrillation.14 Any
history of previous cardiac disease may
predispose patients to more clinically
significant arrhythmias4,6 and suggest
the need for a more aggressive search
for a cardiac cause.
Patients should be asked to tap out
the rhythm of their palpitations, or to
choose from cadences tapped by the
physician, to identify the regularity and
speed of the palpitations. Single skipped
beats or a sensation of the heart stopping and then starting with a pounding, flipping, or jumping sensation, especially while sitting quietly or lying in
bed and lasting only for brief periods,
have traditionally been attributed to
premature atrial or ventricular extra systoles.15,16 An irregular heartbeat, both
in rhythm and strength, that begins and
terminates abruptly suggests atrial
fibrillation.
The association of polyuria and palpitations may indicate supraventricular tachycardia because increased atrial
pressures stimulate production of natriuretic peptides.17 A regular rapidpounding sensation in the neck may signify atrioventricular node reentry
tachycardia when the contraction of the
atria against closed atrioventricular
valves produces increased right atrial
pressures and reflux of blood into the
superior vena cava.18 Associated shirt
flapping, defined as visible movement
of patient’s clothes during the episode, also has been described with both
atrioventricular node reentry tachycar-
©2009 American Medical Association. All rights reserved.
Downloaded from www.jama.com by guest on November 17, 2009
PALPITATIONS AND CARDIAC ARRHYTHMIA
dia and atrioventricular reentry tachycardia.19 Presyncope or syncope may
represent more clinically significant arrhythmias such as ventricular tachycardia (eFigure 1I).16 However, syncope can occasionally result from acute
vasodilatation and/or rapid heart rate
with low cardiac output that occurs at
the beginning of a supraventricular
tachycardia20,21 or due to conversion
pauses occurring at the end, especially in patients with underlying sinus node disease. Conditions such as
hyperthyroidism could be associated
with sinus tachycardia or atrial fibrillation (eFigure 1G, I). Similarly, palpitations associated with a psychiatric
diagnosis such as panic disorder could
suggest sinus tachycardia. However, it
is essential to rule out clinically significant arrhythmias before attributing palpitations to the patient’s psychiatric
condition.4,8,22
Onset during catecholamine excess, such as during exercise, may suggest ventricular tachycardia or sinus
tachycardia (more commonly).23 Palpitations starting during sleep or states
of increased vagal tone (eg, at termination of exercise) can be associated
with vagal-mediated atrial fibrillation
or, less likely, certain subtypes of
long-QT syndromes.24 Other triggers for
tachycardias include alcohol or caffeine consumption.25,26
While patients with QT prolongation and associated arrhythmias usually present with syncope, a medication review is warranted. Drugs that
prolong QT and predispose patients to
torsades de pointes and other ventricular arrhythmias include antiarrhythmics, antimicrobials, antihistamines,
psychotropic drugs, and other miscellaneous drugs such as motility drugs,
diuretics via electrolyte depletion, and
protease inhibitors for human immunodeficiency virus.27-30
Physical Examination
Most patients with episodic palpitations are examined when asymptomatic. Typically, the purpose of the physical examination in this setting is to
identify structural heart abnormalities
that may give rise to an arrhythmia.
When a patient is examined while having palpitations or the examiner detects an asymptomatic arrhythmia, certain physical examination features may
be useful. Atrial fibrillation is suggested by a pulse that is not regular and
has no repeating pattern (ie, irregularly irregular), the presence of a pulse
deficit (ie, obtaining a lower pulse rate
at the wrist than at the apex), or the auscultation of variable first heart sound
intensity. These findings are due to beatto-beat variation in stroke volume that
occurs during atrial fibrillation. The
presence of cannon A waves on the
jugular venous pressure suggests an arrhythmia associated with atrioventricular dissociation such as ventricular
tachycardia.31 A cannon A wave is a
prominent wave in the jugular venous
pressure that occurs due to the contraction of the right atrium against a
closed tricuspid valve.
Diagnostic Tests
Standard 12-lead electrocardiography
is the initial test in patients with palpitations and may identify the arrhythmia or provide insight into underlying structural and electrical abnormality
that may be a precipitant for arrhythmias. Patients with electrical or structural abnormalities on 12-lead electrocardiography may warrant a more
aggressive search for a cardiac cause of
palpitations.
The prototypical clinical event monitor is the Holter monitor that continuously and simultaneously records 2 or
3 electrocardiographic leads. At the end
of the monitoring period (typically 24
or 48 hours), the data are analyzed for
arrhythmias (eFigure 1) and are correlated with symptoms recorded by the
patient. The Holter monitor detects
asymptomatic arrhythmias and may
capture arrhythmias in patients who are
unable to trigger the device (eg, during syncope). Frequently, patients may
not experience their usual symptoms
during monitoring and the test is
nondiagnostic.
Intermittent event recorders can be
worn continuously (loop recorders) or
©2009 American Medical Association. All rights reserved.
applied at the time of symptoms (event
recorders).32 Traditionally, intermittent event recorders store electrocardiographic monitoring for several minutes once activated by the patient and
hence cannot capture asymptomatic arrhythmias or those associated with loss
of consciousness.32 Newer loop recorders provide continuous, real-time outpatient electrocardiographic monitoring and can automatically detect
asymptomatic arrhythmias in addition to being activated by the patient.33,34 Intermittent event recorders
allow for prolonged monitoring (weeks
to months) in patients who have infrequent symptoms. These devices may
have a higher specificity because the patient activates the recording during
symptoms. Specifically, loop monitors save information for a predetermined period prior to the patient trigger, and hence, can help identify the
initiation sequence for arrhythmias.
These stored events can be transmitted through a telephone for physician
review.
An electrophysiologic study is an invasive test of the electrical conduction
system of the heart. Although often performed for diagnostic and therapeutic
purposes in patients with a known arrhythmia or who have presented
with syncope or resuscitated sudden
cardiac death, it is occasionally performed as a diagnostic test in patients
with palpitations in whom there is high
suspicion for cardiac origin.35
Exercise treadmill testing with a standard Bruce protocol may be useful in
patients whose palpitations typically occur during exercise or are provoked by
cardiac ischemia.15,36
When palpitations occur infrequently or are associated with serious
events such as syncope that cannot be
identified using intermittent event
recorders, implantable loop recorders
(implanted under the skin in the left
parasternal region) can record the
patient’s electrocardiogram continuously for prolonged periods (several
months to years).37,38 Patients keep a
diary of their symptoms for symptomrhythm correlation. The device can
(Reprinted) JAMA, November 18, 2009—Vol 302, No. 19
Downloaded from www.jama.com by guest on November 17, 2009
2137
PALPITATIONS AND CARDIAC ARRHYTHMIA
also be triggered with an external
activator.
Echocardiography may identify
structural heart diseases that may be a
precipitant for arrhythmias.15,39 While
the presence of structural heart disease increases the likelihood of a clinically significant arrhythmia and suggests the need for a more aggressive
search for an arrhythmic substrate, it
does not prove that the patient’s palpitations are secondary to an arrhythmia.
METHODS
Search Strategy
and Data Collection
Structured MEDLINE (1950 to August 25, 2009) and EMBASE (1947 to
August 2009) literature searches were
performed to identify Englishlanguage articles relevant to the precision or accuracy of the clinical examination for patients with palpitations.
Search terms included palpitations, heart
racing, heart pounding, physical examination, medical history taking, professional competence, “sensitivity and specificity,” reproducibility of results, observer
variation, “diagnostic tests, routine,” decision support techniques, Bayes theorem, and mass screening. Two authors
independently reviewed the abstracts of
the search and retrieved potentially relevant articles and a third author resolved disagreements. Additional articles were identified by reviewing the
reference lists of retrieved articles and
expert suggestions.15,16,40
Articles reporting original empirical studies evaluating historical features, physical examination, or diagnostic tests against a reference standard
for the diagnosis of palpitations secondary to an arrhythmia were included. Acceptable reference standards included clinical event monitors,
intermittent event recorders, implantable loop recorders, in-hospital telemetry, 12-lead electrocardiographic
monitoring during symptoms, or electrophysiological study. Excluded studies (1) focused primarily on nonarrhythmic diagnoses in patients with
palpitations; (2) enrolled patients with
several presenting complaints but did
not provide separate data for the subgroup with palpitations; (3) focused
only on comparison between specific
arrhythmias or used the presence of arrhythmias as opposed to palpitations as
inclusion criteria; or (4) did not require symptom rhythm correlation for
the diagnosis of arrhythmia. From the
results of the same literature search,
studies were identified providing data
on the diagnostic yield of the various
tests (eg, electrocardiography and loop
monitoring).
The data extracted were the number of patients enrolled, symptoms,
signs or tests assessed, the number of
patients with and without arrhythmia
for each clinical parameter, and the frequency of typical symptoms and clinically significant arrhythmias (when present). From this, the likelihood ratios
(LRs) were calculated for the individual findings described, along with
the 95% confidence intervals (CIs).
Where possible, the LRs were separately calculated for detecting any arrhythmias and clinically significant arrhythmias. An arrhythmia was defined
as any rhythm with a heart rate of 60/
min or less, or 100/min or greater,
and/or that was not normal sinus
rhythm. Clinically significant arrhythmias were those that likely require specific management including ventricular tachycardia, atrioventricular node
reentry tachycardia, atrioventricular reentry tachycardia, atrial fibrillation,
atrial flutter, atrial tachycardia, junctional tachycardia, or ventricular ectopic beats occurring in salvos.
The yield of the various diagnostic
tests was calculated and defined as the
number of patients who had any arrhythmia or clinically significant arrhythmia during monitoring. Whenever available, separate data were
provided for the subgroup of patients
who had their typical symptoms during the monitoring period.
Articles were graded for methodological quality using standard methods with a threshold of more than 100
patients distinguishing level 1 from level
2 studies.41
2138 JAMA, November 18, 2009—Vol 302, No. 19 (Reprinted)
RESULTS
Only 7 studies met inclusion criteria
for the assessment of diagnostic
accuracy (T ABLE 1; eFigure 2 is a
flow diagram illustrating the identification of articles and is available at
http://www.jama.com).4-6,11,12,18,42 Palpitations were the predominant presenting complaint in these studies
(99.4% of the included patients). The
majority of the data was extracted from
the 2 level 1 studies.5,6 Only 1 study
assessed a limited number of physical
examination signs in patients with palpitations.6 No study evaluated a combination of historical and physical examination features or the precision of
any historical or physical examination
feature. The reference standards in the
included studies were electrophysiological study,18 24-hour Holter monitor, 12,42 intermittent event recorders,5,6 and in 2 studies a combination
of methods.4,11 Among studies that used
loop recorders (both for diagnostic accuracy and yield data), only 1 study34
had the automatic trigger feature to record asymptomatic arrhythmias.
Only 2 of the 7 diagnostic accuracy
studies distinguished clinically insignificant and significant arrhythmias,5,6 although only 1 allowed for the
calculation of LRs for both types of
rhythm disturbances.5 Other studies
looked only at clinically significant arrhythmias11,18,42 or did not differentiate between the 2.4,12
Seven studies examined the utility of
the features on history for diagnosing
an arrhythmia as the cause of palpitations (TABLE 2). Most of the data are
obtained from studies with small sample
sizes. Although several features increase the likelihood that a patient’s
palpitations were secondary to an arrhythmia, most have 95% CIs crossing unity and thus may not be clinically useful.
The only findings with an LR of 2.00
or greater for any arrhythmia were a history of cardiac disease (LR, 2.03; 95%
CI, 1.33-3.11) and palpitations affected by sleeping (LR, 2.29; 95% CI,
1.33-3.94; which are presumably palpitations that are severe enough to wake
©2009 American Medical Association. All rights reserved.
Downloaded from www.jama.com by guest on November 17, 2009
PALPITATIONS AND CARDIAC ARRHYTHMIA
patients up from sleep) or while the patient was at work (LR, 2.17; 95% CI,
1.19-3.96). Although description of palpitations as either regular (LR, 1.66;
95% CI, 1.20-2.29) or irregular (LR,
1.65; 95% CI, 1.22-2.22) had little value
in the likelihood of cardiac arrhythmia, this information may be helpful in
the right context because certain arrhythmias are typically regular while
others are irregular.
The 2 factors with an LR of 0.50 or
less for any arrhythmia were an underlying history of panic disorder (LR,
0.26; 95% CI, 0.07-1.01) and duration
of palpitation less than 5 minutes (LR,
0.38; 95% CI, 0.22-0.63) (Table 2).
However, these observations are based
on single studies and the upper bound
of the 95% CI for a history of panic disorder included 1.00.
The presence of an associated
regular rapid-pounding sensation in
the neck (LR, 177; 95% CI, 25-1251)
increased the likelihood that the
patient’s symptoms of palpitations
are due to atrioventricular node reentry tachycardia.18 The absence of an
associated regular rapid-pounding
sensation in the neck significantly
decreased the likelihood of atrioventricular node reentry tachycardia
(LR, 0.07; 95% CI, 0.03-0.19). How-
ever, a second study 11 found that
neck fullness is not useful for distinguishing atrioventricular node reentry tachycardia from other arrhythmias (LR, 0.85; 95% CI, 0.44-1.64),
but the presence of visible neck pulsations may be useful (LR, 2.68; 95%
CI, 1.25-5.78). More recently, the
description of palpitations in the
neck in patients with documented
narrow complex tachycardia was
shown to distinguish atrioventricular
node reentry tachycardia from atrioventricular reentry tachycardia with
an LR of 2.41 (95% CI, 1.54-3.76).10
From the reviewed studies, no other
features appear to be useful for ruling in or ruling out a clinically significant arrhythmia.
In these 7 studies,4-6,11,12,18,42 all patients including those who had no
symptoms during the monitored period were included in the accuracy
analysis. Only 1 study provided data on
a subgroup of 81 patients who had their
typical symptoms during the monitoring period.5 For these patients, the most
useful feature for detecting an arrhythmia was the occurrence of palpitations at work (LR, 2.38; 95% CI, 1.035.50). Potentially useful features for
detecting clinically significant arrhythmias include palpitations described as
regular (LR, 1.52; 95% CI, 1.04-2.24)
or those that were affected by sleeping
(LR, 1.83; 95% CI, 1.03-3.27).
Although no study specifically
assessed the accuracy of the associated symptom of shirt flapping in
patients with palpitations, 1 study19
found that in 326 patients with documented arrhythmias, the proportion
of patients with atrioventricular node
reentry tachycardia (58%) who
reported shirt flapping was greater
than that reported by patients with
other arrhythmias such as atrioventricular reentry tachycardia (44%),
ventricular tachycardia (32%), atrial
flutter (17%), and atrial fibrillation
(13%).
Based on a single study6 (TABLE 3),
the presence of resting bradycardia
(⬍60/min) during the examination increases the likelihood of a clinically significant arrhythmia (LR, 3.00; 95% CI,
1.27-7.08). No other physical examination findings, including the presence of murmurs, have been evaluated in patients presenting with
palpitations
No studies reported on the sensitivity and specificity of baseline 12-lead
electrocardiographic abnormalities in
predicting a cardiac arrhythmia as a
cause of symptoms. Nevertheless, base-
Table 1. Accuracy Studies Assessing Clinical Features for the Diagnosis of a Cardiac Arrhythmia in Patients With Palpitations
Source a
Gürsoy et al,18 1992
No. of
Patients
244
Barsky et al,42 1994
145
Barsky et al,12 1994
131
Weber and Kapoor,4 1996
190
Summerton et al,5 2001
139
Hoefman et al,6 2007
127
Sakhuja et al,11 2009
239
Patient Population
Patients with palpitations referred for
electrophysiological study
Patients referred for ambulatory monitoring
due to palpitations
Patients referred for ambulatory monitoring
due to palpitations
Patients with palpitations at least once in
the past 3 mo presenting to
emergency department, general
practitioner, or admitted to hospital
Patients with palpitations in past 3 mo
presenting to general practitioner
Patients with history of palpitations and/or
light-headedness presenting to a
general practitioner
Patients with palpitations referred for
electrophysiological study,
cardioversion, or ablation
Any Arrhythmia,
No. (%)
NA
Study
Level b
3
24-h Holter monitoring
28 (19)
3
24-h Holter monitoring
27 (21)
3
Electrocardiography,
Holter monitoring,
telemetry, loop monitoring,
electrophysiological study
Event recorder
75 (39)
4
42 (30)
1
Loop monitoring
83 (65)
1
224 (94)
4
Reference Standard
Electrophysiological study
Electrophysiological study,
telemetry, Holter
monitoring, 12-lead
electrocardiography
Abbreviation: NA, data not available.
a All studies were of prospective cohort design.
b Methodologic quality of studies determined using standard methods with a threshold of more than 100 patients distinguishing level 1 from level 2 studies.41
©2009 American Medical Association. All rights reserved.
(Reprinted) JAMA, November 18, 2009—Vol 302, No. 19
Downloaded from www.jama.com by guest on November 17, 2009
2139
PALPITATIONS AND CARDIAC ARRHYTHMIA
line electrocardiography is typically performed prior to other diagnostic
tests.39,43
A total of 16 studies4-6,12,34,37,42,44-52 provided diagnostic yield data (eTable 1 is
available at http://www.jama.com). Di-
agnostic yield refers to the occurrence
of a cardiac arrhythmia detected during the monitoring period in either all
Table 2. Accuracy of Clinical Features for the Diagnosis of Arrhythmia
Likelihood Ratio (95% CI)
Any Arrhythmia a
Finding
Demographic and historical features
Cardiac disease
Male sex
Age ⬎60 y
Smoking (⬎11 cigarettes/d)
Anxiety disorder
Family history of palpitations
Alcohol use (⬎10 drinks/wk)
Panic disorder
Any psychiatric disorder
Description of palpitations
Regular
Irregular
Duration ⬎5 min
Duration ⬎60 s
Continuous symptoms
Heart rate ⬎100/min
Patient setting during palpitations
or precipitating factors
Affected by sleeping
Occurring at work
Affected by caffeine
Occurring during holiday
Occurring during weekend
Affected by alcohol
While lying in bed
Affected by exercise
Affected by breathing
While resting
Associated symptoms
Regular rapid-pounding
sensation in neck
Neck fullness
Visible neck pulsations
Dizzy spells
Chest pain
Dyspnea
Vasovagal symptoms
(pale and/or sweaty)
Presyncope
Significant Arrhythmia
Source
No./Total
(%)
Positive
Negative
Positive
Negative
Hoefman et al6
Weber and Kapoor4
Weber and Kapoor4
NA
61/190 (32)
74/190 (39)
NA
2.03 (1.33-3.11)
1.73 (1.21-2.48)
NA
0.71 (0.57-0.88)
0.69 (0.54-0.89)
0.42 (0.06-3.06)
NA
NA
1.07 (0.96-1.20)
NA
NA
Summerton et al5
Hoefman et al6
Summerton et al5
Hoefman et al6
Summerton et al5
Summerton et al5
46/139 (33)
33/127 (26)
33/139 (24)
32/127 (25)
16/133 (12)
46/133 (35)
1.63 (1.02-2.58)
NA
1.70 (0.95-3.06)
NA
0.78 (0.27-2.26)
0.98 (0.59-1.63)
0.76 (0.56-1.03)
NA
0.83 (0.66-1.05)
NA
1.03 (0.91-1.17)
1.01 (0.77-1.32)
1.20 (0.69-2.11)
1.37 (0.71-2.66)
1.89 (1.03-3.47)
1.43 (0.74-2.78)
0.77 (0.26-2.25)
0.92 (0.49-1.72)
0.90 (0.65-1.26)
0.88 (0.65-1.19)
0.77 (0.56-1.06)
0.87 (0.64-1.18)
1.03 (0.91-1.17)
1.04 (0.78-1.39)
Summerton et al5
Summerton et al5
Barsky et al12
Barsky et al42
29/133 (22)
21/130 (16)
32/131 (24)
36/145 (25)
0.86 (0.41-1.77)
0.76 (0.30-1.92)
0.26 (0.07-1.01)
NA
1.04 (0.87-1.26)
1.05 (0.90-1.23)
1.30 (1.10-1.53)
NA
1.07 (0.49-2.37)
1.02 (0.38-2.79)
NA
0.67 (0.29-1.58)
0.98 (0.78-1.24)
1.00 (0.83-1.19)
NA
1.12 (0.91-1.37)
67/139 (48)
90/190 (47)
50/101 (50)
127/190 (67)
77/101 (76)
95/135 (70)
102/139 (73)
71/139 (51)
1.66 (1.20-2.29)
1.65 (1.22-2.22)
NA
1.52 (1.25-1.85)
NA
1.15 (0.93-1.43)
1.06 (0.86-1.30)
0.91 (0.63-1.31)
NA
0.62 (0.46-0.84)
NA
0.38 (0.22-0.63)
NA
0.69 (0.36-1.31)
NA
NA
1.38 (1.02-1.86)
NA
0.79 (0.46-1.36)
NA
1.02 (0.79-1.32)
1.17 (0.93-1.48)
0.93 (0.71-1.23)
1.08 (0.78-1.50)
0.55 (0.27-1.14)
NA
1.23 (0.81-1.86)
NA
0.95 (0.40-2.24)
0.63 (0.27-1.44)
1.20 (0.62-2.31)
0.86 (0.44-1.68)
Summerton et al5
Summerton et al5
Summerton et al5
Summerton et al5
Summerton et al5
Summerton et al5
36/138 (26)
31/136 (23)
16/138 (12)
20/137 (15)
29/137 (21)
16/137 (12)
2.29 (1.33-3.94)
2.17 (1.19-3.96)
1.84 (0.74-4.61)
1.56 (0.69-3.53)
1.43 (0.74-2.76)
1.36 (0.53-3.49)
0.70 (0.53-0.93)
0.76 (0.60-0.98)
0.91 (0.79-1.07)
0.92 (0.78-1.09)
0.90 (0.73-1.11)
0.96 (0.83-1.10)
2.44 (1.43-4.14)
1.54 (0.78-3.04)
2.06 (0.78-5.39)
0.79 (0.25-2.49)
0.72 (0.27-1.88)
1.94 (0.74-5.12)
0.63 (0.42-0.93)
0.86 (0.65-1.14)
0.89 (0.72-1.09)
1.04 (0.88-1.24)
1.08 (0.89-1.32)
0.90 (0.74-1.09)
Summerton et al5
Summerton et al5
Summerton et al5
Hoefman et al6
84/137 (61)
33/139 (24)
38/138 (28)
71/122 (58)
1.30 (1.01-1.68)
0.74 (0.36-1.50)
0.52 (0.25-1.08)
NA
0.61 (0.35-1.07)
1.09 (0.90-1.32)
1.23 (1.02-1.49)
NA
1.02 (0.73-1.44)
0.78 (0.33-1.82)
0.52 (0.20-1.33)
1.02 (0.69-1.50)
0.97 (0.57-1.65)
1.07 (0.87-1.33)
1.20 (0.98-1.48)
0.97 (0.56-1.69)
Gürsoy et al18
50/190 (26)
NA
NA
177 (25-1251)
0.07 (0.03-0.19)
Sakhuja et al11
Sakhuja et al11
Summerton et al5
Summerton et al5
48/239 (20)
23/239 (10)
72/137 (53)
34/137 (25)
NA
NA
0.93 (0.65-1.33)
0.81 (0.42-1.59)
NA
NA
1.08 (0.75-1.57)
1.07 (0.87-1.30)
0.85 (0.44-1.64)
2.68 (1.25-5.78)
1.34 (0.96-1.88)
0.92 (0.42-1.98)
1.04 (0.90-1.20)
0.87 (0.76-1.00)
0.67 (0.39-1.18)
1.02 (0.81-1.30)
Summerton et al5
Hoefman et al6
17/139 (12)
49/127 (39)
0.31 (0.07-1.29)
NA
NA
NA
0.27 (0.04-1.96)
1.72 (1.11-2.65)
1.12 (1.01-1.25)
0.63 (0.39-1.03)
Hoefman et al6
72/127 (57)
NA
NA
1.04 (0.71-1.51)
0.95 (0.57-1.61)
Summerton et al5
Weber and Kapoor4
Hoefman et al6
Weber and Kapoor4
Hoefman et al6
Summerton et al5
Summerton et al5
Summerton et al5
Abbreviations: CI, confidence interval; NA, data not available or cannot be calculated.
a Includes clinically significant and nonsignificant arrhythmias (premature atrial or ventricular contractions and sinus tachycardia).
2140 JAMA, November 18, 2009—Vol 302, No. 19 (Reprinted)
©2009 American Medical Association. All rights reserved.
Downloaded from www.jama.com by guest on November 17, 2009
PALPITATIONS AND CARDIAC ARRHYTHMIA
of the patients included in a study or
only in the subgroup of patients who
had symptoms during monitoring.
The diagnostic yield of 12-lead
electrocardiography performed during symptoms ranged from 3% to 26%4,6
for any arrhythmias and 2%6 for clinically significant arrhythmias. The yield
of the 24-hour Holter monitoring was
34%44 for any arrhythmia and ranged
between 3% and 24%44,45 for clinically
significant arrhythmias. One study46
used a 48-hour Holter monitor as a reference standard and had a diagnostic
yield of 21% for any arrhythmia and 0%
for clinically significant arrhythmias.
The diagnostic yield for loop monitors ranged from 34%6 to 84%47 for any
arrhythmia and from 8%48 to 36%47 for
clinically significant arrhythmias. A
2-week loop recorder had a greater yield
than a 1-week recorder, however, using
it for 3 weeks had minimal49 or no additional yield.47 The use of loop recorders with an automatic trigger function
for asymptomatic arrhythmias had a
slightly higher yield for clinically significant arrhythmias.34 The yield for
event recorders ranged from 30%5 to
60%50 for any arrhythmia and from
17%50 to 19%5 for a clinically significant arrhythmia (eTable 1). Among patients with typical symptoms during
monitoring (eTable 2), the yield of intermittent event recorders was higher
for any arrhythmia and for clinically significant arrhythmias.5,6,51 Based on 1
study,37 the yield of implantable loop
recorders was 73% for clinically significant arrhythmias during a mean
(SD) monitoring period of 279 (228)
days.
LIMITATIONS OF
PUBLISHED STUDIES
Only 7 studies provided data on diagnostic accuracy and only 2 of these5,6
were of high methodological quality
(level 1). Many of the studies had small
sample sizes and in some cases data
from subgroups in single studies were
relied on to evaluate the accuracy of
clinical parameters. Therefore, caution should be taken in interpreting our
results.
Table 3. Accuracy of Physical Examination Features for the Diagnosis of Arrhythmias in the
Study by Hoefman et al6
Significant Arrhythmia,
LR (95% CI)
Physical Examination
Abnormal heart rate ⬍60/min
or ⬎100/min
Obesity
Hypertension on examination
No./Total
(%)
17/127 (13)
Positive
3.00 (1.27-7.08)
Negative
0.78 (0.60-1.02)
15/126 (12)
42/127 (33)
1.55 (0.54-4.44)
1.01 (0.54-1.90)
0.93 (0.77-1.13)
1.00 (0.73-1.36)
Abbreviations: CI, confidence interval; LR, likelihood ratio.
Our review focused on studies of
patients presenting with palpitations
rather than patients with conditions,
such as hyperthyroidism, who had
palpitations as part of their symptom
complex. As such, our results are
most relevant for patients without an
obvious underlying medical problem
or structural heart disease that might
cause their palpitations. Also, the
data does not provide information
about the specific kind of arrhythmia
experienced.
A significant proportion of the patients in the included studies did not
have symptoms during the monitored
period and only a few features have
been evaluated in the 81 patients with
symptoms during monitoring. Therefore, the majority of the LRs were calculated using all included patients
rather than only those with symptoms
during monitoring. Similarly, except in
3 studies (eTable 2),5,6,51 the yield data
was extracted from studies in which
some of the patients did not experience their symptoms during monitoring. Because some of these patients may
actually have an arrhythmia, we could
have underestimated the true yield of
the diagnostic tests.
Finally, there are no published data
evaluating combinations of features or
the precision of the clinical examination. As a result, multiplying together
individual LRs or applying them sequentially may substantially overestimate posttest probability.
SCENARIO RESOLUTION
The pretest probability of any cardiac
arrhythmia in this patient based on a
study4 that would have enrolled this pa-
©2009 American Medical Association. All rights reserved.
tient is 40%. While the nonspecific description of symptoms as “heart racing” and the inability to tell the cadence
of the rhythm are not helpful, the previous diagnosis of panic disorder (LR,
0.26) and the duration of less than 5
minutes (LR, 0.38) decreases the likelihood of any arrhythmia. The posttest probability of any arrhythmia based
only on the patient’s previous history
of panic disorder would be 15%. The
absence of a regular rapid-pounding
sensation in the neck decreases the likelihood of atrioventricular node reentry tachycardia (LR, 0.07).
While many physicians would not
pursue further testing initially because of the relatively low posttest probability, it is essential to recognize that
patients with panic disorders may also
have clinically significant arrhythmias22,42; and it may be prudent to perform long-term electrocardiographic
monitoring to rule out clinically significant arrhythmias before attributing the symptoms to panic disorder.
Structural cardiac assessment could be
deferred unless the patient has persistent palpitations, develops more alarming symptoms such as syncope, or a
clinically significant arrhythmia is identified on electrocardiographic monitoring.
BOTTOM LINE
When evaluating patients with palpitations, the presence of underlying
medical conditions should be carefully considered. In the emergency department, primary cardiac diagnoses are
the most common reason for palpitations (43%), but anxiety or panic disorders are also frequent (31%).4
(Reprinted) JAMA, November 18, 2009—Vol 302, No. 19
Downloaded from www.jama.com by guest on November 17, 2009
2141
PALPITATIONS AND CARDIAC ARRHYTHMIA
A known history of cardiac disease
(LR, 2.03; 95% CI, 1.33-3.11) and
palpitations affected by sleeping (LR,
2.29; 95% CI, 1.33-3.94) or while at
work (LR, 2.17; 95% CI, 1.19-3.96)
slightly increase the likelihood of a
cardiac arrhythmia while palpitations
lasting less than 5 minutes (LR, 0.38;
95% CI, 0.22-0.63) and a known history of panic disorder make the diagnosis less likely (LR, 0.26; 95% CI,
0.07-1.01). The presence of a regular
rapid-pounding sensation in the neck
as opposed to neck fullness in association with palpitations increases the
likelihood that the patient has atrioventricular node reentry tachycardia
(LR, 177; 95% CI, 25-1251), whereas
its absence makes atrioventricular
node reentry tachycardia less likely
(LR, 0.07; 95% CI, 0.03-0.19). The
presence of visible neck pulsations
also increases the likelihood of atrioventricular node reentry tachycardia
(LR, 2.68; 95% CI, 1.25-5.78).
Because of the limitations of the literature and the consequences of missing an important rhythm disturbance,
no clinical examination features appear to be sufficiently accurate to exclude other clinically significant arrhythmias, especially in high-risk
patients. Therefore, when a clinically
significant arrhythmia is suspected, further testing including evaluating cardiac structure with transthoracic echocardiography and attempting to
establish symptom-rhythm correlation with prolonged electrocardiographic monitoring should be undertaken. The selection of the monitoring
type depends on the frequency of the
symptoms. If the symptoms occur daily,
a Holter monitor may be of reasonable
diagnostic yield, with emphasis on the
importance of accurate diary recording. If symptoms occur more infrequently, an intermittent event recorder such as a loop monitor is a more
appropriate test.
Author Contributions: Dr Thavendiranathan had full
access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Thavendiranathan, Bagai,
Khoo, Dorian, Choudhry.
Acquisition of data: Thavendiranathan, Bagai, Khoo.
Analysis and interpretation of data: Thavendiranathan,
Bagai, Dorian, Choudhry.
Drafting of the manuscript: Thavendiranathan, Bagai,
Dorian, Choudhry.
Critical revision of the manuscript for important intellectual content: Thavendiranathan, Bagai, Khoo,
Choudhry.
Statistical analysis: Thavendiranathan, Bagai,
Choudhry.
Administrative, technical, or material support:
Thavendiranathan, Khoo, Dorian, Choudhry.
Study supervision: Dorian, Choudhry.
Financial Disclosures: None reported.
Additional Information: eTable 1 and eTable 2 and
eFigure 1 and eFigure 2 are available at http://www
.jama.com.
Additional Contributions: We thank Emmy Hoefman, MD (Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands) for providing necessary
information regarding her study; Luigi Casella, MD,
and Chi Ming Chow, MD (both with the Division of
Cardiology, St Michael’s Hospital, University of
Toronto, Toronto, Ontario, Canada) for providing the
electrocardiogram strips; David Simel, MD, MHS (Duke
University Medical Center and Durham Veteran Affairs Medical Center, Durham, North Carolina) for helping with question synthesis, data extraction, manuscript composition, and editing; and Camilla Wong,
MD (Department of Geriatrics, St Michael’s Hospital,
University of Toronto, Toronto, Ontario, Canada) and
Albert Sun, MD (Department of Cardiology, Duke University Medical Center, Durham, North Carolina) for
reviewing and commenting on the manuscript. No financial compensation was received by any of the individuals listed in this section.
REFERENCES
1. Mayou R, Sprigings D, Birkhead J, Price J. Characteristics of patients presenting to a cardiac clinic with
palpitation. QJM. 2003;96(2):115-123.
2. Barsky AJ, Ahern DK, Bailey ED, Delamater BA. Predictors of persistent palpitations and continued
medical utilization. J Fam Pract. 1996;42(5):465472.
3. Hoefman E, van Weert HC, Reitsma JB, Koster RW,
Bindels PJ. Diagnostic yield of patient-activated loop
recorders for detecting heart rhythm abnormalities in
general practice: a randomised clinical trial. Fam Pract.
2005;22(5):478-484.
4. Weber BE, Kapoor WN. Evaluation and outcomes
of patients with palpitations. Am J Med. 1996;
100(2):138-148.
5. Summerton N, Mann S, Rigby A, Petkar S, Dhawan
J. New-onset palpitations in general practice: assessing the discriminant value of items within the clinical
history. Fam Pract. 2001;18(4):383-392.
6. Hoefman E, Boer KR, van Weert HC, Reitsma JB,
Koster RW, Bindels PJ. Predictive value of history taking and physical examination in diagnosing arrhythmias in general practice. Fam Pract. 2007;24(6):
636-641.
7. Brugada P, Gürsoy S, Brugada J, Andries E. Investigation of palpitations. Lancet. 1993;341(8855):
1254-1258.
8. Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. The
clinical course of palpitations in medical outpatients.
Arch Intern Med. 1995;155(16):1782-1788.
9. Porter MJ, Morton JB, Denman R, et al. Influence
of age and gender on the mechanism of supraventricular tachycardia. Heart Rhythm. 2004;1(4):
393-396.
10. González-Torrecilla E, Almendral J, Arenal A, et al.
Combined evaluation of bedside clinical variables and
the electrocardiogram for the differential diagnosis of
paroxysmal atrioventricular reciprocating tachycar-
2142 JAMA, November 18, 2009—Vol 302, No. 19 (Reprinted)
dias in patients without pre-excitation. J Am Coll
Cardiol. 2009;53(25):2353-2358.
11. Sakhuja R, Smith LM, Tseng ZH, et al. Test characteristics of neck fullness and witnessed neck pulsations in the diagnosis of typical AV nodal reentrant
tachycardia. Clin Cardiol. 2009;32(8):E13-E18.
12. Barsky AJ, Cleary PD, Sarnie MK, Ruskin JN. Panic
disorder, palpitations, and the awareness of cardiac
activity. J Nerv Ment Dis. 1994;182(2):63-71.
13. Hermida JS, Minassian A, Jarry G, et al. Familial
incidence of late ventricular potentials and electrocardiographic abnormalities in arrhythmogenic right
ventricular dysplasia. Am J Cardiol. 1997;79(10):
1375-1380.
14. Marcus GM, Smith LM, Vittinghoff E, et al. A firstdegree family history in lone atrial fibrillation patients.
Heart Rhythm. 2008;5(6):826-830.
15. Abbott AV. Diagnostic approach to palpitations.
Am Fam Physician. 2005;71(4):743-750.
16. Zimetbaum P, Josephson ME. Evaluation of patients with palpitations. N Engl J Med. 1998;338
(19):1369-1373.
17. Abe H, Nagatomo T, Kobayashi H, et al. Neurohumoral and hemodynamic mechanisms of diuresis
during atrioventricular nodal reentrant tachycardia. Pacing Clin Electrophysiol. 1997;20(11):2783-2788.
18. Gürsoy S, Steurer G, Brugada J, Andries E, Brugada
P. Brief report: the hemodynamic mechanism of pounding in the neck in atrioventricular nodal reentrant
tachycardia. N Engl J Med. 1992;327(11):772774.
19. Laurent G, Leong-Poi H, Mangat I, et al. Influence of ventriculoatrial timing on hemodynamics
and symptoms during supraventricular tachycardia
[published online ahead of print September 3,
2009]. J Cardiovasc Electrophysiol. 2008;20(2):
176-181.
20. Goldreyer BN, Kastor JA, Kershbaum KL. The
hemodynamic effects of induced supraventricular
tachycardia in man. Circulation. 1976;54(5):783789.
21. Leitch JW, Klein GJ, Yee R, Leather RA, Kim
YH. Syncope associated with supraventricular
tachycardia: an expression of tachycardia rate or
vasomotor response? Circulation. 1992;85(3):
1064-1071.
22. Lessmeier TJ, Gamperling D, Johnson-Liddon
V, et al. Unrecognized paroxysmal supraventricular
tachycardia: potential for misdiagnosis as panic
disorder. Arch Intern Med. 1997;157(5):537543.
23. Varma N, Josephson ME. Therapy of “idiopathic” ventricular tachycardia. J Cardiovasc
Electrophysiol. 1997;8(1):104-116.
24. Coumel P. Clinical approach to paroxysmal
atrial fibrillation. Clin Cardiol. 1990;13(3):209212.
25. Lampert R, Joska T, Burg MM, Batsford WP,
McPherson CA, Jain D. Emotional and physical precipitants of ventricular arrhythmia. Circulation.
2002;106(14):1800-1805.
26. Hansson A, Madsen-Hardig B, Olsson SB.
Arrhythmia-provoking factors and symptoms at the
onset of paroxysmal atrial fibrillation: a study based
on interviews with 100 patients seeking hospital
assistance. BMC Cardiovasc Disord. 2004;4:13.
27. De Ponti F, Poluzzi E, Cavalli A, Recanatini M,
Montanaro N. Safety of non-antiarrhythmic drugs
that prolong the QT interval or induce torsade de
pointes: an overview. Drug Saf. 2002;25(4):263286.
28. Yap YG, Camm AJ. Drug induced QT prolongation and torsades de pointes. Heart. 2003;89
(11):1363-1372.
29. Roden DM. Drug-induced prolongation of the
QT interval. N Engl J Med. 2004;350(10):10131022.
30. Ray WA, Murray KT, Meredith S, Narasimhulu
©2009 American Medical Association. All rights reserved.
Downloaded from www.jama.com by guest on November 17, 2009
PALPITATIONS AND CARDIAC ARRHYTHMIA
SS, Hall K, Stein CM. Oral erythromycin and the
risk of sudden death from cardiac causes. N Engl J
Med. 2004;351(11):1089-1096.
31. Cook DJ, Simel DL. Does this patient have
abnormal central venous pressure? In: The Rational
Clinical Examination. New York, NY: McGraw-Hill;
2009:125-135.
32. Crawford MH, Bernstein SJ, Deedwania PC, et al.
ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations: a
report of the American College of Cardiology
/American Heart Association task force on practice
guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography). Circulation. 1999;
100(8):886-893.
33. Joshi AK, Kowey PR, Prystowsky EN, et al. First
experience with a Mobile Cardiac Outpatient Telemetry (MCOT) system for the diagnosis and management of cardiac arrhythmia. Am J Cardiol. 2005;
95(7):878-881.
34. Olson JA, Fouts AM, Padanilam BJ, Prystowsky
EN. Utility of mobile cardiac outpatient telemetry for
the diagnosis of palpitations, presyncope, syncope, and
the assessment of therapy efficacy. J Cardiovasc
Electrophysiol. 2007;18(5):473-477.
35. Zipes DP, DiMarco JP, Gillette PC, et al. Guidelines for clinical intracardiac electrophysiological and
catheter ablation procedures: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on
Clinical Intracardiac Electrophysiologic and Catheter
Ablation Procedures), developed in collaboration
with the North American Society of Pacing and
Electrophysiology. J Am Coll Cardiol. 1995;26
(2):555-573.
36. Gibbons RJ, Balady GJ, Bricker JT, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to
Update the 1997 Exercise Testing Guidelines). ACC
/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Committee to Update the 1997
Exercise Testing Guidelines). Circulation. 2002;
106(14):1883-1892.
37. Giada F, Gulizia M, Francese M, et al. Recurrent
unexplained palpitations (RUP) study comparison of
implantable loop recorder versus conventional diagnostic strategy. J Am Coll Cardiol. 2007;49(19):
1951-1956.
38. Seidl K, Rameken M, Breunung S, et al;
Reveal-Investigators. Diagnostic assessment of recurrent unexplained syncope with a new subcutaneously implantable loop recorder. Europace. 2000;
2(3):256-262.
39. Blomström-Lundqvist C, Scheinman MM, Aliot
EM, et al; American College of Cardiology; American
Heart Association Task Force on Practice Guidelines;
European Society of Cardiology Committee for Practice Guidelines; Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias. ACC/AHA/ESC guidelines for the
management of patients with supraventricular arrhythmias–executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European
Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for
the Management of Patients With Supraventricular
Arrhythmias). Circulation. 2003;108(15):18711909.
40. Zwietering PJ, Knottnerus JA, Rinkens PE, Kleijne
MA, Gorgels AP. Arrhythmias in general practice: diagnostic value of patient characteristics, medical history and symptoms. Fam Pract. 1998;15(4):343353.
41. Simel DL, Keitz S. Update: primer on precision and
accuracy. In: The Rational Clinical Examination. New
York, NY: McGraw-Hill; 2009:9-16.
42. Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN.
Psychiatric disorders in medical outpatients complaining of palpitations. J Gen Intern Med. 1994;9(6):
306-313.
43. Rutten FH, Kessels AG, Willems FF, Hoes AW.
Electrocardiography in primary care: is it useful? Int J
Cardiol. 2000;74(2-3):199-205.
©2009 American Medical Association. All rights reserved.
44. Scalvini S, Zanelli E, Martinelli G, Baratti D, Giordano
A, Glisenti F. Cardiac event recording yields more diagnoses than 24-hour Holter monitoring in patients
with palpitations. J Telemed Telecare. 2005;11
(suppl 1):14-16.
45. Barsky AJ, Ahern DK, Delamater BA, Clancy SA,
Bailey ED. Differential diagnosis of palpitations: preliminary development of a screening instrument. Arch
Fam Med. 1997;6(3):241-245.
46. Kinlay S, Leitch JW, Neil A, Chapman BL, Hardy
DB, Fletcher PJ. Cardiac event recorders yield more
diagnoses and are more cost-effective than 48-hour
Holter monitoring in patients with palpitations: a controlled clinical trial. Ann Intern Med. 1996;124
(1 pt 1):16-20.
47. Zimetbaum PJ, Kim KY, Josephson ME, Goldberger
AL, Cohen DJ. Diagnostic yield and optimal
duration of continuous-loop event monitoring
for the diagnosis of palpitations: a cost-effectiveness analysis. Ann Intern Med. 1998;128(11):890895.
48. Wu CC, Hsieh MH, Tai CT, et al. Utility of patientactivated cardiac event recorders in the detection of
cardiac arrhythmias. J Interv Card Electrophysiol. 2003;
8(2):117-120.
49. Hoefman E, van Weert HC, Boer KR, Reitsma J,
Koster RW, Bindels PJ. Optimal duration of event recording for diagnosis of arrhythmias in patients with
palpitations and light-headedness in the general
practice. Fam Pract. 2007;24(1):11-13.
50. Arjona Barrionuevo JdeD, Barón-Esquivias G,
Núñez Rodrı́guez A, et al. Utility of cardiac event
recorders in diagnosing arrhythmic etiology of
palpitations in patients without structural heart
disease. Rev Esp Cardiol. 2002;55(2):107-112.
51. Zimetbaum P, Kim KY, Ho KK, Zebede J, Josephson
ME, Goldberger AL. Utility of patient-activated cardiac event recorders in general clinical practice. Am J
Cardiol. 1997;79(3):371-372.
52. Fogel RI, Evans JJ, Prystowsky EN. Utility and cost
of event recorders in the diagnosis of palpitations, presyncope, and syncope. Am J Cardiol. 1997;79
(2):207-208.
(Reprinted) JAMA, November 18, 2009—Vol 302, No. 19
Downloaded from www.jama.com by guest on November 17, 2009
2143