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Initial assessment
Cardiac
monitoring
strategies
Case studies
The authors
DR SUSAN CORCORAN,
cardiologist, Caulfield Hospital,
Alfred Health, Caulfield,
Victoria.
DR DAVID LIGHTFOOT,
emergency physician, Monash
Medical Centre, Clayton,
Victoria.
Palpitations
Background
PALPITATIONS are a common
symptom in primary practice. The
term is used to describe an uncomfortable awareness of the heart beating and does not necessarily indicate
that the patient has an arrhythmia.
For a patient complaining of palpitations, the initial assessment is guided
by three principles:
• Do the palpitations represent an
arrhythmia?
• Are the palpitations a symptom of
associated heart disease?
News
• Are the palpitations a symptom of
comorbid non-cardiac disease?
Initial assessment of patients with
palpitations should always involve
two parallel courses of investigation:
investigating the palpitations themselves (often involving cardiac-monitoring strategies); and assessing for
and managing underlying cardiac and
non-cardiac conditions that may
result in palpitations and require
management in their own right.
Patients who present with palpita-
tions will most frequently be found to
have sinus rhythm, sinus tachycardia, or atrial or ventricular ectopy as
the cause of their symptoms. However, 20-30% of patients will be
found to have rhythms requiring further investigation and/or management. Most frequently these will be
atrial fibrillation or other forms of
supraventricular tachycardia. Ventricular tachycardia rarely causes palpitations, and more commonly presents
with syncope or presyncope.
Comment
Prognosis of a patient presenting
with palpitations in general relates not
to the cause of the palpitations themselves but to the prognosis of the
underlying cardiac and non-cardiac
conditions with which they are associated. A common exception to this rule
is sustained atrial arrhythmias (atrial
fibrillation and flutter), which are associated with risk of stroke. The risk of
stroke however, increases with the
number of comorbid conditions.
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HOW TO TREAT Palpitations
Initial assessment
Aim
THE aim of the initial
assessment is to:
• Make a clinical diagnosis
as to the most likely cause
of the palpitations based
on:
— description of the
symptoms.
— the patient’s age.
— comorbidities.
• Identify features in the
history that indicate the
patient may be at risk of a
serious cause for the palpitations, for which early
or emergent cardiology
referral is indicated:
— palpitations in association with syncope or
presyncope.
— onset of palpitations
during exercise.
— sustained palpitations
in association with
known structural heart
disease.
— sustained palpitations
in association with
other symptoms suggestive of significant
heart disease, eg, dyspnoea or angina.
History of the symptoms
A clinical diagnosis as to
the likely cause of a
patient’s palpitations can
often be made by the
description of the palpitations. In general it is helpful
to ask:
• In what circumstances did
the palpitations occur?
• Did they commence when
lying, sitting or standing?
• Did they come on at rest
or with exercise?
• Were they regular or
irregular?
• How fast were they?
• Did they come on suddenly?
• Did they stop suddenly?
• How often are they occurring?
• Is there any relationship
between medication, alcohol or drugs and the palpitations?
• Could the patient have
been dehydrated?
• If the patient was feeling
anxious, was this before
or after the onset of the
palpitations?
Remember that palpitations are an uncomfortable
awareness of the heart beating and do not always
reflect a tachyarrhythmia.
Patients who are dehydrated or anxious may be
uncomfortably aware of a
resting pulse rate of 80-100
beats/minute in sinus
rhythm. Many medications
can cause sinus tachycardia
as a side effect (table 1).
It is often helpful to tap
out different heart rates to
obtain an indication of how
fast the rhythm was that the
patient experienced.
How does sinus
rhythm/sinus tachycardia
feel when it causes
palpitations?
34
Table 1: Medications that can cause sinus tachycardia
Medications with anticholinergic actions
Agents acting on the central nervous system:
• tricyclic antidepressants
• antipsychotics:
— chlorpromazine
— clozapine
— haloperidol/droperidol
— quetiapine
— olanzapine
Agents used for bladder function disorders:
• oxybutynin
• solifenacin
• tolterodine
Agents used for the GI system:
• atropine
• hyoscine compounds
• hyoscyamine
• prochlorperazine
Antihistamines (promethazine)
Bronchodilators (ipratropium)
Bronchodilators
Beta agonists, eg, salbutamol
Theophylline
Antihypertensives
Dihydropyridine calcium antagonists:
• felodipine
• amlodipine
• lercanidipine
Diuretics (dehydration)
Clonidine
Hydralazine
Cold and flu remedies,
eg, pseudoephedrine, ephedrine
Weight-loss remedies,
eg, sympathomimetic appetite suppressants
Stimulants
Caffeine
Nicotine
Amphetamines
Cocaine
Table 2: Likely causes of palpitations according to age and
underlying heart disease
Underlying heart disease
Likely cause of palpitations
Nil – age <50
Sinus rhythm, sinus tachycardia, atrial or ventricular ectopy
Re-entrant supraventricular tachycardia
Nil – age >50
As above plus atrial arrhythmias
Ischaemic heart disease
Sinus rhythm, sinus tachycardia, atrial or ventricular ectopy
Atrial arrhythmias
(Ventricular tachycardia)
Cardiomyopathy
Sinus rhythm, sinus tachycardia, atrial or ventricular ectopy
Atrial arrhythmias
(Ventricular tachycardia)
Hypertensive heart disease,
valvular heart disease
Sinus rhythm, sinus tachycardia, atrial or ventricular ectopy
Atrial arrhythmias
Sinus rhythm may be experienced as palpitations when
the rate is excessive for the
level of exertion at the time
it occurs.
Sinus rhythm is usually
experienced as palpitations
with gradual onset and
offset. Patients most commonly complain of symptoms occurring at rest, sitting or lying or with
prolonged standing. The
rhythm is regular but may
feel forceful. When tapped
out it is usually at a rate of
80-120 beats/minute.
Rarely, patients who have
conditions associated with
an inappropriate sinus
tachycardia can develop
sinus rates up to 160
beats/minute while standing
at rest.
How do ectopic beats feel
when they cause
palpitations?
Atrial and ventricular
ectopics are often experienced as a flutter followed
by a pause then a big
thump. Ventricular ectopics
in particular are experienced as a ‘skipped beat’
and may result in a pulse
deficit. This is because the
ectopic comes early in the
cardiac cycle, resulting in a
short ventricular filling time
| Australian Doctor | 13 March 2009
Table 3: Non-cardiac diseases predisposing to
palpitations
Condition
Thyrotoxicosis
Anaemia
Acute and chronic lung
disease, pulmonary
hypertension
Systemic infection or
or inflammation
Non-cardiac surgery
Likely cause of palpitations
Sinus tachycardia, atrial arrhythmias
Sinus tachycardia
Sinus tachycardia, atrial arrhythmias
Sinus tachycardia, atrial arrhythmias,
atrial or ventricular ectopy
Sinus tachycardia, atrial arrhythmias,
atrial or ventricular ectopy
and therefore a low volume
output for that beat. Resetting of the sinus pacemaker
results in a pause after the
ectopic. The post-ectopic
beat therefore has a long
filling time and thus it produces a large volume output
— the thump.
Ventricular ectopics often
cause an uncomfortable
feeling in the throat and a
need to cough, due to a
reversal of the normal activation pattern of the heart,
resulting in contraction of
the atria against closed atrioventricular valves and
increased peripheral and
pulmonary venous pressures
for that beat.
Patients are most commonly aware of ectopic
beats when sitting or lying
quietly, such as when driv-
ing the car, sitting reading,
watching television or in
bed at night. They may be
more symptomatic if the
patient is dehydrated and
can occur in association
with intercurrent illnesses
such as respiratory illnesses.
How does atrial fibrillation
feel when it causes
palpitations?
Atrial fibrillation does not
always cause palpitations;
some patients may be
entirely asymptomatic.
When it is symptomatic
patients are usually aware
of a sudden onset and offset
of
symptoms.
Many
patients are aware of the
irregularity of the rhythm,
particularly if it is tapped
out for them.
Onset is unrelated to pos-
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Atrial and
ventricular
ectopics are often
experienced as a
flutter followed
by a pause then a
big thump.
ture, although in a subset of
patients episodes begin
more frequently at night.
The duration can vary considerably.
How does re-entrant
supraventricular
tachycardia feel when it
causes palpitations?
Re-entrant supraventricular
tachycardia is of sudden
onset and offset. It is a
rapid regular rhythm, commonly 170-200 beats
/minute. It is often associated with a tight feeling in
the throat and chest, due to
simultaneous activation of
the atria and ventricles.
Patients may have discovered that the Valsalva
manoeuvre can occasionally
terminate the arrhythmia.
How does ventricular
tachycardia feel when it
causes palpitations?
Sustained ventricular tachycardia rarely presents with
palpitations unless it is one
of the forms of ventricular
tachycardia that occur in
normal hearts, such as right
ventricular outflow tract
(RVOT) ventricular tachycardia . In most other cases,
ventricular tachycardia
occurs in association with
structural heart disease and
presents with syncope, presyncope or shortness of
breath due to the loss of
atrioventricular synchrony.
Non-sustained ventricular
tachycardia is often felt in
the throat and may be followed by a pause and
thump, as with ventricular
ectopy.
Clinical history
A detailed past history is
essential. The past history
may give an indication as to
the cardiac rhythms a
patient is at risk of developing (table 2). Patients
with a past history of heart
disease are at increased risk
of developing cardiac
arrhythmias. Non-cardiac
diseases may also predispose patients to cardiac
arrhythmias, for example,
atrial fibrillation in thyrotoxicosis.
A family history may
indicate rare but serious
inherited rhythm disorders
such as long-QT syndrome,
particularly if there is a
family history of early unexplained sudden cardiac
death.
Medications, over-thecounter preparations, recreational drugs (including
high caffeine intake from
coffee and energy drinks
and high nicotine intake)
may cause sinus tachycardia or trigger arrhythmias
such as atrial fibrillation or
re-entrant supraventricular
tachycardia in a predisposed
patient.
Age is also a helpful risk
stratifier. Younger adults
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(<50) are most likely to
have normal hearts, therefore they are more likely to
have the rhythms that cause
palpitations in normal
hearts. These include sinus
rhythm, sinus tachycardia,
and atrial or ventricular
ectopy as a cause for their
palpitations. This group of
patients may also present
with re-entrant supraventricular tachycardia.
Older patients and those
with a past history of heart
disease are at greater risk of
having a more serious cause
for their palpitations. They
are less likely to have a
normal heart and are likely
to have a greater number of
comorbid conditions.
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Figure 1: Sinus rhythm with a short PR interval, delta waves and abnormal QRS axis as seen in Wolff-Parkinson-White syndrome.
Clinical examination
Unfortunately, most patients
present between episodes of
palpitations. The purpose of
the clinical examination, in
the absence of the symptomatic rhythm, is to assess
for underlying cardiac or
non-cardiac conditions that
predispose the patient to
particular arrhythmias (see
tables 2 and 3).
Blood pressure and pulse
should be taken supine and
after standing for five minutes to assess for postural
hypotension or tachycardia.
The patient should be
assessed for:
• Clinical signs of current
systemic infection or
inflammation.
• Clinical signs of anaemia
or thyroid disease.
• Cardiorespiratory examination to assess for:
— signs of valvular heart
disease (murmurs).
— signs of heart failure
Figure 2: Sinus tachycardia with frequent unifocal ventricular ectopics, each followed by a compensatory pause.
(elevated jugular venous
pressure, enlarged heart,
oedema or pulmonary
congestion).
— signs of chronic lung
disease.
An ECG must be performed on all patients presenting with palpitations.
The ECG may indicate
underlying electrical disorders or evidence of heart
disease that will predispose
the patient to certain
arrhythmias. For example,
it may reveal the short PR
interval and delta waves of
Wolff-Parkinson-White syndrome (figure 1), which predisposes the patient to reentrant supraventricular
tachycardia. It may perhaps
demonstrate left ventricular
hypertrophy and left atrial
enlargement — predisposing
the patient to atrial fibrillation. Occasionally you may
capture the symptomatic
rhythm, such as ventricular
ectopics (see figure 2).
Investigations
Baseline investigations
An FBC, serum electrolytes,
magnesium and thyroid
function studies are a simple
set of screening tests commonly performed in a
patient who presents with
palpitations.
Further investigations
Further investigation is performed for two purposes: to
attempt to document the
cardiac rhythm at the time
of symptoms; and to further
assess for underlying cardiac
or non-cardiac disease, if
indicated, based on the initial history, ECG and baseline bloods.
Cardiac monitoring strategies
THE purpose of cardiac monitoring strategies is to obtain symptom
–rhythm correlation. The technique
used will depend on the frequency
of symptoms.
Holter monitoring
Holter monitoring involves continuous cardiac monitoring for 24hours. The patient is unable to
shower during the time period and
presses a button to mark symptoms. Holter monitoring is widely
available. It is helpful for symptoms that are occurring daily. It can
be helpful to confirm a clinical
diagnosis of ventricular ectopy and
to assess the frequency of ectopy
(see box ‘How to treat ventricular
ectopy’, page 36).
Cardiac event monitoring
Event monitors are usually worn
for 1-2 weeks and are useful if the
patient’s symptoms are occurring
weekly. They are less widely available than Holter monitors and are
associated with a higher incidence
of technical problems but are often
very useful in diagnosing palpitations.
Cardiac event monitoring can be
It can often be
difficult to obtain
symptom–rhythm
correlation in patients
with infrequent
symptoms.
performed in two different ways.
The first involves continuous monitoring for a period of a week. The
patient is able to remove ECG electrodes for showering and reapply
new ones afterwards. The monitor
has a continuous loop recording
mechanism. The patient presses the
button when symptoms occur.
The device freezes a variable
amount of ECG pre- and post-activation. This information can sometimes then be transmitted over a
telephone line. Some event monitors of this type also store automatically detected but asymptomatic arrhythmias.
A second type of monitor is
placed against the chest during
symptoms, which it then records
for a variable duration — usually
30-90 seconds. This device is not
useful for very brief palpitations,
as they will have finished by the
time the device is applied and
therefore will not be captured.
Monitoring in the patient with
infrequent palpitations
Holter monitoring is generally not
helpful in patients whose symptoms occur infrequently. However,
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on occasion it may reveal asymptomatic rhythms that may require
treatment in their own right, such
as prolonged episodes of atrial
tachyarrhythmias.
Long-term
(three
years)
implantable cardiac monitors are
available that continuously record
the patient’s heart rhythm and can
store arrhythmias automatically or
during the patient’s symptoms.
However, these are usually reserved
for investigating patients with syncope.
Alternative strategies depend on
the duration of the symptoms on
each occasion. These include giving
the patient a request form for an
ECG to be performed during symptoms. Depending on the severity of
the symptoms and the comorbidities present, the patient may be
instructed to call an ambulance or
present to the emergency department with the symptoms.
It can often be difficult to obtain
symptom–rhythm correlation in
patients with infrequent symptoms.
A clinical diagnosis may be made
on the basis of the history and
comorbidities. Further investigation
then focuses on risk stratification.
For example, a patient who gives a
history consistent with paroxysmal
atrial fibrillation will need to be
assessed for exacerbating factors
such as hypertension that will
require treatment. An assessment
for stroke risk and need for anticoagulation will also need to be
made.
Electrophysiological testing
Electrophysiological testing is an
invasive study of the cardiac electrical system performed in a cardiac catheterisation laboratory.
The heart is accessed via the
venous system, most commonly
using the femoral vein. Electrode
catheters that can both record cardiac signals and stimulate the
heart are passed via the veins to
the heart and positioned predominantly within the right heart
chambers. The left side of the
heart may be accessed, when
required, by crossing the interatrial septum.
Electrophysiology studies are
used to examine the electrical
system of the heart and to assess
the patterns of cardiac activation
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HOW TO TREAT Palpitations
from previous page
How to treat ventricular ectopy
in the patient, thus determining if
they have the substrate for a particular arrhythmia. Attempts are
made to induce the suspected
arrhythmia using pacing manoeuvres and medications.
Ablation, using radiofrequency
current or cryotherapy, may be
used to destroy a small area of
cardiac tissue critical to the maintenance of an arrhythmia.
Depending on the arrhythmia this
can often be curative. In other circumstances it may be part of a
broader management strategy that
includes medications and/or
devices such as pacemakers and
defibrillators.
An electrophysiological study
(EPS) may be performed when
assessing a patient with palpitations when the history is suggestive of an arrhythmia known to
be inducible during an EPS. On
other occasions the EPS is performed with a view to proceeding
to ablation after a diagnosis has
been made.
Echocardiography
While the echocardiogram will not
identify the rhythm causing the palpitations, it is a useful tool for risk
stratification. The patient with a
normal echocardiogram and
normal ECG, with symptoms
occurring at rest, is at very low risk
of having an adverse outcome and
likely to have a benign cause for
their palpitations.
Exercise stress testing
Exercise stress testing is generally
not indicated for investigating palpitations unless they occur with
exertion or immediately post exertion, or the patient also has symptoms of ischaemic heart disease. In
these circumstances the aim of test-
• Although generally benign, ventricular ectopy can occur in association with underlying heart disease
• Ventricular ectopics themselves are rarely the target of treatment
• Prognosis relates to the presence and severity of underlying heart disease
• Management is focused on:
— Excluding coexistent heart disease
— Optimising management of coexistent heart disease
— Optimising cardiovascular risk-factor management
• All patients with symptoms suggestive of ventricular ectopy require an ECG and clinical cardiovascular examination
• Baseline bloods are generally also indicated
Further investigation:
— Holter or event monitoring can be helpful to confirm ventricular ectopy as the mechanism of the patient’s symptoms
and to assess the frequency of ventricular ectopy
Benign ventricular ectopy
• Infrequent ectopics (<0.1% of beats) occurring at rest in association with a normal clinical examination and baseline
ECG are considered benign
• Echocardiography is not indicated in these circumstances but can be useful for providing further reassurance,
particularly in an anxious patient
• Stress testing is not indicated in these circumstances unless the patient has other symptoms concerning for
ischaemic heart disease
• Management of benign ventricular ectopy:
— Patient reassurance
— Identify and remove triggering factors (caffeine, alcohol, nicotine, dehydration, stress)
— If very symptomatic a beta blocker can be trialled. Anti-arrhythmic agents are rarely used and may be harmful
When is further investigation/referral indicated?
• Historical or patient factors may indicate serious underlying heart disease associated with the ectopics. Further
investigation and cardiology referral is indicated for patients with the following features:
— Ventricular ectopy occuring with exertion or immediately post exertion
— Ventricular ectopy associated with syncope or presyncope
— Ventricular ectopy that is very frequent (>1% of beats on Holter monitoring)
— A baseline ECG that is significantly abnormal
— When advice regarding optimisation of management of known heart disease is required
— When previously undiagnosed heart disease is discovered in the course of investigation for the palpitations
• In these circumstances further investigation is targeted at assessing for underlying heart disease or reassessing
patients with known heart disease. This will allow for optimal management of the underlying condition with which the
ventricular ectopy is associated
— If not performed recently, echocardiography is indicated to assess cardiac structure and function
— Stress testing (± nuclear/echocardiographic imaging) may be performed to assess for ischaemic heart disease or
rare arrhythmic disorders (eg, long QT syndrome)
— Coronary angiography may be required if significant coronary disease is suspected after the initial evaluation
ing is to reproduce the palpitations
or assess for coexistent ischaemic
heart disease that requires treatment
in its own right.
Cardiac perfusion imaging,
coronary angiography, cardiac
CT or MRI
While these are not required for
How to manage common
findings on Holter
monitoring
Ventricular ectopics
(see box at left)
Atrial ectopics
• Rare atrial ectopics (<0.1%) are a
common normal finding
• More frequent atrial ectopy is
found less commonly. It does not
require treatment unless the
patient is symptomatic
Brief supraventricular
tachycardia episodes
• Brief (<1 minute) supraventricular
tachycardia episodes are a
common normal finding,
particularly in patients over 50
• Infrequent episodes require no
specific treatment
• Frequent episodes can indicate a
propensity to longer episodes of
atrial arrhythmias at other times.
They should prompt assessment
of modifiable risk factors for atrial
fibrillation and assessment of
thromboembolic risk
• Aspirin may be started if not
contraindicated. Anti-arrhythmic
or AV-node blocking agents may
be initiated if symptomatic
Non-sustained ventricular
tachycardia
• This is an uncommon finding on
Holter monitoring
• Structural heart disease should be
excluded
• Assessment of cardiac function
and cardiology referral is
appropriate
investigating palpitations, initial investigation of the patient may reveal cardiac conditions that require further
assessment using these modalities.
Authors’ case study 1
MR AB, 65, presents complaining of palpitations. He
has noticed them on and off
for the past few weeks.
They can occur at any time
and are not related to posture or exercise. He cannot
identify any particular precipitating or relieving factors. They can last from a
few seconds up to 20 minutes. They are rapid but he
is not sure if they are regular or irregular.
He feels uncomfortable
with the palpitations and
prefers to sit still with them.
He does not feel lightheaded or faint when they
occur. He has never had
chest pain and has normal
exercise tolerance. Symptoms are currently occurring
a few times a week.
Mr AB has a past history
of hypertension for 15 years
and type 2 diabetes for five
years. He stopped smoking
five years ago and has a 20pack-year history of smoking.
His current medications
are perindopril/indapamide
4mg/1.25mg mane, aspirin
100mg daily and metformin
500mg bd.
Mr AB’s blood pressure is
36
Figure 3: ECG demonstrating criteria for left ventricular hypertrophy and left atrial enlargement.
150/90mmHg on examination. He is in sinus rhythm
with a pulse rate of 88
| Australian Doctor | 13 March 2009
beats/minute. His cardiovascular examination is normal.
His ECG demonstrates cri-
teria for left ventricular
hypertrophy and left atrial
enlargement (figure 3).
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Approach to management
The approach in this patient
is to determine the cause of
his palpitations while simultaneously addressing his
overall cardiovascular risk:
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successful at capturing his
rhythm during his usual
symptoms.
Approach to management of atrial fibrillation/flutter
Atrial fibrillation and flutter are some the most complex rhythms to manage. When assessing a
patient with these arrhythmias there are four key principles:
1. Why?
What are the predisposing cardiac and non-cardiac factors that require treatment in this patient,
eg, pneumonia, thyroid disease, uncontrolled hypertension?
2. Anticoagulation?
• Are there any serious contraindications to anticoagulation?
• If no serious contraindications, which anticoagulant should be used?
Use the CHADS2 scoring table below for patients with non-valvular atrial fibrillation/flutter.
Condition
Points
C
Congestive heart failure or LVEF <35%
1
H
Hypertension (or treated hypertension)
1
1
A
Age ≥75 years
D
Diabetes
1
Prior TIA or stroke
2
S2
The S2 indicates that a history of prior TIA or stroke earns the patient two points. Points are added
to achieve the CHADS2 score. Recommendations based on the score are shown below:
CHADS2 score
Risk
Anticoagulation therapy
0
Low
Aspirin 81-325mg/day
1
Moderate
Aspirin 81-325mg/day
or warfarin (INR 2.0-3.0)
≥2
Moderate or high
Warfarin (INR 2.0-3.0)
3. Rate control
This is the initial focus of management after deciding about anticoagulation.
4. Rhythm control
Managing a patient with atrial fibrillation will include decisions about maintenance of sinus rhythm.
This may involve a combination of strategies over time. These decisions will often be made in
consultation with a cardiologist or physician.
• Mr AB has the known risk
factors for cardiovascular
disease of age, male gender,
hypertension, diabetes and
prior smoking. A family
history and fasting lipids
will complete this assessment.
• After this initial assessment
he is at least at moderate
risk of a cardiovascular
event in the next five years.
• Because of his comorbidities, including evidence of
cardiac end-organ damage
due to hypertension, he is
at risk of serious cardiac
arrhythmias, in particular,
atrial fibrillation. Atrial fibrillation as a cause of his
palpitations would place
him at risk of thromboembolic events (see box,
Approach to management
of atrial fibrillation/flutter).
• A ventricular arrhythmia is
less likely as the cause of
his symptoms. However,
evaluating his ventricular
function (with an echocardiogram) will assist in the
risk assessment for ventricular arrhythmias and aid
with further management.
This patient should be
referred early for specialist
cardiology care. In addition
to arranging an early cardiology referral:
• Baseline blood tests including thyroid function tests
should be performed. Fasting lipids and assessment
of diabetic control (HbA1C
and testing for microalbuminuria) will assist in further assessing his cardiovascular risk.
• As his hypertension control
is suboptimal, antihyper-
tensives should be added or
the dose increased.
• If no contraindications
exist, lipid-lowering therapy should be started after
lipid estimations, baseline
creatine kinase and LFTs
are performed. In the setting of diabetes the target
LDL cholesterol is ≤ 2.0
mmol/L, HDL >1.0mmol/L
and triglycerides <1.5
mmol/L.
Further assessment of the
palpitations
Mr AB is most likely to have
a paroxysmal atrial arrhythmia as the cause of his intermittent palpitations because:
• The sudden onset and
offset is against sinus
tachycardia.
• The palpitations are rapid
and the description is not
Progress
consistent with ectopics.
• Re-entrant supraventricular tachycardia uncommonly first presents in this
age group.
• A ventricular arrhythmia is
very unlikely in the absence
of significant structural
heart disease.
Cardiac monitoring is
likely to be helpful in these
circumstances, as the palpitations are occurring fairly
frequently.
Because the palpitations
are occurring a few times a
week, a 24-hour Holter monitor has about a 30% chance
of capturing his rhythm at
the time of symptoms.
An event monitor is much
more likely to be helpful.
Given the frequency of symptoms, a monitor worn for 12 weeks is very likely to be
Mr AB has normal baseline
electrolyte levels, FBC and
thyroid function. His HbA1C
is 7% and there is no
microalbuminuria. His total
cholesterol is 6.0mmol/L,
LDL 4.5mmol/L and HDL
1.1mmol/L, with triglycerides 2.0 mmol/L.
He is referred to a diabetic
educator for further dietary
management of diabetes and
hypercholesterolaemia and
started on a statin. His blood
pressure on review is
130/80mmHg after initiation
of amlodipine 5mg daily.
A cardiac echo reveals
mild left ventricular hypertrophy and moderate left
atrial enlargement but
normal ventricular size and
function and no significant
valvular heart disease.
Cardiac event monitoring
during brief palpitations
reveals paroxysms of atrial
fibrillation with a ventricular rate of 150 beats/minute.
Mr AB is seen by a cardiologist, who adds sotalol
80mg bd for both rhythm
and rate control of atrial fibrillation. Amlodipine is
stopped because of concerns
he may become hypotensive.
Although his atrial fibrillation has been short-lived
thus far, future episodes may
last longer and are likely to
be less symptomatic with initiation of sotalol.
Sotalol will only prevent
the recurrence of atrial fibrillation long term in 40%
of people. Therefore, given
a CHADS 2 score of 2 (see
box, above), he is started on
warfarin for prophylaxis
against stroke, aiming for an
INR of 2-3. Aspirin is continued for thromboprophylaxis against other vascular
events.
Authors’ case study 2
MS CD, 35, presents with a history of palpitations, occurring on
and off over the last six weeks.
They make her feel very uncomfortable. She often has to cough
with the episodes and feels her
heart stops and then cuts back in
with a big thump.
She feels strange with the
episodes but does not feel as
though she will faint. She is very
anxious, as the palpitations have
occurred a number of times while
driving her children to school. She
has also noticed them when reading in bed at night.
She feels otherwise well and
exercises three times a week at the
gymnasium without any symptoms.
She occasionally notices the palpitations driving to or from the gym
but never when exercising or
immediately after exercise. Currently symptoms are occurring
daily.
Ms CD does not smoke. She
drinks two glasses of wine three
nights a week. Her only current
replacement in his 70s.
On examination Ms CD’s blood
pressure in 120/65mmHg and her
pulse is 75 beats/minute and regular. Her cardiovascular examination is unremarkable. An ECG is
performed: the trace shows sinus
rhythm with a normal QT interval.
Approach to management
This history is consistent with
benign ventricular ectopy. This
patient has no concerning features
in her history or on examination.
She has a clinically normal heart
and a normal ECG. She requires
minimal investigations and reassurance after these investigations are
confirmed to be normal.
Investigations
medication is the oral contraceptive pill. She has no other medical
problems. There is no family history of arrhythmias and no one in
the family has died suddenly. Her
grandfather had a heart valve
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• Baseline electrolytes, FBC and
thyroid function studies
• No further investigations are necessary — this is a classic history.
However, patients are often anxious to have the diagnosis
‘proven’. In these circumstances,
if palpitations are occurring daily,
a Holter monitor can be useful
to demonstrate the ectopy at the
time of the patient’s symptoms.
Palpitations occurring weekly can
usually be documented on an
event monitor.
• Echocardiography is not indicated when the patient has infrequent ectopy and a normal baseline ECG and examination.
However, it can be helpful for
reassuring the patient that they
have a normal heart.
Management
• Reassurance that, although very
uncomfortable, the ectopy is
benign.
• Explain the mechanism whereby
ectopics cause a ‘flutter, pause,
thump’.
• Try to identify precipitating factors such as dehydration, caffeine
or over-the-counter preparations
containing stimulants such as
pseudoephedrine.
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13 March 2009 | Australian Doctor |
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HOW TO TREAT Palpitations
Summary
Authors’ case study 3
MS EF, 23, presents with three
episodes of palpitations over
the past six months. The palpitations are very rapid and she
thinks they are regular. They
have come on after an argument with her now exboyfriend, on another occasion
when drinking strong coffee to
stay awake while studying late
at night, and recently the day
after a ball where she drank a
lot of alcohol. She thinks they
start and stop suddenly, and
they have lasted up to one
hour. She feels very anxious
with the palpitations. They
make her feel tight in the chest
and throat.
Ms EF is single and lives
in a share house; her family
live interstate. She is in her
fourth year of university
studying arts/law. She also
works part time as a waitress. She has been under a lot
of stress lately because of
financial and study pressures.
She recently broke up with
her boyfriend of two years.
Between episodes she feels
well and attends spin classes
at the local gym three times a
week.
Ms EF is otherwise well.
She had childhood asthma
and occasionally experiences
symptoms now after viral
infections. There is no family
history of heart disease and
her parents are well. Her
only current medication is the
oral contraceptive pill.
On examination her blood
pressure is 115/65mmHg and
she is in sinus rhythm with a
rate of 65 beats/minute. Her
cardiovascular examination is
normal. An ECG is in sinus
rhythm at a rate of 65
beats/minute and is normal.
FBC, electrolytes and thyroid
function are normal.
Approach to management
This young woman has a
normal ECG and clinically
normal heart. She has no
cardiac symptoms between
episodes. This history is suggestive of either:
• Sinus tachycardia
— the palpitations have
occurred in circumstances of stress, dehydration and caffeine
excess.
— the palpitations are regular.
• Re-entrant supraventricular tachycardia
— the palpitations are of
sudden onset and offset.
— they are rapid and regular and cause tightness
in the throat.
— they are triggered by circumstances of increased
sympathetic activity.
Investigations
Cardiac monitoring
The palpitations are very
infrequent so monitoring
techniques are unlikely to be
useful.
As the palpitations have
lasted for up to one hour, Ms
EF could be given an ECG
38
Figure 4. Atrioventricular nodal re-entrant tachycardia.
Fast pathway
Right atrium
Bundle of His
AV node
Left bundle
branch
Slow pathway
Right bundle
branch
Figure 5. Atrioventricular re-entrant tachycardia. A: Orthodromic tachycardia – the impulse follows the normal direction of conduction
then re-enters the atria via an accessory electrical pathway. B: Antidromic re-entry – the circuit occurs in the reverse direction.
(See box below for further description.)
A.
B.
Orthodromic atrioventricular re-entry
Antidromic atrioventricular re-entry
Accessory
pathway
Accessory
pathway
• Palpitations are a
common symptom.
• An ECG should be
performed in all patients
with palpitations.
• Frequency of symptoms
should be considered
before arranging cardiac
monitoring. Holter
monitoring is not useful
unless the symptoms are
occurring daily.
• Patients at risk of an
adverse outcome can be
identified by assessing for
comorbid cardiac and
non-cardiac conditions.
• A cardiac echo is a useful
tool for risk-stratifying
patients with palpitations.
• Patients under 50 with a
normal ECG and
examination, with
palpitations occurring at
rest and not associated
with syncope or
presyncope, usually have
a very good prognosis.
• Older patients and those
with a significantly
abnormal ECG or
examination or known
structural heart disease
are more likely to have an
adverse outcome. An
early cardiology referral
should be made.
Further reading
request form to have an
ECG with symptoms, or
requested to present to the
emergency department with
the palpitations. (However,
she should not drive herself.)
Echocardiography
Although not specifically
indicated in these circumstances, an echocardiogram
can provide further reassurance that there is unlikely to
be a serious underlying cause
for the palpitations. This can
be particularly useful in a situation where it may take
some time to confirm the
clinical diagnosis.
Electrophysiological studies
This is a circumstance when
referral to a cardiac electrophysiologist with a view to
an EPS would be warranted.
There are many features of
this history to suggest reentrant supraventricular
tachycardia as a mechanism.
An EPS would determine if
the patient has the substrate
for this arrhythmia, and the
arrhythmia can usually be
induced if it is the cause.
Curative ablation could then
be offered.
| Australian Doctor | 13 March 2009
Re-entrant supraventricular tachycardia
This is the likely cause of palpitations in a patient who presents with sudden onset of rapid regular
palpitations. It occurs in patients with structurally normal hearts who have the electrical substrate
for these rhythms. There are two common types.
Atrioventricular nodal re-entry
• This is the most common cause of re-entrant supraventricular tachycardia. Despite its common
name, this rhythm is not confined to the compact AV node but rather is re-entry occurring within
the tissue surrounding the AV node.
• For it to occur there must be critical differences in the conducting properties of two bundles of
fibres that approach the AV node known as the ‘fast’ and ‘slow’ pathways. If these differences
are present, re-entry can occur (see figure 4).
• As the conducting properties of these pathways can change with age, a patient can develop the
substrate for this arrhythmia at any age. Patients with this arrhythmia most commonly present in
mid-life.
• In these circumstances the ECG is usually normal. Intermittent first-degree AV block, or firstdegree AV block after an atrial ectopic can be a clue to the presence of the substrate for this
arrhythmia.
Atrioventricular re-entry
• In this circumstance the patient is born with an accessory electrical pathway that allows an
impulse to travel down the normal conducting system, then back up to the atria via the
accessory pathway, initiating a loop of re-entry (orthodromic re-entry). This results in a narrow
complex regular tachycardia (see figure 5A).
• This can occur in the reverse direction also (antidromic re-entry), but in this circumstance the
tachycardia has a broad complex because the ventricles are activated via an inefficient path and
so take longer to depolarise (see figure 5B).
• Patients often present in childhood and may have the resting ECG features of Wolff-ParkinsonWhite syndrome. The accessory pathway may however be ‘concealed’ and the ECG entirely
normal.
As symptoms usually occur infrequently, monitoring techniques are a waste of time (and money) in
these conditions.
Patients with symptoms suggestive of these arrhythmias may be referred for early
electrophysiological studies, which can confirm the diagnosis. Ablation may then be offered for
cure of these rhythms, at low risk to the patient. Alternatively the patient may opt for medical, or
no treatment, if symptoms are infrequent.
www.australiandoctor.com.au
• Sulfi S, et al. Limited
clinical utility of Holter
monitoring in patients
with palpitations or
altered consciousness:
analysis of 8973
recordings in 7394
patients. Annals of
Noninvasive
Electrocardiology 2008;
1:39-43.
• Medi C, et al. Clinical
update – atrial fibrillation.
Medical Journal of
Australia 2007; 186:197202.
• Zimetbaum P, Josephson
ME. Evaluation of
palpitations. New England
Journal of Medicine 1998;
338:1369-77.
Online resources
• Heart Rhythm Society,
About patient education:
www.hrsonline.org/Patient
Info/
• Heart Rhythm Society,
Patient education PDFs:
www.hrsonline.org/Educat
ion/Resources
• HealthInsite, Arrhythmia:
www.healthinsite.gov.au/to
pics/Arrhythmia
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HOW TO TREAT Palpitations
GP’s contribution
DR ROSS WILSON
Bathurst, NSW
Case study
Mr EB, 64, owns a small
business selling batteries for
cars and trucks. He has been
under considerable stress
because of both the global
financial crisis and his wife
recently developing metastatic breast cancer necessitating chemotherapy. He has
no significant past medical
history; his height is 180cm
and weight 70kg.
His presenting complaint
is an irregular thumping in
his chest and the feeling that
he may faint when these
episodes occur. He has not
lost consciousness, still regularly walks 3-4km daily and
despite his age, plays squash
weekly. He has not experi-
Ambulatory monitor results
enced any of his palpitations
while exercising.
Physical examination is
unremarkable. He is normotensive, with no stigma of
thyroid disease and dual
heart sounds. ECG shows
sinus rhythm and is within
normal limits. Haematology,
done partly at his request, is
normal. Thyroid function
tests, cholesterol and triglycerides are normal.
His Holter monitor report
is shown at right.
Questions for the author
Should we further investigate
Mr EB?
Yes. Mr EB has recent
onset of frequent ventricular
ectopy with associated presyncope. Given his age
alone, he has a 5-10% fiveyear risk of cardiovascular
events. He should have a
cardiac echo to assess his
ventricular function and a
stress test to assess for
ischaemic heart disease.
What role would beta blockade play in controlling his
symptoms?
Beta blockers are variably
effective in suppressing ventricular ectopy and may
cause side effects. A trial of
beta blockade could be discussed with the patient if
investigations are unremarkable.
Will reassurance and stress
management have any role
or effect?
Often a patient is very
reassured if cardiac investigations are unremarkable,
and can learn to ignore the
ectopy. Although reduction
of stress is often mentioned
in the management of ventricular ectopy, there are no
studies to demonstrate its
benefit.
How to Treat Quiz
Duration of recording
Resting ECG report
Average heart rate (range)
Rhythm during recording
Patient-reported events
Ventricular ectopy
Supraventricular ectopy
Bradycardia/pauses
Tachycardia
ST-segment changes
Other
Conclusions
23:43 hours
Sinus rhythm, within normal limits
65bpm (range 48-93 bpm)
Sinus rhythm
Nil events reported by patient, although event button
pushed eight times, with no arrhythmia at any time
Moderately frequent uniform ventricular ectopy with
no complex ventricular arrhythmias apart from a very
occasional couplet. Ventricular ectopy persisted
throughout the 24-hour period
Occasional supraventricular ectopy with only one fourbeat run of SVT
Nil
Nil
No significant ST-segment changes
Nil
Resting ECG shows sinus rhythm
No patient-reported events
Moderately frequent simple ventricular ectopy
Occasional supraventricular ectopy with a single
four-beat run of SVT of no clinical significance
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Palpitations — 13 March 2009
1. Claire, 38, presents with palpitations on and
off for a few months. She describes the
sensation of her “heart skipping a beat”,
followed by a “thump”. Claire mainly notices
the palpitations when watching TV or lying in
bed at night. She is otherwise well and takes
no prescribed medications. Which TWO
statements are correct?
a) It is important to ask if Claire has felt lightheaded or faint with the palpitations
b) It is not important to ask whether the
palpitations occur with exercise
c) Asking about a family history of heart disease is
not important as it is unlikely to be of relevance
d) It is important to enquire about any use of overthe-counter (OTC) medications and recreational
drugs
2. The palpitations are occurring every day,
which is making Claire anxious, but she does
not feel unwell with them. They never occur
when she is exercising. Her family history is
unremarkable. Claire’s cardiovascular
examination is normal. Which TWO statements
are correct?
a) Claire’s history is typical of benign ventricular
ectopy and therefore no investigations are
required
b) Claire should have an ECG
c) Claire should have baseline bloods including
FBC, electrolytes, magnesium and thyroid
function tests
d) Claire should have a chest X-ray
3. Claire’s ECG shows sinus rhythm and is
normal. She undergoes Holter monitoring,
which demonstrates infrequent ventricular
ectopics (<0.1% of beats) at rest. Which TWO
statements are correct?
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a) Claire can be reassured that infrequent
ventricular ectopics (<0.1% of beats) at rest in
association with a normal clinical
examination and ECG are considered benign
b) Claire needs to have an echocardiogram to
exclude structural heart disease
c) Claire’s management should include
identification and removal of any triggering
factors such as caffeine or dehydration
d) Claire should be started on an antiarrhythmic agent
4. Which TWO statements about re-entrant
supraventricular tachycardia are correct?
a) Re-entrant supraventricular tachycardia is of
sudden onset and offset
b) Re-entrant supraventricular tachycardia only
occurs in patients with structurally abnormal
hearts
c) Cardiac event monitoring is the best method
of diagnosing of re-entrant supraventricular
tachycardia
d) Ablation may be curative for re-entrant
supraventricular tachycardia
5. Which TWO statements about
atrioventricular re-entrant tachycardia are
correct?
a) Atrioventricular re-entrant tachycardia is the
most common cause of re-entrant
supraventricular tachycardia
b) Atrioventricular re-entrant tachycardia
always presents with a narrow complex
tachycardia
c) In atrioventricular re-entrant tachycardia the
ECG may be entirely normal
d) The ECG in atrioventricular re-entant
tachycardia may have the resting features of
Wolff-Parkinson-White syndrome
6. Which TWO statements about
atrioventricular (AV) nodal re-entrant
tachycardia are correct?
a) Patients with atrioventricular nodal reentrant tachycardia are born with an
accessory electrical pathway
b) Patients with atrioventricular nodal reentrant tachycardia most commonly present
in childhood
c) In atrioventricular nodal re-entrant
tachycardia the ECG is usually normal
d) Intermittent first-degree AV block can be a
clue to the presence of the substrate for
atrioventricular nodal re-entrant tachycardia
7. Barbara, 67, presents with episodic
palpitations. The episodes last up to an
hour and have been 2-3 weeks apart. The
palpitations start and stop suddenly and
can occur at any time. She describes them
as fast and irregular, and feels
uncomfortable with them, but not faint.
Barbara has hypertension and type 2
diabetes, but is otherwise well. She takes
an ACE inhibitor and metformin. Her BP is
145/90mmHg but cardiovascular
examination is otherwise normal. An ECG
shows sinus rhythm and meets the criteria
for left ventricular hypertrophy. Which
TWO statements are correct?
a) Barbara’s history is suggestive of sinus
tachycardia as a likely cause of her
palpitations
b) Barbara should have baseline blood tests
for palpitations including FBC,
electrolytes, magnesium and thyroid
function tests
c) In addition to the usual baseline blood
tests, Barbara should have an assessment
of her lipids and diabetes control
d) A 24-hour Holter monitor would be the best
method of cardiac monitoring for Barbara
8. Barbara is found to have paroxysmal
atrial fibrillation. An echocardiogram shows
a normal left ventricular ejection fraction
and no significant valvular disease. What is
her CHADS2 score?
a) 0
b) 1
c) 2
d) 3
9. Barbara does not have any serious
contraindications to anticoagulation. Based
on her CHADS2 score, what would be the
recommendation regarding anticoagulation
therapy?
a) Anticoagulation therapy would not be
recommended
b) Aspirin at a dose of 81-325mg/day
c) Warfarin with a target INR of 1.5-2.0
d) Warfarin with a target INR of 2.0-3.0
10. Which THREE statements regarding some
common findings on Holter monitoring are
correct?
a) Rare atrial ectopics (<0.1% of beats) are a
common normal finding
b) All patients with atrial ectopy that is more
frequent (>0.1% of beats) require treatment
c) Brief (<1 minute) supraventricular tachycardia
episodes are a common normal finding and if
infrequent do not require specific treatment
d) Frequent episodes of brief (<1 minute)
supraventricular tachycardia can indicate a
propensity to longer episodes of atrial
arrhythmias at other times
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HOW TO TREAT Editor: Dr Wendy Morgan
Co-ordinator: Julian McAllan
Quiz: Dr Wendy Morgan
NEXT WEEK Chronic pelvic pain can be a symptom of many different conditions of the GI, urological and genital tracts. Nearly three times as many women as men experience chronic pelvic pain. Understanding the dynamic relationship of the organs in the pelvic area in treating chronic pelvic pain in women is the subject of next week’s How to Treat. The author is Dr Jason Abbott, senior lecturer in obstetrics and gyaecology, University of New South Wales, Sydney, and the school of women’s and children’s health, Royal Hospital for Women, Randwick, NSW.
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| Australian Doctor | 13 March 2009
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