13.07.2015 Views

Management of patients with palpitations: a position paper from the ...

Management of patients with palpitations: a position paper from the ...

Management of patients with palpitations: a position paper from the ...

SHOW MORE
SHOW LESS

You also want an ePaper? Increase the reach of your titles

YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.

922A. Raviele et al.atrial tachycardia <strong>with</strong> variable atrioventricular conduction, torsadesde pointes). 16,17 By contrast, bradyarrhythmias are more rarely perceivedas <strong>palpitations</strong>: <strong>the</strong>se arrhythmias comprise sinus pauses andsevere sinus bradycardia seen in sick sinus syndrome, sudden onset<strong>of</strong> high-degree atrioventricular block, or <strong>of</strong> intermittent left-bundlebranch block. Anomalies in <strong>the</strong> functioning and/or programming <strong>of</strong>pacemakers and implantable cardioverter defibrillators (ICDs)(pacemaker-mediated tachycardia, pectoral or diaphragmaticstimulation, pacemaker syndrome, etc.) may also be responsiblefor <strong>palpitations</strong>.Palpitations due to structural heartdiseaseSome structural heart diseases can give rise to <strong>palpitations</strong> in <strong>the</strong>absence <strong>of</strong> true rhythm disorders. These include, among o<strong>the</strong>rs,mitral valve prolapse, severe mitral and aortic regurgitation, congenitalheart disease <strong>with</strong> significant shunt, hypertrophic cardiomyopathy,and mechanical pros<strong>the</strong>tic valves. 18,19Palpitations due to psychosomaticdisordersPsychosomatic disorders that are most frequently associated <strong>with</strong><strong>palpitations</strong> include anxiety, panic attacks, depression, and somatization,which can ei<strong>the</strong>r induce sinus tachycardia or modify <strong>the</strong>patient’s subjective perception <strong>of</strong> a heartbeat that is o<strong>the</strong>rwisenormal or presents minimal irregularities. 20 – 23 If no o<strong>the</strong>r potentialcauses can be identified, <strong>the</strong> <strong>palpitations</strong> are considered tobe <strong>of</strong> psychosomatic origin when <strong>the</strong> patient fulfils <strong>the</strong> criteriaspecified in <strong>the</strong> literature for one or more <strong>of</strong> <strong>the</strong> abovementionedpsychosomatic disorders. It must be borne in mind, however, thatcardiac arrhythmias and psychosomatic disorders are not mutuallyexclusive. 5,24 In addition, <strong>the</strong> adrenergic hyperactivation connected<strong>with</strong> intense emotions and anxiety can, in itself, predispose <strong>the</strong>25 – 27patient to supraventricular and/or ventricular arrhythmias.Indeed, in <strong>the</strong> last few years, some studies investigating <strong>the</strong> correlationbetween anxiety syndrome and <strong>the</strong> appearance <strong>of</strong> arrhythmiashave suggested that anxiety exerts a facilitating effect onarrhythmogenesis 28 as well as on <strong>the</strong> patient’s perception <strong>of</strong> <strong>the</strong>arrhythmia. 29 Finally, in a study conducted on <strong>patients</strong> <strong>with</strong> documentedsupraventricular tachycardia, it was found that two-thirdshad previously been wrongly diagnosed as suffering <strong>from</strong> panicattack disorder, and that <strong>the</strong> diagnosed ‘psychosomatic disease’could be cured by ca<strong>the</strong>ter ablation in most <strong>of</strong> <strong>the</strong>se <strong>patients</strong>. 30Thus, even in <strong>patients</strong> affected by psychosomatic disorders, it isimportant to carry out a thorough investigation before excludingan organic cause, particularly arrhythmic, <strong>of</strong> <strong>palpitations</strong>.Palpitations due to systemic causesA sensation <strong>of</strong> palpitation may stem <strong>from</strong> sinus tachycardia and/orincreased cardiac contractility, both <strong>of</strong> which may have variouscauses: fever, anaemia, orthostatic hypotension, hyperthyroidism/thyreotoxicosis, postmenopausal syndrome, pregnancy, hypogly-Palpitationscaemia, hypovolaemia, pheochromocytoma, arteriovenous fistula,31 – 39postural orthostatic tachycardia syndrome, among o<strong>the</strong>rs.due to <strong>the</strong> effects <strong>of</strong> medicaland recreational drugsIn such cases, <strong>palpitations</strong> may be linked to sinus tachycardia; drugsinvolved include sympathomimetics, anticholinergics, vasodilators,and hydralazine. 40 The sudden suspension <strong>of</strong> b-blocker <strong>the</strong>rapymay also give rise to sinus tachycardia and <strong>palpitations</strong> through<strong>the</strong> induction <strong>of</strong> a hyperadrenergic state as a result <strong>of</strong> <strong>the</strong>‘rebound’ effect. Moreover, <strong>palpitations</strong> may even occur after <strong>the</strong>initiation or dose-increase <strong>of</strong> b-blockers, due to <strong>the</strong> perception<strong>of</strong> pulsations caused by increased stroke volume <strong>with</strong> lowerheart rate, or ventricular ectopic beats if sinus overdrive is <strong>with</strong>drawn.Likewise, stimulants such as caffeine and nicotine, or <strong>the</strong>use <strong>of</strong> illicit drugs (cocaine, heroin, amphetamines, LSD, syn<strong>the</strong>ticdrugs, cannabis, etc.) can lead to sympa<strong>the</strong>tic hyperactivation andsinus tachycardia, even in young subjects <strong>with</strong>out heartdisease. 41,42 Drugs that prolong QT and predispose <strong>patients</strong> to torsadesde pointes and o<strong>the</strong>r tachyarrhythmias, such as antidepressivedrugs, besides provoking dizziness or syncope, may also inducearrhythmia-related <strong>palpitations</strong>. 43,44 In <strong>the</strong> absence <strong>of</strong> o<strong>the</strong>r potentialcauses, <strong>palpitations</strong> are regarded as secondary to <strong>the</strong> use <strong>of</strong>drugs when <strong>the</strong>y are associated temporally to administration <strong>of</strong><strong>the</strong> drug and when <strong>the</strong>y cease on suspension <strong>of</strong> <strong>the</strong> drug.EpidemiologyThe prevalence <strong>of</strong> <strong>palpitations</strong> is dependent on definitions anddiagnostic methods used and varies substantially in different populations.Never<strong>the</strong>less, <strong>the</strong>re is evidence that <strong>palpitations</strong> are a veryfrequent symptom in <strong>the</strong> general population 2,9 and, in particular, in<strong>patients</strong> suffering <strong>from</strong> hypertension or heart disease. In studies inprimary care settings, <strong>palpitations</strong> account for 16% <strong>of</strong> <strong>the</strong> symptomsthat prompt <strong>patients</strong> to visit <strong>the</strong>ir general practitioner, and aresecond only to chest pain as <strong>the</strong> presenting complaint for specialistcardiologic evaluation. 1,3,4 This high prevalence <strong>of</strong> <strong>palpitations</strong>emphasizes <strong>the</strong> need for a structured, ideally evidence-based, stepwisework-up that may allow to distinguish, since <strong>the</strong> beginning,between <strong>patients</strong> <strong>with</strong> benign prognosis and those <strong>with</strong> poorerprognosis.With regard to <strong>the</strong> prevalence <strong>of</strong> <strong>the</strong> various causes <strong>of</strong> <strong>palpitations</strong>,clinical evidence indicates that a considerable number <strong>of</strong> subjects<strong>with</strong> <strong>palpitations</strong> have normal sinus rhythm or minor rhythmanomalies, such as short bursts <strong>of</strong> supraventricular extrasystoles orsporadic ventricular extrasystoles. Never<strong>the</strong>less, clinically significantarrhythmias such as atrial fibrillation/flutter or paroxysmalsupraventricular tachycardias are also a frequent finding. 45,46 In aprospective study by Weber and Kapoor 47 in 190 <strong>patients</strong> presenting<strong>with</strong> a complaint <strong>of</strong> <strong>palpitations</strong> at an university medical centre,<strong>palpitations</strong> were due to arrhythmias in 41% <strong>of</strong> <strong>the</strong>se <strong>patients</strong> (16%<strong>of</strong> whom had atrial fibrillation/flutter, 10% had supraventriculartachycardia, and 2% had ventricular tachycardia), to structuralheart disease in 3%, to psychosomatic disorders in 31% (mainlypanic and anxiety disorders), to systemic causes in 4%, and to <strong>the</strong>use <strong>of</strong> a medication, illicit substances, or stimulants in 6%. Accordingto <strong>the</strong> case records, <strong>the</strong> prevalence <strong>of</strong> anxiety syndrome and panic20 – 22attacks in <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> ranges <strong>from</strong> 15% to 31%.In <strong>the</strong> study by Weber and Kapoor, 47 male sex, description <strong>of</strong> anDownloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011


Managing <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> 923irregular heartbeat, history <strong>of</strong> heart disease, and event duration.5 min were found to be independent predictors <strong>of</strong> a cardiacaetiology. No specific cause <strong>of</strong> <strong>palpitations</strong> could be identified in16% <strong>of</strong> <strong>the</strong> <strong>patients</strong> despite a thorough evaluation including <strong>the</strong>use <strong>of</strong> loop recorders. Indeed, it is not always possible to establisha definite cause <strong>of</strong> <strong>palpitations</strong>; <strong>of</strong>ten, only a likely cause can begiven, and, in some cases, several possible causes have to betaken into consideration. 8,42 In <strong>the</strong> literature, <strong>the</strong>re are insufficientdata about <strong>the</strong> age and gender distribution <strong>of</strong> <strong>palpitations</strong>. Ingeneral, however, older <strong>patients</strong> and men are more likely tohave an arrhythmic cause <strong>of</strong> <strong>palpitations</strong> and younger <strong>patients</strong>47 – 51and women a psychosomatic cause.PrognosisThe prognostic implications <strong>of</strong> <strong>palpitations</strong> are dependent on <strong>the</strong>underlying aetiology as well as clinical characteristics <strong>of</strong> <strong>the</strong>patient. Available data, especially in terms <strong>of</strong> long-term prognosis,are scarce. Although <strong>palpitations</strong> are generally associated <strong>with</strong> lowrates <strong>of</strong> mortality, 4,47 <strong>the</strong>y should bring to attention a potentialserious condition in <strong>patients</strong> <strong>with</strong> structural or arrhythmogenicheart disease or a family history <strong>of</strong> sudden death. This is alsoimportant to keep in mind if <strong>the</strong> <strong>palpitations</strong> are associated <strong>with</strong>symptoms <strong>of</strong> haemodynamic impairment (dyspnoea, syncope, presyncope,dizziness, fatigue, chest pain, neurovegetative symptoms).5 On <strong>the</strong> one hand, depending on <strong>the</strong> clinical characteristics<strong>of</strong> <strong>the</strong> patient, <strong>palpitations</strong> due to arrhythmias, in particular <strong>of</strong> ventricularorigin, but also atrial fibrillation, are associated <strong>with</strong> differentprognostic implications. 15 – 17 On <strong>the</strong> o<strong>the</strong>r hand, in <strong>patients</strong><strong>with</strong>out relevant heart disease, <strong>palpitations</strong> (especially ifanxiety-related or extrasystolic) generally have a benign prognosis.A retrospective American study that analysed case recordsobtained <strong>from</strong> general practitioners found no difference in 5-yearmortality and morbidity between <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> and agroup <strong>of</strong> asymptomatic control subjects. 4 Also in <strong>the</strong> abovementionedstudy by Weber and Kapoor 47 on a general population <strong>of</strong><strong>patients</strong> presenting <strong>with</strong> <strong>palpitations</strong> at an university medicalcentre, despite <strong>the</strong> high rate <strong>of</strong> cardiac cause, 1-year mortalitywas only 1.6%. However, even in <strong>patients</strong> <strong>with</strong>out severe heartdisease, <strong>palpitations</strong> may be due to significant arrhythmias, suchas atrial fibrillation, atrial flutter, or ventricular ectopic beats, all<strong>of</strong> which require adequate investigation and treatment. Moreover,clinical characteristics <strong>of</strong> <strong>the</strong> patient, such as age, presence <strong>of</strong> heartdisease, and ECG abnormalities, do not always allow <strong>the</strong> physicianto identify a priori those cases in which <strong>palpitations</strong> are caused byclinically significant rhythm disorders. 8,47,48,52 – 54 An exception tothis is given by changes in <strong>the</strong> resting ECG that are indicative <strong>of</strong>primary electrical heart diseases.In athletes, <strong>palpitations</strong> are not uncommon. Sudden death, inparticular in younger athletes, is rare and mostly associated <strong>with</strong>underlying structural heart disease or primary arrhythmic disorders,and <strong>palpitations</strong> may be <strong>the</strong> initial clinical symptom or anincidental finding possibly leading to <strong>the</strong> recognition <strong>of</strong> a previouslyundiagnosed relevant heart disease. 55,56 Moreover, because <strong>of</strong>potentially life-threatening haemodynamic consequences <strong>of</strong> evensupraventricular arrhythmias, such as rapidly conducted preexcitedatrial fibrillation during exertion, careful cardiac evaluation,in particular <strong>of</strong> symptomatic competitive as well as recreationalathletes, is warranted. 57Although <strong>palpitations</strong> display a low mortality rate, <strong>the</strong> recurrence<strong>of</strong> symptoms is, however, very frequent. In <strong>the</strong> study by Weber andKapoor, 47 77% <strong>of</strong> <strong>patients</strong> experienced at least one recurrence <strong>of</strong><strong>palpitations</strong>, and <strong>the</strong> effect on <strong>the</strong>ir quality <strong>of</strong> life was unfavourable:one-third <strong>of</strong> <strong>patients</strong> reported an impairment <strong>of</strong> <strong>the</strong>ir ability toattend to household chores, 19% claimed that <strong>the</strong>ir workingcapacity had diminished, and 12% said that <strong>the</strong>y had taken days<strong>of</strong>f work. These findings are confirmed by a prospective study conductedby Barsky et al. 58 on 145 <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong>, whowere followed up for 6 months and compared <strong>with</strong> an asymptomaticcontrol group. These authors observed that <strong>patients</strong> <strong>with</strong><strong>palpitations</strong>, in spite <strong>of</strong> having a favourable prognosis in terms <strong>of</strong>mortality, remained symptomatic and functionally impaired overtime and exhibited a high incidence <strong>of</strong> panic attacks and psychologicalsymptoms. 58 Frequent and recurrent <strong>palpitations</strong>, <strong>the</strong>refore,can impair <strong>the</strong> patient’s quality <strong>of</strong> life, giving rise to anxiety and frequentvisits to <strong>the</strong> emergency department. 3 In many respects, <strong>palpitations</strong>seem to behave like a chronic disorder that has afavourable prognosis, but <strong>with</strong> periodic attacks followed by transitoryremission. 3,4Clinical presentationDuration and frequency <strong>of</strong> <strong>palpitations</strong>With regard to duration, <strong>palpitations</strong> may be ei<strong>the</strong>r short-lasting orpersistent. In short-lasting forms, <strong>the</strong> symptom terminates spontaneously<strong>with</strong>in a brief period <strong>of</strong> time. In persistent forms, <strong>the</strong> <strong>palpitations</strong>are ongoing and terminate only after adequate medicaltreatment. With regard to frequency, <strong>palpitations</strong> may occurdaily, weekly, monthly, oryearly.Types <strong>of</strong> <strong>palpitations</strong>Patients report a wide range <strong>of</strong> sensations to describe <strong>the</strong>ir symptoms.The most common descriptions, and those most useful inclinical practice in differential diagnoses among <strong>the</strong> variouscauses <strong>of</strong> <strong>palpitations</strong>, enable <strong>palpitations</strong> to be classified accordingto <strong>the</strong> rate, rhythm, and intensity <strong>of</strong> heartbeat 5 – 9,59,60 : extrasystolic<strong>palpitations</strong>, tachycardiac <strong>palpitations</strong>, anxiety-related <strong>palpitations</strong>,and pulsation <strong>palpitations</strong> (Table 2). It should, however, be stressedthat <strong>patients</strong> are not always able to describe <strong>the</strong> characteristics <strong>of</strong><strong>the</strong>ir symptoms precisely. It may <strong>the</strong>refore be difficult to identify<strong>the</strong> type <strong>of</strong> palpitation accurately, especially in <strong>the</strong> case <strong>of</strong> normalrate<strong>palpitations</strong>. 5,9,61Extrasystolic <strong>palpitations</strong>, due to ectopic beats, generally producefeelings <strong>of</strong> ‘missing/skipping a beat’ and/or a ‘sinking <strong>of</strong> <strong>the</strong> heart’interspersed <strong>with</strong> periods during which <strong>the</strong> heart beats normally;<strong>patients</strong> report that <strong>the</strong> heart seems to stop and <strong>the</strong>n startagain, causing an unpleasant, almost painful, sensation <strong>of</strong> a blowto <strong>the</strong> chest. Linked to <strong>the</strong> presence <strong>of</strong> atrial or ventricular extrasystolicbeats, this type <strong>of</strong> palpitation is frequently encounteredeven in young subjects, <strong>of</strong>ten in <strong>the</strong> absence <strong>of</strong> heart disease,and generally has a benign prognosis. In extrasystolic <strong>palpitations</strong>,particularly if <strong>the</strong>y are <strong>of</strong> ventricular origin, <strong>the</strong> sensation is dueto <strong>the</strong> increased strength <strong>of</strong> contraction <strong>of</strong> <strong>the</strong> post-extrasystolicDownloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011


924A. Raviele et al.Table 2 Types <strong>of</strong> <strong>palpitations</strong> and <strong>the</strong>ir clinical presentationsType <strong>of</strong> SubjectiveHeartbeatOnset and Trigger Possible associated symptomspalpitation descriptiontermination situations...............................................................................................................................................................................Extrasystolic ‘Skipping/missing a Irregular, interspersed <strong>with</strong> Sudden Rest —beat’, ‘sinking <strong>of</strong> <strong>the</strong> periods <strong>of</strong> normalheart’heartbeatTachycardiac‘Beating wings’ in <strong>the</strong>chestRegular or irregular,markedly acceleratedAnxiety-related Anxiety, agitation Regular, slightlyacceleratedSuddenGradualPhysical effort,cooling downStress, AnxietyattacksPulsation Heart pounding Regular, normal frequency Gradual Physical effort As<strong>the</strong>niaSyncope, dyspnoea, fatigue, chestpainTingling in <strong>the</strong> hands and face, lumpin <strong>the</strong> throat, atypical chest pain,sighing dyspnoeaTable 3 Clinical characteristics <strong>of</strong> tachycardiac <strong>palpitations</strong>Type <strong>of</strong> arrhythmia Heartbeat Trigger situations Associated symptoms Vagal manoeuvres...............................................................................................................................................................................AVRT, AVNRT Sudden onset regular <strong>with</strong> periods <strong>of</strong> Physical effort, changes in Polyuria, frog signSudden interruptionelevated heart ratepostureAtrial fibrillation Irregular <strong>with</strong> variable heart rate Physical effort, cooling down,post meal, alcohol intakeAtrial tachycardia andatrial FlutterVentriculartachycardiasbeat, which accentuates <strong>the</strong> movement <strong>of</strong> <strong>the</strong> heart inside <strong>the</strong>chest, or to <strong>the</strong> post-extrasystolic pause, or to <strong>the</strong> altered activation<strong>of</strong> <strong>the</strong> heart. When <strong>the</strong> extrasystoles are particularly numerousand/or repetitive, it may prove difficult to make a differentialdiagnosis between extrasystolic and tachycardiac <strong>palpitations</strong>,especially those due to atrial fibrillation.In <strong>the</strong> case <strong>of</strong> tachycardiac <strong>palpitations</strong>, <strong>the</strong> sensation described by<strong>the</strong> patient is that <strong>of</strong> a rapid fluctuation like ‘beating wings’ in <strong>the</strong>chest. The heartbeat is generally perceived to be very rapid (sometimeshigher than <strong>the</strong> maximum heart rate estimated on <strong>the</strong> basis<strong>of</strong> <strong>the</strong> patient’s age); it may be regular, as in atrioventricular reentranttachycardia, atrial flutter, or ventricular tachycardia, or irregularor arrhythmic, as in atrial fibrillation or post-atrialfibrillation-ablation atypical atrial flutter (Table 3). These <strong>palpitations</strong>are generally linked to supraventricular or ventriculartachyarrhythmias, which begin and usually end suddenly (sometimes<strong>the</strong> termination is gradual due to <strong>the</strong> increase in sympa<strong>the</strong>tictone during tachycardia that tends to persist and declines slowlyafter its interruption), or to sinus tachycardia due to systemiccauses or to <strong>the</strong> use <strong>of</strong> drugs or illicit substances (in <strong>the</strong>se cases,<strong>palpitations</strong> begin and end gradually).Anxiety-related <strong>palpitations</strong> are perceived by <strong>the</strong> patient as a form<strong>of</strong> anxiety. The heartbeat is slightly elevated, but never higher than<strong>the</strong> maximum heart rate estimated on <strong>the</strong> basis <strong>of</strong> <strong>the</strong> patient’s age.These <strong>palpitations</strong>, whe<strong>the</strong>r paroxysmal or persistent, begin andPolyuriaRegular (irregular if A-V conduction isvariable) <strong>with</strong> elevated heart rateRegular <strong>with</strong> elevated heart rate Physical effort Signs/symptoms <strong>of</strong>haemodynamicimpairmentAVRT, atrio-ventricular reentrant tachycardia; AVNRT, atrio-ventricular node reentrant tachycardia; A-V, atrioventricular.Transitory reductionin heart rateTransitory reductionin heart rateNo effectend gradually, and <strong>patients</strong> describe numerous o<strong>the</strong>r associatedunspecific symptoms, such as tingling in <strong>the</strong> hands and face, alump in <strong>the</strong> throat, mental confusion, agitation, atypical chestpains, and sighing dyspnoea, that normally precede <strong>the</strong> <strong>palpitations</strong>.Anxiety-related <strong>palpitations</strong> are due to psychosomatic disordersand usually require exclusion <strong>of</strong> an arrhythmic cause <strong>of</strong> <strong>the</strong>symptoms.Pulsation <strong>palpitations</strong> are felt as strong, but regular and not particularlyrapid, heartbeats. They tend to be persistent and are generallylinked to structural heart diseases, such as aorticregurgitation, or to systemic causes involving a high strokevolume, such as fever and anaemia.Associated symptoms and circumstancesCertain symptoms and circumstances associated to <strong>palpitations</strong> are<strong>of</strong>ten connected <strong>with</strong> <strong>the</strong> various causes <strong>of</strong> <strong>the</strong> <strong>palpitations</strong> and maybe very helpful in making differential diagnoses. 5–9,59,60 Palpitationsarising after sudden changes in posture are frequently due to intoleranceto orthostatis or to episodes <strong>of</strong> atrioventricular nodal reentranttachycardia. The occurrence <strong>of</strong> syncope or o<strong>the</strong>r symptoms,such as severe fatigue, dyspnoea, or angina, in addition to <strong>palpitations</strong>,is much more frequent in <strong>patients</strong> <strong>with</strong> structural heartdisease. However, syncope may also occur at <strong>the</strong> onset <strong>of</strong> supraventriculartachycardia in <strong>patients</strong> <strong>with</strong> a normal heart, as <strong>the</strong> result <strong>of</strong><strong>the</strong> triggering <strong>of</strong> a vasovagal reaction. 62,63Downloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011


Managing <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> 925Polyuria, which is due to <strong>the</strong> hypersecretion <strong>of</strong> natriuretichormone, is typical <strong>of</strong> atrial tachyarrhythmias, particularly atrialfibrillation. By contrast, <strong>the</strong> sensation <strong>of</strong> a rapid, regular pulse in<strong>the</strong> neck (usually associated <strong>with</strong> <strong>the</strong> ‘frog sign’) raises suspicion<strong>of</strong> supraventricular tachycardia, particularly atrioventricular nodalreentrant tachycardia. 64 It is <strong>the</strong> result <strong>of</strong> atria contracting againstclosed tricuspid and mitral valves. 9,65 An atrioventricular mechanicaldissociation may also occur in <strong>the</strong> case <strong>of</strong> ventricular extrasystoles.In this case, however, only one or few pulses are felt in <strong>the</strong>neck, and <strong>the</strong> rhythm is more irregular. In supraventricular tachycardiasinvolving <strong>the</strong> atrioventricular node, <strong>patients</strong> <strong>of</strong>ten learnto interrupt <strong>the</strong> episode by <strong>the</strong>mselves by applying vagal stimulationthrough Valsalva’s manoeuvre or carotid sinus massage.Palpitations that arise in situations <strong>of</strong> anxiety or during panicattacks are generally due to episodes <strong>of</strong> more or less rapid sinustachycardia secondary to <strong>the</strong> mental disturbance. In some cases,however, <strong>the</strong> patient may have difficulty in discerning whe<strong>the</strong>r<strong>the</strong> <strong>palpitations</strong> precede or follow <strong>the</strong> onset <strong>of</strong> <strong>the</strong> anxiety orpanic attack, and may <strong>the</strong>refore be unable to suggest whe<strong>the</strong>r<strong>the</strong> <strong>palpitations</strong> are <strong>the</strong> cause or <strong>the</strong> effect <strong>of</strong> <strong>the</strong> psychologicaldistress.During physical exercise, due to an increase in <strong>the</strong> sympa<strong>the</strong>ticdrive, <strong>patients</strong> may experience, in addition to <strong>the</strong> normal sensation<strong>of</strong> a rapid heart rate elicited by intense effort, <strong>palpitations</strong> due tovarious types <strong>of</strong> arrhythmia, such as right ventricular outflowtract tachycardia, atrioventricular node reentrant tachycardia, andpolymorphic catecholaminergic ventricular tachycardia. Finally, episodes<strong>of</strong> paroxysmal atrial fibrillation may occur in <strong>the</strong> phaseimmediately following <strong>the</strong> cessation <strong>of</strong> physical effort, duringDefinitive§ orsuspected diagnosishistory, physical examination, ECG, psychosomaticcounselling*which a sudden reduction in sympa<strong>the</strong>tic tone is accompanied byan increase in vagal tone.Accuracy <strong>of</strong> clinical features for <strong>the</strong>diagnosis <strong>of</strong> arrhythmiasThe utility <strong>of</strong> <strong>the</strong> features on history for diagnosing an arrhythmiccause <strong>of</strong> <strong>palpitations</strong> has been examined in a recent systematicreview. 48 The likelihood ratio <strong>of</strong> each feature is, in general, lowand only a few features are really predictive. They include history<strong>of</strong> cardiac disease, <strong>palpitations</strong> affected by sleeping, or while <strong>the</strong>patient is at work. O<strong>the</strong>r features such as underlying history <strong>of</strong>panic disorder and duration <strong>of</strong> <strong>palpitations</strong> less than 5 minappear to be useful for ruling out a clinically significant arrhythmia.47 However, data in this regard come <strong>from</strong> studies <strong>with</strong>small sample sizes.Diagnostic strategyIn <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> <strong>the</strong> diagnostic strategy should aim at:(i) distinguishing <strong>the</strong> mechanism <strong>of</strong> <strong>the</strong> <strong>palpitations</strong>; (ii) obtainingan electrocardiographic recording during symptoms; and (iii) evaluating<strong>the</strong> underlying heart disease. All <strong>patients</strong> suffering <strong>from</strong> <strong>palpitations</strong>should <strong>the</strong>refore undergo an initial clinical evaluationcomprising history, physical examination, and a standard 12-leadECG (Figure 1). This usually should be performed in a primarycare setting.In specific situations, specialist evaluation and certain specificinstrumental and laboratory investigations should be considered. 59unexplained <strong>palpitations</strong>Downloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011confirmationheart disease orabnormal ECGno heart diseaseand normal ECG+ -Echo,AECG,MRI*,Stress Test*, EPS*frequent orsevererare or welltoleratedtreatment+-stoptreatmentILRFigure 1 Diagnostic flow-chart <strong>of</strong> <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong>. *Indicated only in selected cases; § refers to ECG–symptom correlation available.ECG, electrocardiogram (12-lead); Echo, echocardiography; AECG, ambulatory ECG; MRI, magnetic resonance imaging; EPS, electrophysiologicalstudy; ILR, implantable loop recorder.


926A. Raviele et al.Stress testing is indicated if <strong>the</strong> <strong>palpitations</strong> are associated <strong>with</strong>physical exertion (e.g. right ventricular outflow tract extrasystoles),in athletes and when coronary heart disease is suspected. The role<strong>of</strong> echocardiography is <strong>of</strong> paramount importance to evaluate <strong>the</strong>presence <strong>of</strong> structural heart disease. The need to conductfur<strong>the</strong>r non-invasive cardiologic investigations (particularlycardiac magnetic resonance imaging to evaluate <strong>patients</strong> <strong>with</strong>structural normal heart, <strong>palpitations</strong>, and frequent ventriculararrhythmias) or invasive investigations (coronary angiography,etc.) will depend on <strong>the</strong> nature <strong>of</strong> <strong>the</strong> heart disease suspectedor ascertained. Comparable to exercise-induced syncope,exercise-induced <strong>palpitations</strong> should raise suspicion for ischaemic,valvular, or o<strong>the</strong>r structural heart disease <strong>with</strong> <strong>the</strong> correspondingwork-up. Whenever a systemic or pharmacological cause <strong>of</strong> <strong>palpitations</strong>is suspected, specific laboratory tests should be performedon <strong>the</strong> basis <strong>of</strong> <strong>the</strong> clinical presentation <strong>of</strong> <strong>the</strong> symptom and <strong>the</strong>patient’s clinical characteristics (e.g. haemochrome, electrolytes,glycaemia, thyroid function, urinary catecholamines, detection <strong>of</strong>illicit substances in <strong>the</strong> blood or urine). If, on <strong>the</strong> contrary, a psychosomaticcause is suspected, <strong>the</strong> patient’s mental state must beassessed ei<strong>the</strong>r by means <strong>of</strong> specific questionnaires or through7,8,20 – 23referral for specialist examination.The initial clinical evaluation leads to a definitive or probablediagnosis <strong>of</strong> <strong>the</strong> cause <strong>of</strong> <strong>the</strong> <strong>palpitations</strong> in about half <strong>of</strong> <strong>patients</strong>,and excludes <strong>with</strong> reasonable certainty <strong>the</strong> presence <strong>of</strong> causes thathave an unfavourable prognosis. 47 Moreover, a thorough initialclinical evaluation will indicate which specific investigations, if any,are necessary.If <strong>the</strong> initial clinical evaluation proves completely unremarkable—which is more frequent in paroxysmal, short-lasting<strong>palpitations</strong>—<strong>the</strong> <strong>palpitations</strong> are deemed to be <strong>of</strong> unknownorigin. In subjects <strong>with</strong> <strong>palpitations</strong> <strong>of</strong> unknown origin who have alow probability <strong>of</strong> an arrhythmic cause (i.e. <strong>patients</strong> <strong>with</strong> gradualonset <strong>of</strong> <strong>palpitations</strong> and <strong>with</strong>out significant heart disease and those<strong>with</strong> anxiety-related or extrasystolic <strong>palpitations</strong>), fur<strong>the</strong>r investigationsare <strong>of</strong>ten not required. The patient should be reassured and afollow-up clinical examination may be scheduled. It should be underlined,however, that, in <strong>the</strong> absence <strong>of</strong> electrocardiographic recordingduring an episode <strong>of</strong> <strong>palpitations</strong>, only a presumed or probablediagnosis can be made. 30 By contrast, in instances <strong>of</strong> subjects <strong>with</strong><strong>palpitations</strong> <strong>of</strong> unknown origin presenting <strong>with</strong> clinical features suggestive<strong>of</strong> an arrhythmic cause 66 (Table 4), or when <strong>palpitations</strong> aresuspected to be related to atrial fibrillation in individuals <strong>with</strong> riskfactors for thromboembolism, 14,67 <strong>patients</strong> should be referred toTable 4 Clinical features suggestive <strong>of</strong> <strong>palpitations</strong> <strong>of</strong>arrhythmic originStructural heart diseasePrimary electrical heart diseaseAbnormal ECGFamily history <strong>of</strong> sudden deathAdvanced ageTachycardiac <strong>palpitations</strong>Palpitations associated <strong>with</strong> haemodynamic impairmentan arrhythmia centre, and second-level investigations should be considered;<strong>the</strong>se include ambulatory ECG monitoring and electrophysiologicalstudy (EPS) (Figure 1). Finally, second-levelinvestigations should also be carried out in <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong><strong>of</strong> unknown origin whose symptoms are frequent or associated <strong>with</strong>impaired haemodynamic function or impaired quality <strong>of</strong> life or states <strong>of</strong>anxiety. 9Initial clinical evaluationHistoryIt represents a major part <strong>of</strong> <strong>the</strong> initial examination as most<strong>patients</strong> at <strong>the</strong> time <strong>the</strong>y visit a physician have no <strong>palpitations</strong>and <strong>the</strong> diagnosis has to be performed retrospectively. 5 – 9,48 Thefirst step is to establish that symptoms described by <strong>the</strong> patientmatch to <strong>palpitations</strong> and are not confused <strong>with</strong> chest pain oro<strong>the</strong>r manifestations arising in <strong>the</strong> chest, but that do not correspondto <strong>the</strong> definition <strong>of</strong> <strong>palpitations</strong> described in this article.When this first step has been achieved several important questionshave to be asked, <strong>the</strong> most important <strong>of</strong> which are summarizedin Table 5. Answers to some <strong>of</strong> <strong>the</strong>se questions may requireTable 5 Main questions to ask a patient <strong>with</strong><strong>palpitations</strong>Circumstances prior to <strong>the</strong> beginning <strong>of</strong> <strong>palpitations</strong>Activity (rest, sleeping, during sport or normal exercise, change inposture, after exercise)Position (supine or standing)Predisposing factors (emotional stress, exercise, squatting orbending)Onset <strong>of</strong> <strong>palpitations</strong>Abrupt or slowly arisingPreceded by o<strong>the</strong>r symptoms (chest pain, dyspnoea, vertigo, fatigue,etc.)Episode <strong>of</strong> <strong>palpitations</strong>Type <strong>of</strong> <strong>palpitations</strong> (regular or not, rapid or not, permanent or not)Associated symptoms (chest pain, syncope or near syncope,sweating, pulmonary oedema, anxiety, nausea, vomiting, etc.)End <strong>of</strong> <strong>the</strong> episodeAbrupt or slowly decreasing, end or perpetuation <strong>of</strong> accompanyingsymptoms, duration, urinationSpontaneously or <strong>with</strong> vagal manoeuvres or drug administrationBackgroundAge at <strong>the</strong> first episode, number <strong>of</strong> previous episodes, frequencyduring <strong>the</strong> last year or monthPrevious cardiac diseasePrevious psychosomatic disordersPrevious systemic diseasesPrevious thyroid dysfunctionFamily history <strong>of</strong> cardiac disease, tachycardia or sudden cardiacdeathMedications at <strong>the</strong> time <strong>of</strong> <strong>palpitations</strong>Drug abuse (alcohol and/or o<strong>the</strong>rs)Electrolytes imbalanceDownloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011


Managing <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> 927inputs <strong>from</strong> o<strong>the</strong>r members <strong>of</strong> <strong>the</strong> family or <strong>from</strong> individuals whohave witnessed an episode <strong>of</strong> <strong>palpitations</strong>. Description <strong>of</strong> <strong>the</strong> type<strong>of</strong> <strong>palpitations</strong> (regular or not, rapid or not) could help to determineits underlying mechanism (Table 2). It may be useful to ask<strong>the</strong> patient to mimic <strong>the</strong> perceived cardiac rhythm, ei<strong>the</strong>r vocallyor by drumming <strong>with</strong> <strong>the</strong> fingers on a table.Circumstances during which <strong>palpitations</strong> have occurred are generallyhelpful to evaluate <strong>the</strong>ir cause. Some <strong>of</strong> <strong>the</strong>se circumstancesare presented in Table 3. When, after this history-taking, itbecomes likely that <strong>palpitations</strong> are not related to arrhythmiabut ra<strong>the</strong>r to psychosomatic disorders, before starting moreextensive cardiovascular procedures, it is judicious to take <strong>the</strong>help <strong>of</strong> a mental health expert. 1,22,23,47,58It is naturally useless to perform this extensive history-taking if<strong>the</strong> patient has <strong>the</strong> feeling <strong>of</strong> palpitation even during <strong>the</strong> consultation.The first examination in <strong>the</strong>se circumstances is to instantaneouslyrecord ECG.Physical examinationDuring <strong>palpitations</strong>The execution <strong>of</strong> <strong>the</strong> physical examination while <strong>the</strong> patient is stillsymptomatic is not <strong>the</strong> most frequent situation. However, whenthis occurs it is crucial to have some notions about frequencyand regularity <strong>of</strong> heart rhythm by listening to <strong>the</strong> patient’s chestor by palpation <strong>of</strong> <strong>the</strong> arterial pulse. The differential diagnosis <strong>of</strong>various types <strong>of</strong> tachycardia may be guided by vagal manoeuvres 68such as carotid sinus massage: sudden interruption <strong>of</strong> <strong>the</strong> tachycardiais highly suggestive <strong>of</strong> a tachycardia involving <strong>the</strong> atrioventricularjunction whereas a temporary reduction <strong>of</strong> <strong>the</strong> frequency issuggestive <strong>of</strong> atrial fibrillation, flutter, or atrial tachycardia (Table 3).When this essential stage has been performed, examinationshould aim to evaluate <strong>the</strong> tolerance <strong>of</strong> a possible heart rhythmdisturbance (blood pressure, signs <strong>of</strong> cardiac failure, and so on),to assess <strong>the</strong> cardiovascular status (i.e. <strong>the</strong> presence <strong>of</strong> structuralheart disease), and, in case <strong>of</strong> a sinus rhythm or sinus tachycardia,to evaluate <strong>the</strong> presence <strong>of</strong> systemic diseases potentially responsiblefor <strong>palpitations</strong>.In <strong>the</strong> absence <strong>of</strong> <strong>palpitations</strong>When <strong>the</strong> patient is examined in <strong>the</strong> absence <strong>of</strong> <strong>the</strong> culpritsymptom, <strong>the</strong> aim is to find signs <strong>of</strong> structural heart disease thatcould explain <strong>the</strong> occurrence <strong>of</strong> <strong>palpitations</strong> (cardiac murmur,hypertension, vascular diseases, signs <strong>of</strong> heart failure, and so on).It is also important to search for signs <strong>of</strong> systemic diseases.Standard electrocardiogramDuring <strong>palpitations</strong>If <strong>the</strong> patient is examined during <strong>palpitations</strong>, 12-lead ECG represents<strong>the</strong> diagnostic gold standard. Thus, <strong>patients</strong> should beadvised to come as quickly as possible to an emergency departmentor a physician when an ECG has never been recordedduring symptoms. It allows <strong>the</strong> physician to analyse P and QRSmorphologies and <strong>the</strong> relationship between <strong>the</strong>se two waves,and <strong>the</strong> frequency and regularity <strong>of</strong> <strong>the</strong> heart rhythm, and finallybrings an accurate diagnosis on <strong>the</strong> concordance between <strong>palpitations</strong>and <strong>the</strong> presence or absence <strong>of</strong> arrhythmia. This distinctionbetween arrhythmic or non-arrhythmic palpitation is <strong>of</strong> paramountimportance for <strong>the</strong> future evaluation. 1,5 – 9,47 Fur<strong>the</strong>rmore, preciseanalysis <strong>of</strong> ECG during arrhythmia ei<strong>the</strong>r provides <strong>the</strong> mechanismor gives important data that lead to this diagnosis. It should bestressed, however, that P waves during rapid tachycardia are notalways visible, making <strong>the</strong> diagnosis difficult. Vagal manoeuvresand pharmacological tests, such as intravenous adenosine or ajmaline,performed during ECG recording are <strong>of</strong> major interest as <strong>the</strong>ycan unmask <strong>the</strong> atrial activity or interrupt suddenly <strong>the</strong> tachycardia,resulting in <strong>the</strong> diagnosis <strong>of</strong> <strong>the</strong> type <strong>of</strong> arrhythmia. 16,68 Alternatively,<strong>the</strong> possibility <strong>of</strong> taking a transoesophageal ECG duringtachycardia must be considered.Table 6 Electrocardiographic features recorded onstandard electrocardiogram in absence <strong>of</strong> <strong>palpitations</strong>and suggestive <strong>of</strong> <strong>palpitations</strong> <strong>of</strong> arrhythmic originVentricular pre-excitationAtrioventricular reciprocating tachycardiaAtrial fibrillationP-wave abnormalities, supraventricular premature beats, sinusbradycardiaAtrial fibrillationLeft ventricular hypertrophyVentricular tachycardiaAtrial fibrillationFrequent ventricular premature beatsVentricular tachycardiaQ wave, signs <strong>of</strong> arrhythmogenic right ventricular cardiomyopathy,Brugada syndrome or early repolarization syndromeVentricular tachycardia/fibrillationLong or short QTPolymorphic ventricular tachycardiaA-V block, tri- or bifascicular blockTorsades de pointesParoxysmal A-V blockTable 7 List <strong>of</strong> eletrocardiographic signs indicative <strong>of</strong>primary electrical heart diseasesECG signsSuspected disease................................................................................Corrected QT interval .0.46 sLong QT syndromeCorrected QT interval ,0.32 sShort QT syndromeRight bundle branch block <strong>with</strong> coved type/ Brugada syndromesaddle type ST segment elevation in <strong>the</strong>right precordial ECG leads (V1–V3) ei<strong>the</strong>rspontaneous or provoked by flecainide orajmaline1-wave and/or T-wave inversion <strong>with</strong> QRSduration .110 ms in <strong>the</strong> right precordialECG leads (V1–V3); ventricular ectopicbeats <strong>with</strong> left bundle branch block andright-axis deviation morphologyHigh voltage in <strong>the</strong> precordial leads, Q wave,ST changesArrythmogenic rightventricularcardiomyopathyHypertrophiccardiomyopathyDownloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011


928A. Raviele et al.In <strong>the</strong> absence <strong>of</strong> <strong>palpitations</strong>Even when <strong>the</strong> ECG is recorded in <strong>the</strong> absence <strong>of</strong> <strong>palpitations</strong> itprovides important data that can suggest <strong>the</strong> arrhythmic origin <strong>of</strong><strong>palpitations</strong> (Tables 6 and 7). In some instances, for example incase <strong>of</strong> evident pre-excitation when <strong>the</strong> patient reports rapidregular <strong>palpitations</strong>, <strong>the</strong> diagnosis is formal even if tachycardiahas never been recorded.Ambulatory electrocardiogrammonitoringAmbulatory ECG monitoring serves to document <strong>the</strong> cardiacrhythm during an episode <strong>of</strong> <strong>palpitations</strong> if this cannot be doneby means <strong>of</strong> standard ECG, as in <strong>the</strong> case <strong>of</strong> short-lasting symptoms.Indeed, ambulatory ECG monitoring utilizes electrocardiographicrecorders that are able to monitor <strong>the</strong> patient’s cardiacrhythm for long periods <strong>of</strong> time or that can be activated by <strong>the</strong>patient when symptoms occur. 69,70The devices currently used for ambulatory ECG monitoring canbe subdivided into two main categories: external and implantable.External devices comprise Holter recorders, hospital telemetry(reserved for hospitalized <strong>patients</strong> at high risk <strong>of</strong> malignant arrhythmias),event recorders, external loop recorders, and, very recently,mobile cardiac outpatient telemetry. Implantable devices comprisepacemakers and ICDs equipped <strong>with</strong> diagnostic features (usedexclusively in <strong>patients</strong> requiring such devices for <strong>the</strong>rapeutic purposes)and implantable loop recorders (ILRs).Event recorders or handheld patient-operated ECG systemshave been shown to improve <strong>the</strong> diagnosis <strong>of</strong> transient ECGchanges in <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong>. 71,72 These devices are reasonablypriced and easy to use. The external and implantable looprecorders, mobile cardiac outpatient telemetry, and pacemakersand ICDs can detect asymptomatic clinically significant arrhythmiasautomatically (i.e. <strong>with</strong> no activation by <strong>the</strong> patient) and provide asignificantly higher yield than standard patient-activated loop recordersin <strong>patients</strong> <strong>with</strong> infrequent <strong>palpitations</strong>. 49,73 – 79 Ano<strong>the</strong>r majorbenefit <strong>of</strong> <strong>the</strong> latest diagnostic systems is that many <strong>of</strong> <strong>the</strong>m notonly allow automatic detection <strong>of</strong> <strong>the</strong> arrhythmias but also allowimmediate wireless transmission <strong>of</strong> pertinent ECG data to a centralmonitoring station via a mobile telephone line or <strong>the</strong> Internet.The alarms incorporated into <strong>the</strong> network providing telemetricdata to specialists improve <strong>the</strong> efficiency <strong>of</strong> patient management,since <strong>the</strong> physicians can check <strong>the</strong>ir patient’s data remotely <strong>with</strong>no delay. This permits greater emphasis on documentation andcharacterization <strong>of</strong> spontaneous arrhythmic episodes, and it isexpected to allow prompt reaction to clinical events as well asto act as a potential for reduced resource use. 80 Moreover, <strong>the</strong>ability to detect <strong>the</strong> onset <strong>of</strong> <strong>the</strong> episode provides valuable informationon <strong>the</strong> mechanism <strong>of</strong> <strong>the</strong> arrhythmias. The main technicalcharacteristics <strong>of</strong> <strong>the</strong> different ambulatory ECG monitoringsystems are summarized in Table 8.Diagnostic valueAmbulatory ECG monitoring is regarded as diagnostic only when it ispossible to establish a correlation between <strong>palpitations</strong> and an electrocardiographicrecording. 69,70 In <strong>patients</strong> who do not developTable 8 Technical characteristics <strong>of</strong> <strong>the</strong> differentambulatory electrocardiogram monitoring devicesDeviceCharacteristics................................................................................Holter monitoring Utilizes external recorders connected to <strong>the</strong>patient by means <strong>of</strong> skin electrodes; <strong>the</strong>serecorders are able to perform continuousbeat-to-beat electrocardiographicmonitoring via several leads (up to 12 in<strong>the</strong> latest models).Event recorders Small, easy-to-use, portable devices that areapplied to <strong>the</strong> patient’s skin wheneversymptoms are experienced. They provideprospective one-leadelectrocardiographic recording for a fewseconds.External looprecordersMobile cardiacoutpatienttelemetryImplantable looprecordersPacemakers/ICDsIEGM, intracardiac electrogram.Connected continuously to <strong>the</strong> patient bymeans <strong>of</strong> skin electrodes and equipped<strong>with</strong> a memory loop, <strong>the</strong>se devicesprovide one to three-leadelectrocardiographic recording for a fewminutes before and after activation by <strong>the</strong>patient when symptoms arise. The latestdevices are also able to self-activateautomatically when arrhythmic eventsoccur.Made up <strong>of</strong> an external loop recorderconnected to <strong>the</strong> patient by means <strong>of</strong> skinelectrodes, and <strong>of</strong> a portable receiver thatis able to transmit an electrocardiographictrace to a remote operating centre or to adedicated website via <strong>the</strong> telephone. Inthis way, <strong>the</strong> patient’s rhythm can bemonitored in real time.Similar in size to a pacemaker, <strong>the</strong>se devicesare implanted beneath <strong>the</strong> skin through asmall incision <strong>of</strong> about 2 cm in <strong>the</strong> leftprecordial region. They are equipped <strong>with</strong>a memory loop and, once activated by <strong>the</strong>patient through an external activator at<strong>the</strong> moment when <strong>the</strong> symptoms arise,record one-lead electrocardiographictrace for several minutes before and after<strong>the</strong> event. They are also able to record anyarrhythmic event automatically (i.e. <strong>with</strong>no intervention by <strong>the</strong> patient). In general,monitoring lasts ei<strong>the</strong>r until a diagnosis isreached or until <strong>the</strong> battery runs down.On completion <strong>of</strong> monitoring, <strong>the</strong> deviceis removed <strong>from</strong> <strong>the</strong> patient.Provided by an internal memory, <strong>the</strong>y areable to detect and store an atrial andventricular IEGM separately (dualchamber devices), and to record anyarrhythmic events automatically. Somemodels may also be activated manually by<strong>the</strong> <strong>patients</strong> when <strong>palpitations</strong> occur.symptoms during monitoring, <strong>the</strong>refore, this examination is <strong>of</strong>tennon-contributory. In some <strong>patients</strong> <strong>with</strong>out <strong>palpitations</strong> on monitoring,<strong>the</strong> presence <strong>of</strong> clinically significant arrhythmias that areDownloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011


Managing <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> 929asymptomatic (i.e. not associated <strong>with</strong> <strong>palpitations</strong>) may suggest aprobable diagnosis and/or guide <strong>the</strong> decision to undertake fur<strong>the</strong>rinvestigations. 15,59 The specificity <strong>of</strong> ambulatory ECG monitoring, atleast in formulating a diagnosis <strong>of</strong> arrhythmic <strong>palpitations</strong> or nonarrhythmic<strong>palpitations</strong>, is optimal, whereas <strong>the</strong> sensitivity is extremelyvariable and depends on <strong>the</strong> following factors: <strong>the</strong> monitoringtechniques used, <strong>the</strong> duration <strong>of</strong> monitoring, patient compliance,and, most importantly, <strong>the</strong> frequency <strong>of</strong> <strong>the</strong> attacks.In <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> <strong>of</strong> unknown origin, Holter monitoringhas displayed a ra<strong>the</strong>r low sensitivity value (33–35%). 81 In ameta-analysis <strong>of</strong> seven studies conducted on <strong>patients</strong> <strong>with</strong>syncope and/or <strong>palpitations</strong> <strong>of</strong> unknown origin, Holter monitoringhas been seen to have a sensitivity value <strong>of</strong> only 22%. 82 By contrast,in <strong>patients</strong> in whom <strong>the</strong> symptoms are quite frequent (i.e. daily orweekly), external loop recorders and event recorders have shownboth a higher diagnostic value (66–83%) and a better cost/effectivenessratio than Holter devices. 71,83 Finally, in <strong>patients</strong> <strong>with</strong>symptoms <strong>of</strong> possible arrhythmic origin, mobile cardiac outpatienttelemetry has been seen to exhibit a higher diagnostic value than<strong>the</strong> o<strong>the</strong>r external devices. 71,84,85ILRs have been successfully used to study syncope, in which <strong>the</strong>yhave shown a better cost/effectiveness ratio than <strong>the</strong> conventionaltests, 86,87 and <strong>the</strong>y can be useful in <strong>the</strong> study <strong>of</strong> <strong>palpitations</strong> <strong>of</strong>unknown origin. 69,88,89 Indeed, <strong>the</strong> RUP study (recurrent unexplained<strong>palpitations</strong> study) recently demonstrated <strong>the</strong> superiority<strong>of</strong> ILR over <strong>the</strong> conventional diagnostic strategy <strong>of</strong> Holter andevent recorder monitoring and EPS in <strong>the</strong> evaluation <strong>of</strong> a relativelysmall cohort <strong>of</strong> <strong>patients</strong> <strong>with</strong> infrequent <strong>palpitations</strong> (i.e. monthlyfrequency) reporting both a higher diagnostic value (73% vs. 21%)and a better cost/effectiveness ratio. 52 In <strong>patients</strong> implanted <strong>with</strong>pacemakers or ICDs, useful information on <strong>the</strong> origin <strong>of</strong> <strong>palpitations</strong>can be obtained by interrogating <strong>the</strong> memory <strong>of</strong> <strong>the</strong> device. 90Although many <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> <strong>of</strong> unknown originwho undergo ambulatory ECG monitoring prove to have rhythmdisorders that are generally benign, such as atrial or ventricularpremature beats, or episodes <strong>of</strong> sinus rhythm and sinus tachycardia,a substantial percentage (6–35%) <strong>of</strong> <strong>the</strong> arrhythmias diagnosedprove to be clinically significant, such as supraventricular tachycardiasand atrial fibrillation. 5 Ventricular tachycardia is much lesscommon and is typical <strong>of</strong> <strong>patients</strong> <strong>with</strong> structural or arrhythmogenicheart diseases. Finally, a small percentage <strong>of</strong> <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong><strong>of</strong> unknown origin have major bradyarrhythmic disorders,such as severe sinus bradycardia and paroxysmal advanced atrioventricularblock. 52,71LimitationsAmbulatory ECG monitoring has some important limitations.Indeed, it is not always possible to formulate a precise diagnosis<strong>of</strong> <strong>the</strong> type <strong>of</strong> arrhythmia recorded, especially when single-leadECG devices are used. For example, it may be difficult to make acorrect differential diagnosis between a supraventricular tachycardia<strong>with</strong> aberrant conduction and a ventricular tachycardia. Moreover,ambulatory ECG monitoring is unable to distinguish <strong>with</strong>certainty between bradyarrhythmias due to a reflex mechanismand those caused by a disorder <strong>of</strong> <strong>the</strong> cardiac conductionsystem, a distinction that has prognostic and <strong>the</strong>rapeutic implications.Finally, ambulatory ECG monitoring requires <strong>the</strong> patientto experience a recurrence <strong>of</strong> symptoms. This delays <strong>the</strong> diagnosisand, should <strong>the</strong> <strong>palpitations</strong> be due to malignant arrhythmias,exposes <strong>the</strong> patient to <strong>the</strong> potential risk <strong>of</strong> adverse events. Themain advantages and limitations <strong>of</strong> <strong>the</strong> different ambulatory ECGmonitoring systems are summarized in Table 9.IndicationsAccording to <strong>the</strong> ACC/AHA guidelines for <strong>the</strong> use <strong>of</strong> ambulatoryECG monitoring, 69,70 recurrent <strong>palpitations</strong> <strong>of</strong> unknown originconstitute a class-I indication for long-term ECG monitoring. Therecommendations regarding <strong>the</strong> choice <strong>of</strong> <strong>the</strong> ambulatory ECGmonitoring device most suited to <strong>the</strong> individual patient arereported in Table 9. ILRs are used in selected <strong>patients</strong> <strong>with</strong>severe and infrequent <strong>palpitations</strong> (inter-symptom interval .4weeks) and when all o<strong>the</strong>r investigations, including external ambulatoryECG monitoring, prove to be negative. 66Electrophysiological studyElectrophysiological study, as an invasive procedure, is usually consideredat <strong>the</strong> end <strong>of</strong> <strong>the</strong> diagnostic work-up. However, EPS hassome important advantages over ambulatory ECG monitoring.First <strong>of</strong> all, it is able to correctly identify <strong>the</strong> type <strong>of</strong> arrhythmiaresponsible for <strong>the</strong> <strong>palpitations</strong>. Moreover, it enables ablative<strong>the</strong>rapy <strong>of</strong> <strong>the</strong> induced tachyarrhythmias to be performed during<strong>the</strong> same session in which <strong>the</strong> diagnosis is made. Finally, whileEPS enables a diagnosis to be made and specific <strong>the</strong>rapy to beinitiated immediately, ambulatory ECG monitoring requires <strong>the</strong>patient to experience a recurrence <strong>of</strong> symptoms. This delays <strong>the</strong>diagnosis and, should <strong>the</strong> <strong>palpitations</strong> be due to malignant arrhythmias,exposes <strong>the</strong> patient to <strong>the</strong> potential risk <strong>of</strong> adverse events.For this reason, in <strong>patients</strong> <strong>with</strong> significant heart disease and inthose <strong>with</strong> <strong>palpitations</strong> that precede syncope, in whom <strong>the</strong> risk<strong>of</strong> adverse events is higher, electrophysiological evaluation generallyprecedes <strong>the</strong> use <strong>of</strong> ambulatory ECG monitoring. In all o<strong>the</strong>rcases, it normally follows ambulatory ECG monitoring when <strong>the</strong>latter proves non-diagnostic. For <strong>the</strong> recommendations <strong>of</strong> EPS in<strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> <strong>of</strong> unknown origin we refer <strong>the</strong>readers to <strong>the</strong> ACC/AHA/ESC 2003 Guidelines on supraventriculararrhythmias 16 and <strong>the</strong> ACC/AHA/ESC 2006 Guidelines formanagement <strong>of</strong> <strong>patients</strong> <strong>with</strong> ventricular arrhythmias and <strong>the</strong> prevention<strong>of</strong> sudden cardiac death. 17Specific needs in <strong>patients</strong> at risk<strong>of</strong> strokeIt is well known that atrial fibrillation is associated <strong>with</strong> anincreased risk <strong>of</strong> thromboembolism, especially in <strong>patients</strong> <strong>with</strong>certain risk factors as those considered in <strong>the</strong> CHA 2 DS 2 VAScrisk score. 14 It is <strong>the</strong>refore important to exclude atrial fibrillation as<strong>the</strong> underlying cause <strong>of</strong> <strong>the</strong> symptoms in <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong><strong>of</strong> unknown origin and a high thromboembolic risk.However, it must be underlined that once atrial fibrillation hasbeen diagnosed as a cause <strong>of</strong> <strong>palpitations</strong>, <strong>the</strong>re is up to nowonly limited data on <strong>the</strong> importance <strong>of</strong> assessing atrial fibrillationDownloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011


930A. Raviele et al.Table 9 Advantages, limitations, and indications <strong>of</strong> <strong>the</strong> different ambulatory electrocardiogram monitoring devicesHolter monitoring Event recorders External loop Implantable loop Pacemakers/ICDsrecorders/MCOT recorders...............................................................................................................................................................................Advantages Low cost; possibility to Low cost; easy to userecord asymptomaticarrhythmiasLimitationsIndicationsMonitoring limited to24 h to 7 days; sizemay preventactivities that maytrigger <strong>the</strong>arrhythmias; <strong>patients</strong><strong>of</strong>ten fail to completeadequately <strong>the</strong>clinical diary uponwhich <strong>the</strong>correlation betweensymptoms and <strong>the</strong>arrhythmiasrecorded is basedFrom daily to weekly<strong>palpitations</strong>; <strong>patients</strong>who are unable touse o<strong>the</strong>rambulatory ECGmonitoring devicesMonitoring cannot becarried out for morethan 3–4 weeks; verybrief arrhythmias arenot recorded;arrhythmic triggersare not revealed;poor ECG recordsFrom weekly tomonthly, fairlylong-lasting<strong>palpitations</strong> notaccompanied byhaemodynamicimpairment;compliant <strong>patients</strong>Retrospective andprospective ECGrecords; possibility torecord asymptomaticarrhythmiasautomaticallyMonitoring cannot becarried out for morethan 3–4 weeks;continualmaintenance isrequired; devices areuncomfortable; quitepoor ECG recordsFrom weekly tomonthly,short-lasting<strong>palpitations</strong>associated tohaemodynamicimpairment; verycompliant <strong>patients</strong>Retrospective andprospective ECGrecords; quite goodECG records;monitoring capability upto 36 months; possibilityto record asymptomaticarrhythmiasautomaticallyInvasiveness; risk <strong>of</strong> localcomplications at <strong>the</strong>implantation site: highercost; limited memoryand specificityFrom monthly to yearly<strong>palpitations</strong> associated<strong>with</strong> haemodynamiccompromise; when all<strong>the</strong> o<strong>the</strong>r examinationsprove inconclusive;non-compliant <strong>patients</strong><strong>with</strong>out haemodynamiccompromise when aclinically significantarrhythmic cause islikely or must be ruledoutBetter discriminationbetween ventricular andsupraventriculararrhythmias, due to dualchamber IEGMrecordings; betterdefinition <strong>of</strong> arrhythmicburden; monitoringduration for many years(corresponding to <strong>the</strong>expected life <strong>of</strong> <strong>the</strong>device); possibility torecord asymptomaticarrhythmiasautomaticallyInvasiveness; risk <strong>of</strong> earlyand late local andsystemic complications;high costsOnly for <strong>patients</strong> <strong>with</strong>conventional indicationsto pacemakers and ICDsDownloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011IEGM, intracardiac electrogram; MCOT, mobile cardiac outpatient telemetry.burden for <strong>the</strong> evaluation <strong>of</strong> thromboembolic risk, and more informationis still needed. 67,91TherapyTherapy for <strong>palpitations</strong> is, <strong>of</strong> course, directed towards <strong>the</strong> aetiologicalcause (i.e. treatment <strong>of</strong> cardiac arrhythmias, structural heartdiseases, psychosomatic disorders, or systemic diseases) wheneverit can be determined. However, many <strong>of</strong> <strong>the</strong> suggestions that canbe made are based on clinical experience, <strong>with</strong>out scientific documentationto rely on.When a clear-cut aetiology is established and a low-risk curative<strong>the</strong>rapy is available (e.g. ablation for supraventricular arrhythmias),<strong>the</strong>re is no doubt that this is <strong>the</strong> treatment <strong>of</strong> choice. 92 Moreover,in many benign arrhythmias (e.g. premature beats), a number <strong>of</strong>general factors may influence and modulate <strong>the</strong> frequency andseverity <strong>of</strong> <strong>the</strong> symptoms. In this context, changes in lifestyle(e.g. restraining adrenergic substances such as caffeine or alcoholcontainingbeverages) or non-cardiologic <strong>the</strong>rapies (e.g. anxiolyticdrugs or psychiatric counselling) may be useful to control symptomsand should be considered. At times, reassurance <strong>of</strong> <strong>the</strong>patient on <strong>the</strong> benign nature <strong>of</strong> <strong>the</strong> disorder can markedlyreduce symptoms.


Managing <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> 931Table 10 General recommendations for <strong>the</strong> treatment<strong>of</strong> <strong>palpitations</strong>Therapy should be directed towards <strong>the</strong> aetiological cause.Patients should be reassured in case <strong>of</strong> a benign cause.Use <strong>of</strong> adrenergic substances such as caffeine or alcohol-containingbeverages should be restrained.Good control <strong>of</strong> cardiovascular risk factors, specifically <strong>of</strong>hypertension, should be ensured.If <strong>the</strong>re is a recent stressful life-event, psychiatric counselling may be <strong>of</strong>help.In <strong>patients</strong> <strong>with</strong> symptoms <strong>of</strong> anxiety and depression, a specific <strong>the</strong>rapyis warranted.If a specific arrhythmia is found, <strong>the</strong> appropriate <strong>the</strong>rapy may beantiarrhythmic drugs, ablation, or even an implantable defibrillator.In <strong>the</strong> case that arrhythmias are found to be related to systemicdiseases or to <strong>the</strong> use <strong>of</strong> pro-arrhythmic drugs, <strong>the</strong>rapy, <strong>of</strong> course,must aim to remove <strong>the</strong> underlying conditions.Table 11 Criteria for <strong>the</strong> hospitalization <strong>of</strong> <strong>patients</strong><strong>with</strong> <strong>palpitations</strong>Diagnostic purposesSevere structural heart disease, suspected or ascertainedPrimary electrical heart disease, suspected or ascertainedFamily history <strong>of</strong> sudden deathNeed to perform EPS, invasive investigations or in-hospitaltelemetric monitoringTherapeutic purposesBradyarrhythmias requiring implantation <strong>of</strong> pacemakerPacemaker/ICD malfunction not rectifiable by reprogrammingVentricular tachyarrhythmias requiring immediate interruption and/or ICD implantation or ca<strong>the</strong>ter ablationSupraventricular tachycardias requiring interruption immediately orin a short time, or ca<strong>the</strong>ter ablationPresence <strong>of</strong> heart failure or o<strong>the</strong>r symptoms <strong>of</strong> haemodynamiccompromiseSevere structural heart diseases requiring surgery or interventionalproceduresSevere systemic causesSevere psychotic decompensationClearly, <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> will benefit <strong>from</strong> <strong>the</strong> samepreventive measures recommended to <strong>the</strong> general populationand to <strong>patients</strong> <strong>with</strong> cardiovascular disease. 93 Especially in <strong>patients</strong><strong>with</strong> ventricular ectopy 94 and possibly also in <strong>patients</strong> <strong>with</strong> atrialectopic beats 95 , although scientific evidence is lacking, intensifiedreduction <strong>of</strong> cardiovascular risk factors may be warranted. Thismay comprise, among o<strong>the</strong>rs, smoking cessation, <strong>the</strong>rapy <strong>of</strong> dyslipidemia,management <strong>of</strong> hypertension, heart failure, and diabetesmellitus, to name but a few. Moderate exercise is a healthy habitthat helps in controlling cardiovascular risk factors. On <strong>the</strong> o<strong>the</strong>rhand, high-intensity endurance sport practice has been related toan increased risk <strong>of</strong> atrial fibrillation. 96It is beyond <strong>the</strong> scope <strong>of</strong> this <strong>paper</strong> to discuss in depth <strong>the</strong>specific <strong>the</strong>rapy in all arrhythmic conditions causing <strong>palpitations</strong>.In this regard, we refer <strong>the</strong> readers to current guidelines. 16,17 In<strong>the</strong> case that arrhythmias are found to be related to systemic diseasesor to <strong>the</strong> use <strong>of</strong> pro-arrhythmic drugs, <strong>the</strong>rapy, <strong>of</strong> course,must aim to remove <strong>the</strong> underlying conditions. The general recommendationsfor <strong>the</strong> treatment <strong>of</strong> <strong>palpitations</strong> are listed inTable 10.When to hospitalize <strong>the</strong> patientDiagnostic purposesThe vast majority <strong>of</strong> <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> can be assessed in anoutpatient setting. Indeed, most <strong>of</strong> <strong>the</strong> investigations required for<strong>the</strong> diagnostic evaluation <strong>of</strong> <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> can becarried out in an ambulatory or day-hospital setting. In <strong>the</strong> studyby Weber and Kapoor, 47 an EPS and a haemodynamic studywere performed in only 5% <strong>of</strong> <strong>patients</strong>.However, depending on <strong>the</strong> availability <strong>of</strong> outpatient ECG monitoringdevices, hospitalization may be considered for <strong>patients</strong> <strong>with</strong>very frequent symptoms, when short-term bed-side monitoring islikely to reveal <strong>the</strong> underlying diagnosis. Moreover, <strong>patients</strong> <strong>with</strong><strong>palpitations</strong> should also be hospitalized when <strong>the</strong> initial clinicalevaluation suggests an imminent risk for serious arrhythmias(Table 11). For example, <strong>patients</strong> <strong>with</strong> primary electrical heartdiseases should be carefully evaluated when presenting <strong>with</strong>97 – 116<strong>palpitations</strong>.Therapeutic purposesThe criteria for <strong>the</strong> hospitalization <strong>of</strong> <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> for<strong>the</strong>rapeutic purposes are reported in Table 11. Generally, <strong>patients</strong><strong>with</strong> cardiac arrhythmias and/or structural heart disease will needemergency hospitalization when <strong>the</strong>y complain <strong>of</strong> <strong>palpitations</strong>associated <strong>with</strong> haemodynamic compromise, chest pain, orsyncope, as well as if implantation or revision <strong>of</strong> implanted117 – 121devices is indicated.Conflicts <strong>of</strong> interest: A.R. is a consultant for san<strong>of</strong>i-aventis,Boehringer-Ingheleim, Biosense Webster, and St Jude Medical,and has received honoraria <strong>from</strong> san<strong>of</strong>i-aventis, Boehringer Ingheleim,and Medtronic. L.M. has received honoraria or consulting fees<strong>from</strong> Bard, Biosense Webster, Medtronic, Boston Scientific, St JudeMedical, San<strong>of</strong>i Aventis, Biotronik, and Sorin Group, and hasreceived research grants <strong>from</strong> Biosense Webster, Medtronic,Boston Scientific, and St Jude Medical. C.B.-L. has received researchgrants <strong>from</strong> Octopus, AtriCure, and Medtronic. M.J.P.R. is a consultantor advisory-board member for Biosense Webster, BoehringerIngelheim, St Jude Medical, and Stereotaxis. J.M.M. is aconsultant to Medtronic, has received honoraria <strong>from</strong> BostonScientific and St Jude Medical, and has had research support<strong>from</strong> all three companies.References1. Mayou R. Chest pain, <strong>palpitations</strong> and panic. J Psychosom Res 1998;44:53–70.2. Messineo FC. Ventricular ectopic activity: prevalence and risk. Am J Cardiol 1989;64:53J–6J.Downloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011


932A. Raviele et al.3. Kroenke K, Arrington ME, Mangelsdr<strong>of</strong>f AD. The prevalence <strong>of</strong> symptoms inmedical out<strong>patients</strong> and <strong>the</strong> adequacy <strong>of</strong> <strong>the</strong>rapy. Arch Intern Med 1990;150:1685–9.4. Knudson MP. The natural history <strong>of</strong> <strong>palpitations</strong> in a family practice. J Fam Pract1987;24:357–60.5. Zimetbaum P, Josephson ME. Evaluation <strong>of</strong> <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong>. New Engl JMed 1998;338:1369–73.6. Giada F, Raviele A. Diagnostic management <strong>of</strong> <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> <strong>of</strong>unknown origin. Ital Heart J 2004;5:581–6.7. Brugada P, Gursoy S, Brugada J, Andries E. Investigation <strong>of</strong> <strong>palpitations</strong>. Lancet1993;341:1254–8.8. Pickett CC, Zimetbaum PJ. Palpitations: a proper evaluation and approach toeffective medical <strong>the</strong>rapy. Curr Cardiol Rep 2005;7:362–7.9. Abbott AV. Diagnostic approach to <strong>palpitations</strong>. Am Fam Physician 2005;71:743–50.10. Malliani A, Lombardi F, Pagani M. Sensory innervation <strong>of</strong> <strong>the</strong> heart. In: Cervero F,Morrison JFB (eds). Progress in Brain Research. vol. 617. New York: Elsevier; 1986.p39–48.11. Sugishita K, Shiono E, Sugiyama T, Ashida T. Diabetes influences <strong>the</strong> cardiacsymptoms related to atrial fibrillation. Circ J 2003;67:835–8.12. Barsky AJ, Ahern DK, Brener J, Surman OS, Ring C, Dec W. Palpitations andcardiac awareness after heart transplantation. Psychosomatic Med 1998;60:557–62.13. Kirchh<strong>of</strong> P, Auricchio A, Bax J, Crijns H, Camm J, Diener HC et al. Outcomeparameters for trials in atrial fibrillation. Europace 2007;9:1006–23.14. Camm J, Kirchh<strong>of</strong> P, Lip GYH, Schotten U, Saveliera I, Ernst S et al. Guidelinesfor <strong>the</strong> management <strong>of</strong> atrial fibrillation. The task force for <strong>the</strong> management<strong>of</strong> atrial fibrillation <strong>of</strong> <strong>the</strong> European Society <strong>of</strong> Cardiology. Eur Heart J 2010;31:2369–429.15. Flaker JC, Belew KRN, Beckman K, Vidaillet H, Kron J, Safford R et al. Asymptomaticatrial fibrillation: demographic features and prognostic information <strong>from</strong><strong>the</strong> Atrial Fibrillation Follow-up Investigation <strong>of</strong> Rhythm <strong>Management</strong>(AFFIRM) study. Am Heart J 2005;149:657–63.16. Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H,Camm JA et al. ACC/AHA/ESC Guidelines for <strong>the</strong> management <strong>of</strong> <strong>patients</strong><strong>with</strong> supraventricular arrhythmias—executive summary: a report <strong>of</strong> <strong>the</strong> AmericanCollege <strong>of</strong> Cardiology/American Heart Association Task Force on PracticeGuidelines and <strong>the</strong> European Society <strong>of</strong> Cardiology Committee for PracticeGuidelines (Writing Committee to Develop Guidelines for <strong>the</strong> <strong>Management</strong><strong>of</strong> Patients With Supraventricular Arrhythmias). Circulation 2003;108:1871–909.17. Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M et al.ACC/AHA/ESC 2006 Guidelines for management <strong>of</strong> <strong>patients</strong> <strong>with</strong> ventriculararrhythmias and <strong>the</strong> prevention <strong>of</strong> sudden cardiac death: a report <strong>of</strong> <strong>the</strong> AmericanCollege <strong>of</strong> Cardiology/American Heart Association Task Force and <strong>the</strong>European Society <strong>of</strong> Cardiology Committee for Practice Guidelines (WritingCommittee to Develop Guidelines for <strong>Management</strong> <strong>of</strong> Patients With VentricularArrhythmias and <strong>the</strong> Prevention <strong>of</strong> Sudden Cardiac Death): developed in collaboration<strong>with</strong> <strong>the</strong> European Heart Rhythm Association and <strong>the</strong> Heart RhythmSociety. Circulation 2006;114:385–484.18. Braunwald E. Valvular heart disease. In Braunwald E (ed.). Heart Disease: A Textbook<strong>of</strong> Cardiovascular Medicine. 4th ed. Philadelphia: W.B. Sanders; 1992.p1007–65.19. Deveraux RB, Kramer-Fox R, Kligfield O. Mitral valve prolapse: causes, clinicalmanifestations, and management. Ann Int Med 1989;111:305–17.20. Chignon JM, Lepine JP, Ades J. Panic disorder in cardiac out<strong>patients</strong>. Am J Psychiatry1993;150:780–5.21. Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. Psychiatric disorders in medicalout<strong>patients</strong> complaining <strong>of</strong> <strong>palpitations</strong>. J Gen Intern Med 1994;9:306–13.22. Barsky AJ, Cleary PD, Sarnie MK. Panic disorder, <strong>palpitations</strong> and awareness <strong>of</strong>cardiac activity. J Nerv Ment Dis 1994;182:63–71.23. Jeejeebhoy FM, Dorian P, Newman DM. Panic disorder and <strong>the</strong> heart: a cardiologyperspective. J Psychosom Res 2000;48:393–403.24. Barsky AJ, Ahern DK, Delameter BA, Clancy SA, Bailey ED. Differential diagnosis<strong>of</strong> <strong>palpitations</strong>. Preliminary development <strong>of</strong> a screening instrument. Arch FamMed 1997;6:241–5.25. Lampert R, Joska T, Burg MM, Batsford WP, McPherson CA, Jain D. Emotionaland physical precipitants <strong>of</strong> ventricular arrhythmia. Circulation 2002;106:1800–5.26. Ziegelstein RC. Acute emotional stress and cardiac arrhythmias. JAMA 2007;298:324–9.27. Eaker ED, Sullivan LM, Kelly-Hayes M, D’Agostino RB, Benjamin EJ. Anger andhostility predict <strong>the</strong> development <strong>of</strong> atrial fibrillation in men in <strong>the</strong> Framingham<strong>of</strong>fspring study. Circulation 2004;109:1267–71.28. Tavazzi L, Zotti AM, Rondanelli R. The role <strong>of</strong> psychologic stress in <strong>the</strong> genesis<strong>of</strong> lethal arrhythmias in <strong>patients</strong> <strong>with</strong> coronary artery disease. Eur Heart J 1986;7(Suppl A):99–106.29. Domschke K, Kirchh<strong>of</strong> P, Zwanzger P, Gerlach AL, Breithardt G, Deckert J.Coincidence <strong>of</strong> paroxysmal supraventricular tachycardia and panic disorders:two case reports. Ann Gen Psych 2010;9:13 (Epub ahead <strong>of</strong> print).30. Lessmeier TJ, Gamperling D, Johnson-Liddon V, Fromm BS, Steinman RT,Meissner MD. Unrecognized paroxysmal supraventricular tachycardia. Potentialfor misdiagnosis as panic disorder. Arch Intern Med 1997;157:537–43.31. Cryer PE, Gerich JE. Glucose counterregulation, hypoglycemia, and intensiveinsulin <strong>the</strong>rapy in diabetes mellitus. N Engl J Med 1985;313:232–41.32. Klein I. Thyroid hormone and <strong>the</strong> cardiovascular system. Am J Med 1990;88:631–7.33. Bravo EL, Giford RW. Pheocromocitoma: diagnosis, localization and management.N Engl J Med 1984;311:1298–303.34. Rosenthal DS, Braunwald E. Hematological–oncological disorders and heartdisease. In: Braunwald E (ed.). Heart Disease: A Textbook <strong>of</strong> Cardiovascular Medicine.4th ed. Philadelphia: W.B. Sanders; 1992. p1742–4.35. Elkayam U. Pregnancy and cardiovascular disease. In Braunwald E (ed.). HeartDisease: A Textbook <strong>of</strong> Cardiovascular Medicine. 4th ed. Philadelphia: W.B.Sanders; 1992. p1790–3.36. Dinardello CA, Wolff SM. Fever. In: Mandell GL, Douglas RG, Bennett JE (eds).Principles and Practices <strong>of</strong> Infectious Diseases. 3rd ed. New York: Curchill Livingstone;1990. p464–7.37. Holman E. Abnormal arteriovenous communications. Great variability <strong>of</strong> effects<strong>with</strong> particular reference to delayed development <strong>of</strong> cardiac failure. Circulation1966;32:1001–8.38. Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB et al. Guidelines for<strong>the</strong> diagnosis and management <strong>of</strong> syncope. The Task Force for <strong>the</strong> Diagnosis and<strong>Management</strong> <strong>of</strong> Syncope <strong>of</strong> <strong>the</strong> European Society <strong>of</strong> Cardiology (ESC). Developedin collaboration <strong>with</strong> European Heart Rhythm Association (EHRA),Heart Failure Association (HFA), and Heart Rhythm Society (HRS). Eur HeartJ 2009;30:2631–71.39. Thomas JE, Schringer A, Fealey RD, Sheps SG. Orthostatic hypotension. MayoClin Proc 1981;56:117–25.40. Naranjo Ca, Busto U, Sellers EM. A method for estimating <strong>the</strong> probabilty <strong>of</strong>adverse drug reaction. Clin Pharmacol Ther 1981;30:239–45.41. Furlanello F, Vitali-Serdoz L, Cappato R, De Ambroggi L. Illicit drugs and cardiacarrhythmias in athletes. Eur J Cardiovasc Prev Rehabil 2007;14:487–94.42. Lange R, Hillis D. Cardiovascular complications <strong>of</strong> cocaine use. N Engl J Med2001;345:351–8.43. Yap YG, Camm AJ. Drug induced QT prolongation and torsades de pointes. Heart2003;89:1363–72.44. Roden DM. Drug-induced prolongation <strong>of</strong> <strong>the</strong> QT interval. N Engl J Med 2004;350:1013–22.45. Zimetbaum P, Kim KY, Ho KKL, Zebeda J, Josephson ME, Goldberger AL. Utility<strong>of</strong> patient-activated cardiac event recorders in general clinical practice. Am JCardiol 1997;79:371–2.46. Wu CC, Hsieh MH, Tai CT, Chiang CE, Yu WC, Lin YK et al. Utility <strong>of</strong> patientactivatedcardiac event recorders in <strong>the</strong> detection <strong>of</strong> cardiac arrhythmias. IntervCard Electrophysiol 2003;8:117–20.47. Weber BE, Kapoor WH. Evaluations and outcomes <strong>of</strong> <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong>.Am J Med 1996;100:138–48.48. Thavendiranathan P, Bagai A, Khoo C, Dorian P, Choudhry NK. Does this patient<strong>with</strong> <strong>palpitations</strong> have a cardiac arrhythmia? JAMA 2009;302:2135–43.49. Hoefman E, Boer KR, van Weert HCPM, Reitsma JN, Koster RW, Bindels PJE.Predictive value <strong>of</strong> history taking and physical examination in diagnosing arrhythmiasin general practice. Fam Pract 2007;24:636–41.50. Summerton N, Mann S, Rigby A, Petkar S, Dhawan J. New-onset <strong>palpitations</strong> ingeneral practice: assessing <strong>the</strong> discriminant value <strong>of</strong> items <strong>with</strong>in <strong>the</strong> clinicalhistory. Fam Pract 2001;18:383–92.51. Mayou R, Sprigings D, Birkhead J, Price J. Characteristics <strong>of</strong> <strong>patients</strong> presenting toa cardiac clinic <strong>with</strong> <strong>palpitations</strong>. Q J Med 2003;96:115–23.52. Giada F, Gulizia M, Francese M, Croci F, Santangelo L, Santomauro M et al.Recurrent unexplained <strong>palpitations</strong> (RUP) study: comparison <strong>of</strong> implantableloop recorder versus conventional diagnostic strategy. J Am Coll Cardiol 2007;49:1951–6.53. Fogel RI, Evans JJ, Prystowsky EN. Utility and cost <strong>of</strong> event recorders in <strong>the</strong> diagnosis<strong>of</strong> <strong>palpitations</strong>, presyncope and syncope. Am J Cardiol 1997;79:207–8.54. Krahn AD, Klein GJ, Raymond Y, Norris C. Final results <strong>from</strong> a pilot study <strong>with</strong>an implantable loop recorder to determine <strong>the</strong> etiology <strong>of</strong> syncope in <strong>patients</strong><strong>with</strong> negative noninvasive and invasive testing. Am J Cardiol 1998;82:117–9.55. Pelliccia A, Fagard R, Bjørnstad HH, Anastassakis A, Arbustini E, Assanelli D et al.Recommendations for competitive sports participation in athletes <strong>with</strong> cardiovasculardisease: a consensus document <strong>from</strong> <strong>the</strong> Study Group <strong>of</strong> Sports Cardiology<strong>of</strong> <strong>the</strong> Working Group <strong>of</strong> Cardiac Rehabilitation and Exercise Physiologyand <strong>the</strong> Working Group <strong>of</strong> Myocardial and Pericardial Diseases <strong>of</strong> <strong>the</strong> EuropeanSociety <strong>of</strong> Cardiology. Eur Heart J 2005;26:1422–45.Downloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011


Managing <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong> 93356. Delise P, Guiducci U, Zeppilli P, D’Andrea L, Proto C, Bettini R et al. Cardiologicalguidelines for competitive sports eligibility. Ital Heart J 2005;6:661–702.57. Pelliccia A, Zipes DP, Maron BJ. Be<strong>the</strong>sda Conference #36 and <strong>the</strong> EuropeanSociety <strong>of</strong> Cardiology consensus recommendations revisited: a comparison <strong>of</strong>U.S. and European criteria for eligibility and disqualification <strong>of</strong> competitive athletes<strong>with</strong> cardiovascular abnormalities. J Am Coll Cardiol 2008;52:1990–6.58. Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. The clinical course <strong>of</strong> <strong>palpitations</strong>in medical out<strong>patients</strong>. Arch Intern Med 1995;155:1782–8.59. Hlatky MA. Approach to <strong>the</strong> patient <strong>with</strong> <strong>palpitations</strong>. In Goldman L,Braunwald E (eds). Primary Cardiology. Philadelphia: W.B. Saunders; 1998.p122–8.60. Zipes DP, Miles WM, Klein LS. Assessment <strong>of</strong> <strong>patients</strong> <strong>with</strong> cardiac arrhythmia.In Zipes DP, Jalife J (eds). Cardiac Electrophysiology: From Cell to Bedside. Philadelphia:W.B. Saunders; 1995. p1009–12.61. Leitch J, Klein G, Yee R. Can <strong>patients</strong> discriminate between atrial fibrillation andregular supraventricular tachycardia? Am J Cardiol 1991;68:962–6.62. Leitch JW, Klein GJ, Yee R, Lea<strong>the</strong>r RA, Kim YH. Syncope associated <strong>with</strong> supraventriculartachycardia. An expression <strong>of</strong> tachycardia rate or vasomotorresponse? Circulation 1992;85:1064–71.63. Brignole M, Gianfranchi L, Menozzi C, Raviele A, Oddone D, Lolli G et al. Role <strong>of</strong>autonomic reflexes in syncope associated <strong>with</strong> paroxysmal atrial fibrillation. JAmColl Cardiol 1993;22:1123–9.64. González-Torrecilla E, Almendral J, Arenal A, Atienza F, Atea LF, del Castillo Set al. Combined evaluation <strong>of</strong> bedside clinical variables and <strong>the</strong> electrocardiogramfor <strong>the</strong> differential diagnosis <strong>of</strong> paroxysmal atrioventricular reciprocatingtachycardias in <strong>patients</strong> <strong>with</strong>out pre-excitation. J Am Coll Cardiol 2009;53:2359–61.65. Gursoy S, Steurer G, Brugada J, Andries E, Brugada P. Brief report: <strong>the</strong> hemodynamicmechanism <strong>of</strong> pounding in <strong>the</strong> neck in atrioventricular nodal reentranttachycardia. N Engl J Med 1992;327:772–4.66. Brignole M, Vardas P, H<strong>of</strong>fman E, Huikuri H, Moya A, Ricci R et al. Indications for<strong>the</strong> use <strong>of</strong> diagnostic implantable and external ECG loop recorders. Europace2009;11:671–87.67. Botto GL, Padeletti L, Santini M, Capucci A, Gulizia M, Zolezzi F et al. Presenceand duration <strong>of</strong> atrial fibrillation detected by continuous monitoring: crucialimplications for <strong>the</strong> risk <strong>of</strong> thromboembolic events. J Cardiovasc Electrophysiol2009;20:241–8.68. Brembilla-Perrot B. Pharmacological testing in <strong>the</strong> diagnosis <strong>of</strong> arrhythmias.Minerva Cardioangiol 2010;58:505–17.69. Crawford MH, Bernstein SJ, Deedwania PC, Di Marco JP, Ferrick KJ, Garson AJet al. ACC/AHA Guidelines for ambulatory electrocardiography—executivesummary and recommendations: a report <strong>of</strong> <strong>the</strong> American College <strong>of</strong> Cardiology/AmericanHeart Association Task Force on Practice Guidelines (Committeeto Revise <strong>the</strong> Guidelines for Ambulatory Electrocardiography). Circulation 1999;100:886–93.70. Kadish AH, Buxton AE, Kennedy HL, Knight BP, Mason JW, Schuger JD et al.ACC/AHA clinical competence statement on electrocardiography and ambulatoryelectrocardiography: a report <strong>of</strong> <strong>the</strong> ACC/AHA/ACP-ASIM Task Force onClinical Competence (ACC/AHA Committee to Develop a Clinical CompetenceStatement on Electrocardiography and Ambulatory Electrocardiography),endorsed by <strong>the</strong> International Society for Holter and Noninvasive Electrocardiology.J Am Coll Cardiol 2001;38:2091–100.71. Scherr D, Dalal D, Henrikson CA, Spragg DD, Berger RD, Calkins H et al. Prospectivecomparison <strong>of</strong> <strong>the</strong> diagnostic utility <strong>of</strong> a standard event monitor versusa ‘leadless’ portable ECG monitor in <strong>the</strong> evaluation <strong>of</strong> <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong>.J Interv Card Electrophysiol 2008;22:39–44.72. Kaleschke G, H<strong>of</strong>fmann B, Drewitz I, Steinbeck G, Naebauer M, Goette A et al.Prospective, multicentre validation <strong>of</strong> a simple, patient-operated electrocardiographicsystem for <strong>the</strong> detection <strong>of</strong> arrhythmias and electrocardiographicchanges. Europace 2009;11:1362–8.73. Olson JA, Fouts AM, Padalinam BJ, Prystowsky EN. Utility <strong>of</strong> mobile outpatienttelemetry for <strong>the</strong> diagnosis <strong>of</strong> <strong>palpitations</strong>, presyncope, syncope, and <strong>the</strong> assessment<strong>of</strong> <strong>the</strong>rapy efficacy. J Cardiovasc Electrophsiol 2007;18:473–7.74. Rothman SA, Laughlin JC, Seltzer J, Walia JS, Baman RI, Siouffi SY et al. The diagnosis<strong>of</strong> cardiac arrhythmias: a prospective multi-center randomized study comparingmobile cardiac outpatient telemetry versus standard loop eventmonitoring. J Cardiovasc Electrophysiol 2007;18:248–9.75. Reiffel JA, Schulh<strong>of</strong> E, Joseph B. Optimum duration <strong>of</strong> transtelephonic ECGmonitoring when used for transient symptomatic event detection.J Electrocardiol 1991;24:165–8.76. Kinlay S, Leitch JW, Neil A. Cardiac event recorders yield more diagnoses andare more cost-effective than 48-hour Holter monitoring in <strong>patients</strong> <strong>with</strong> <strong>palpitations</strong>.Ann Intern Med 1996;124:16–20.77. Scalvini S, Zanelli E, Martinelli G, Baratti D, Giordano A, Glisenti F. Cardiac eventrecording yields more diagnoses than 24-hour Holter monitoring in <strong>patients</strong><strong>with</strong> <strong>palpitations</strong>. J Telemed Telecare 2005;11(Suppl 1):14–16.78. Brown AP, Dawkins KD, Davies JG. Detection <strong>of</strong> arrhythmias: use <strong>of</strong> a patientactivatedambulatory electrocardiogram device <strong>with</strong> a solid-state memory loop.Br Heart J 1987;58:251–3.79. Antman EM, Ludmer PL, McGowan N, Bosak Fredman PL. Transtelephonic electrocardiographictransmission for management <strong>of</strong> cardiac arrhythmias. Am JCardiol 1988;58:1021–4.80. Raatikainen MJP, Uusimaa P, van Ginneken MME, Janssen JPG, Linnaluoto M.Remote monitoring <strong>of</strong> implantable cardioverter defibrillator <strong>patients</strong>: a safe,time-saving and cost-effective means for follow-up. Europace 2008;10:1145–51.81. Zimtbaum PJ, Josephson ME. The evolving role <strong>of</strong> ambulatory arrhythmia monitoringin general practice. Ann Intern Med 1999;150:848–56.82. Di Marco JP, Philbrick JT. Use <strong>of</strong> ambulatory electrocardiographic (Holter) monitoring.Ann Intern Med 1990;113:53–68.83. Zimetbaum PJ, Kim KY, Josephson ME, Goldberger AL, Cohen DJ. Diagnosticyield and optimal duration <strong>of</strong> continuous-loop event monitoring for <strong>the</strong> diagnosis<strong>of</strong> <strong>palpitations</strong>. Ann Intern Med 1998;28:890–5.84. Hoefman E, van Weert HCPM, Boer KR, Reitsma J, Koster RW, Bindels PJE.Optimal duration <strong>of</strong> event recording for diagnosis <strong>of</strong> arrhythmias in <strong>patients</strong><strong>with</strong> <strong>palpitations</strong> and light-headedness in <strong>the</strong> general practice. Fam Pract 2007;24:11–3.85. Joshi AK, Kowey PR, Prystowsky EN. First exeprience <strong>with</strong> a Mobile CardiacOutpatient Telemetry (MCOT) system for <strong>the</strong> diagnosis and management <strong>of</strong>cardiac arrhythmias. Am J Cardiol 2005;95:878–81.86. Krahn AD, Klein GJ, Yee R, Manda V. The high cost <strong>of</strong> syncope: cost implications<strong>of</strong> a new insertable loop recorder in <strong>the</strong> investigation <strong>of</strong> recurrent syncope. AmHeart J 1999;137:870–7.87. Krahn AD, Klein GJ, Yee R, Skanes AC. Randomized assessment <strong>of</strong> syncope trial:conventional diagnostic testing versus a prolonged monitoring strategy. Circulation2001;104:46–56.88. Waktare JEP, Camm AJ. Holter and event recordings for arrhythmia detection.In: Zareba W, Maison-Blanche P, Locati EH (eds). Noninvasive Electrocardiology inClinical Practice. Armonk, NY: Futura Publishing Company; 2001. p3–30.89. Paisey JR, Yue AM, Treacher K, Roberts PR, Morgan JM. Implantable loop recordersdetect tachyarrhythmias in symptomatic <strong>patients</strong> <strong>with</strong> negative electrophysiologicalstudies. Int J Cardiol 2005;98:35–8.90. Epstein AE, Di Marco JP, Ellenbogen KA, Estes MNA III, Freedman RA, Gettes LSet al. ACC/AHA/HRS 2008 guidelines for device-based <strong>the</strong>rapy <strong>of</strong> cardiacrhythm abnormalities: a report <strong>of</strong> <strong>the</strong> American College <strong>of</strong> Cardiology/AmericanHeart Association Task Force on Practice Guidelines (Writing Committee toRevise <strong>the</strong> ACC/AHA/NASPE 2002 Guideline Update for Implantation <strong>of</strong>Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration<strong>with</strong> <strong>the</strong> American Association for Thoracic Surgery and Society <strong>of</strong> ThoracicSurgeons. Circulation 2008;117:e350–e408.91. Glotzer TV, Daoud EG, Wyse DG, Singer DE, Ezekowitz MD, Hilker C et al. Therelationship between daily atrial tachyarrhythmia burden <strong>from</strong> implantabledevice diagnostics and stroke risk. The TRENDS Study. Circ Arrhythm Electrophysiol2009;2:474–80.92. Macías Gallego A, Díaz-Infante E, García-Bolao I. Spanish Ca<strong>the</strong>ter Ablation Registry.8th <strong>of</strong>ficial report <strong>of</strong> <strong>the</strong> Spanish Society <strong>of</strong> Cardiology Working Group onElectrophysiology and Arrhythmias (2008). Rev Esp Cardiol 2009;62:1276–85.93. Graham I, Atar D, Borch-Jansen K, Boysen G, Burel G, Cifkova R et al. Europeanguidelines on cardiovascular disease prevention in clinical practice: executivesummary. Fourth Joint Task Force <strong>of</strong> <strong>the</strong> European Society <strong>of</strong> Cardiology ando<strong>the</strong>r Societies on Cardiovascular Disease Prevention in Clinical Practice (constitutedby representatives <strong>of</strong> nine societies and by invited experts). Eur Heart J2007;28:2375–414.94. Jouven X, Zureik M, Desnos M, Courbon D, Ducimetiere P. Long-term outcomein asymptomatic men <strong>with</strong> exercise-induced premature ventricular depolarizations.N Engl J Med 2000;343:826–33.95. Binici Z, Intzilakis T, Nielsen OW, Kober L, Sajadich A. Excessive supraventricularectopic activity and increased risk <strong>of</strong> atrial fibrillation and stroke. Circulation2010;121:1904–11.96. Mont L. Arrhythmias and sport practice. Heart 2010;96:398–405.97. Viskin S. The long QT syndromes and torsade de pointes. Lancet 1999;354:1625–33.98. Kirchh<strong>of</strong> P, Franz MR, Bardai A, Wilde AM. Giant T-U waves precede torsades depointes in long QT syndrome: a systematic electrocardiographic analysis in<strong>patients</strong> <strong>with</strong> acquired and congenital QT prolongation. J Am Coll Cardiol 2009;54:143–9.99. Keller DI, Huang H, Zhao J, Frank R, Suarez V, Delacretaz E et al. A novelSCN5A mutation, F1344S, identified in a patient <strong>with</strong> Brugada syndrome andfever-induced ventricular fibrillation. Cardiovasc Res 2006;70:521–9.Downloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011


934A. Raviele et al.100. Keller DI, Rougier JS, Kucera JP, Bennamar N, Fressart V, Guicheney P et al.Brugada syndrome and fever: genetic and molecular characterization <strong>of</strong> <strong>patients</strong>carrying SCN5A mutations. Cardiovasc Res 2005;67:510–9.101. Kum LC, Fung JW, Sanderson JE. Brugada syndrome unmasked by febrile illness.Pacing Clin Electrophysiol 2002;25:1660–1.102. Morita H, Zipes DP, Morita ST, Wu J. Temperature modulation <strong>of</strong> ventriculararrhythmogenicity in a canine tissue model <strong>of</strong> Brugada syndrome. HeartRhythm 2007;4:188–97.103. Junttila MJ, Gonzalez M, Lizotte E, Benito B, Vernooy K, Sarkozy A et al. InducedBrugada-type electrocardiogram, a sign for imminent malignant arrhythmias. Circulation2008;117:1890–3.104. Behr ER, Camm AJ. Letter by Behr and Camm regarding article ‘InducedBrugada-type electrocardiogram, a sign for imminent malignant arrhythmias’. Circulation2008;118:e701; author reply e702.105. Viskin S, Lesh MD, Eldar M, Fish R, Setbon I, Laniado S et al. Mode <strong>of</strong> onset <strong>of</strong>malignant ventricular arrhythmias in idiopathic ventricular fibrillation. J CardiovascElectrophysiol 1997;8:1115–20.106. Haissaguerre M, Derval N, Sacher F, Jesel L, Deisenh<strong>of</strong>er I, de Roy L et al.Sudden cardiac arrest associated <strong>with</strong> early repolarization. N Engl J Med 2008;358:2016–23.107. Rosso R, Kogan E, Belhassen B, Rozovki V, Scheinman MM, Zeltser D et al.J-point elevation in survivors <strong>of</strong> primary ventricular fibrillation and matchedcontrol subjects incidence and clinical significance. J Am Coll Cardiol 2008;52:1231–8.108. Viskin S. Idiopathic ventricular fibrillation ‘Le Syndrome d’Haissaguerre’ and <strong>the</strong>fear <strong>of</strong> J waves. J Am Coll Cardiol 2009;53:620–2.109. Pasquie JL, Sanders P, Hocini M, Hsu LF, Scavée C, Jais P et al. Fever as a precipitant<strong>of</strong> idiopathic ventricular fibrillation in <strong>patients</strong> <strong>with</strong> normal hearts.J Cardiovasc Electrophysiol 2004;15:1271–6.110. Haissaguerre M, Shah DC, Jais P, Shoda M, Kautzner J, Arentz T et al. Role <strong>of</strong>Purkinje conducting system in triggering <strong>of</strong> idiopathic ventricular fibrillation.Lancet 2002;359:677–8.111. Haissaguerre M, Shoda M, Jais P, Nogami A, Shah DC, Kautzner J et al.Mapping and ablation <strong>of</strong> idiopathic ventricular fibrillation. Circulation 2002;106:962–7.112. Viskin S, Rosso R, Rogowski O, Belhassen B. The ‘short-coupled’ variant <strong>of</strong> rightventricular outflow ventricular tachycardia: a not-so-benign form <strong>of</strong> benign ventriculartachycardia? J Cardiovasc Electrophysiol 2005;16:912–6.113. Viskin S, Antzelevitch C. The cardiologists’ worst nightmare: sudden death <strong>from</strong>‘benign’ ventricular arrhythmias. J Am Coll Cardiol 2005;46:1295–7.114. Noda T, Shimizu W, Taguchi A, Ajba T, Satomi K, Sujama K et al. Malignant entity<strong>of</strong> idiopathic ventricular fibrillation and polymorphic ventricular tachycardiainitiated by premature extrasystoles originating <strong>from</strong> <strong>the</strong> right ventricularoutflow tract. J Am Coll Cardiol 2005;46:1288–94.115. Shimizu W. Arrhythmias originating <strong>from</strong> <strong>the</strong> right ventricular outflow tract: howto distinguish ‘malignant’ <strong>from</strong> ‘benign’? Heart Rhythm 2009;6:1507–11.116. Kirchh<strong>of</strong> P, Franz MR, Bardai A, Wilde AM. Giant T-U waves precede torsades depointes in long QT syndrome. J Am Coll Cardiol 2009;54:143–9.117. Colman N, Bakker A, Linzer M, Reitsma JB, Wieling W, Wilde AA. Value <strong>of</strong>history-taking in syncope <strong>patients</strong>: in whom to suspect long QT syndrome? Europace2009;11:937–43.118. Brignole M, Shen WK. Syncope management <strong>from</strong> emergency department tohospital. J Am Coll Cardiol 2008;51:284–7.119. Costantino G, Perego F, Dipaola F, Borella M, Galli A, Cantoni G et al. Short- andlong-term prognosis <strong>of</strong> syncope, risk factors, and role <strong>of</strong> hospital admission:results <strong>from</strong> <strong>the</strong> STePS (Short-Term Prognosis <strong>of</strong> Syncope) study. J Am CollCardiol 2008;51:276–83.120. Brignole M, Alboni P, Benditt DG, Bergfeldt L, Blanc JJ, Bloch-Thomsen PE et al.Guidelines on management (diagnosis and treatment) <strong>of</strong> syncope: update 2004.Europace 2004;6:467–537.121. Brignole M, Menozzi C, Bartoletti A, Giada F, Lagi A, Ungar A et al. Anew management <strong>of</strong> syncope: prospective systematic guideline-based evaluation<strong>of</strong> <strong>patients</strong> referred urgently to general hospitals. Eur Heart J 2006;27:76–82.Downloaded <strong>from</strong> http://europace.oxfordjournals.org/ at :: on December 6, 2011

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!