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

922A. Raviele et al.atrial tachycardia with variable atrioventricular conduction, torsadesde pointes). 16,17 By contrast, bradyarrhythmias are more rarely perceivedas palpitations: these arrhythmias comprise sinus pauses andsevere sinus bradycardia seen in sick sinus syndrome, sudden onsetof high-degree atrioventricular block, or of intermittent left-bundlebranch block. Anomalies in the functioning and/or programming ofpacemakers and implantable cardioverter defibrillators (ICDs)(pacemaker-mediated tachycardia, pectoral or diaphragmaticstimulation, pacemaker syndrome, etc.) may also be responsiblefor palpitations.Palpitations due to structural heartdiseaseSome structural heart diseases can give rise to palpitations in theabsence of true rhythm disorders. These include, among others,mitral valve prolapse, severe mitral and aortic regurgitation, congenitalheart disease with significant shunt, hypertrophic cardiomyopathy,and mechanical prosthetic valves. 18,19Palpitations due to psychosomaticdisordersPsychosomatic disorders that are most frequently associated withpalpitations include anxiety, panic attacks, depression, and somatization,which can either induce sinus tachycardia or modify thepatient’s subjective perception of a heartbeat that is otherwisenormal or presents minimal irregularities. 20 – 23 If no other potentialcauses can be identified, the palpitations are considered tobe of psychosomatic origin when the patient fulfils the criteriaspecified in the literature for one or more of the abovementionedpsychosomatic disorders. It must be borne in mind, however, thatcardiac arrhythmias and psychosomatic disorders are not mutuallyexclusive. 5,24 In addition, the adrenergic hyperactivation connectedwith intense emotions and anxiety can, in itself, predispose the25 – 27patient to supraventricular and/or ventricular arrhythmias.Indeed, in the last few years, some studies investigating the correlationbetween anxiety syndrome and the appearance of arrhythmiashave suggested that anxiety exerts a facilitating effect onarrhythmogenesis 28 as well as on the patient’s perception of thearrhythmia. 29 Finally, in a study conducted on patients with documentedsupraventricular tachycardia, it was found that two-thirdshad previously been wrongly diagnosed as suffering from panicattack disorder, and that the diagnosed ‘psychosomatic disease’could be cured by catheter ablation in most of these patients. 30Thus, even in patients affected by psychosomatic disorders, it isimportant to carry out a thorough investigation before excludingan organic cause, particularly arrhythmic, of palpitations.Palpitations due to systemic causesA sensation of palpitation may stem from sinus tachycardia and/orincreased cardiac contractility, both of 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 others.due to the effects of medicaland recreational drugsIn such cases, palpitations may be linked to sinus tachycardia; drugsinvolved include sympathomimetics, anticholinergics, vasodilators,and hydralazine. 40 The sudden suspension of b-blocker therapymay also give rise to sinus tachycardia and palpitations throughthe induction of a hyperadrenergic state as a result of the‘rebound’ effect. Moreover, palpitations may even occur after theinitiation or dose-increase of b-blockers, due to the perceptionof pulsations caused by increased stroke volume with lowerheart rate, or ventricular ectopic beats if sinus overdrive is withdrawn.Likewise, stimulants such as caffeine and nicotine, or theuse of illicit drugs (cocaine, heroin, amphetamines, LSD, syntheticdrugs, cannabis, etc.) can lead to sympathetic hyperactivation andsinus tachycardia, even in young subjects without heartdisease. 41,42 Drugs that prolong QT and predispose patients to torsadesde pointes and other tachyarrhythmias, such as antidepressivedrugs, besides provoking dizziness or syncope, may also inducearrhythmia-related palpitations. 43,44 In the absence of other potentialcauses, palpitations are regarded as secondary to the use ofdrugs when they are associated temporally to administration ofthe drug and when they cease on suspension of the drug.EpidemiologyThe prevalence of palpitations is dependent on definitions anddiagnostic methods used and varies substantially in different populations.Nevertheless, there is evidence that palpitations are a veryfrequent symptom in the general population 2,9 and, in particular, inpatients suffering from hypertension or heart disease. In studies inprimary care settings, palpitations account for 16% of the symptomsthat prompt patients to visit their general practitioner, and aresecond only to chest pain as the presenting complaint for specialistcardiologic evaluation. 1,3,4 This high prevalence of palpitationsemphasizes the need for a structured, ideally evidence-based, stepwisework-up that may allow to distinguish, since the beginning,between patients with benign prognosis and those with poorerprognosis.With regard to the prevalence of the various causes of palpitations,clinical evidence indicates that a considerable number of subjectswith palpitations have normal sinus rhythm or minor rhythmanomalies, such as short bursts of supraventricular extrasystoles orsporadic ventricular extrasystoles. Nevertheless, 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 patients presentingwith a complaint of palpitations at an university medical centre,palpitations were due to arrhythmias in 41% of these patients (16%of 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 theuse of a medication, illicit substances, or stimulants in 6%. Accordingto the case records, the prevalence of anxiety syndrome and panic20 – 22attacks in patients with palpitations ranges from 15% to 31%.In the study by Weber and Kapoor, 47 male sex, description of anDownloaded from http://europace.oxfordjournals.org/ at :: on December 6, 2011