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

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Managing patients with palpitations 923irregular heartbeat, history of heart disease, and event duration.5 min were found to be independent predictors of a cardiacaetiology. No specific cause of palpitations could be identified in16% of the patients despite a thorough evaluation including theuse of loop recorders. Indeed, it is not always possible to establisha definite cause of palpitations; often, only a likely cause can begiven, and, in some cases, several possible causes have to betaken into consideration. 8,42 In the literature, there are insufficientdata about the age and gender distribution of palpitations. Ingeneral, however, older patients and men are more likely tohave an arrhythmic cause of palpitations and younger patients47 – 51and women a psychosomatic cause.PrognosisThe prognostic implications of palpitations are dependent on theunderlying aetiology as well as clinical characteristics of thepatient. Available data, especially in terms of long-term prognosis,are scarce. Although palpitations are generally associated with lowrates of mortality, 4,47 they should bring to attention a potentialserious condition in patients with structural or arrhythmogenicheart disease or a family history of sudden death. This is alsoimportant to keep in mind if the palpitations are associated withsymptoms of haemodynamic impairment (dyspnoea, syncope, presyncope,dizziness, fatigue, chest pain, neurovegetative symptoms).5 On the one hand, depending on the clinical characteristicsof the patient, palpitations due to arrhythmias, in particular of ventricularorigin, but also atrial fibrillation, are associated with differentprognostic implications. 15 – 17 On the other hand, in patientswithout relevant heart disease, palpitations (especially ifanxiety-related or extrasystolic) generally have a benign prognosis.A retrospective American study that analysed case recordsobtained from general practitioners found no difference in 5-yearmortality and morbidity between patients with palpitations and agroup of asymptomatic control subjects. 4 Also in the abovementionedstudy by Weber and Kapoor 47 on a general population ofpatients presenting with palpitations at an university medicalcentre, despite the high rate of cardiac cause, 1-year mortalitywas only 1.6%. However, even in patients without severe heartdisease, palpitations may be due to significant arrhythmias, suchas atrial fibrillation, atrial flutter, or ventricular ectopic beats, allof which require adequate investigation and treatment. Moreover,clinical characteristics of the patient, such as age, presence of heartdisease, and ECG abnormalities, do not always allow the physicianto identify a priori those cases in which palpitations are caused byclinically significant rhythm disorders. 8,47,48,52 – 54 An exception tothis is given by changes in the resting ECG that are indicative ofprimary electrical heart diseases.In athletes, palpitations are not uncommon. Sudden death, inparticular in younger athletes, is rare and mostly associated withunderlying structural heart disease or primary arrhythmic disorders,and palpitations may be the initial clinical symptom or anincidental finding possibly leading to the recognition of a previouslyundiagnosed relevant heart disease. 55,56 Moreover, because ofpotentially life-threatening haemodynamic consequences of evensupraventricular arrhythmias, such as rapidly conducted preexcitedatrial fibrillation during exertion, careful cardiac evaluation,in particular of symptomatic competitive as well as recreationalathletes, is warranted. 57Although palpitations display a low mortality rate, the recurrenceof symptoms is, however, very frequent. In the study by Weber andKapoor, 47 77% of patients experienced at least one recurrence ofpalpitations, and the effect on their quality of life was unfavourable:one-third of patients reported an impairment of their ability toattend to household chores, 19% claimed that their workingcapacity had diminished, and 12% said that they had taken daysoff work. These findings are confirmed by a prospective study conductedby Barsky et al. 58 on 145 patients with palpitations, whowere followed up for 6 months and compared with an asymptomaticcontrol group. These authors observed that patients withpalpitations, in spite of having a favourable prognosis in terms ofmortality, remained symptomatic and functionally impaired overtime and exhibited a high incidence of panic attacks and psychologicalsymptoms. 58 Frequent and recurrent palpitations, therefore,can impair the patient’s quality of life, giving rise to anxiety and frequentvisits to the emergency department. 3 In many respects, palpitationsseem to behave like a chronic disorder that has afavourable prognosis, but with periodic attacks followed by transitoryremission. 3,4Clinical presentationDuration and frequency of palpitationsWith regard to duration, palpitations may be either short-lasting orpersistent. In short-lasting forms, the symptom terminates spontaneouslywithin a brief period of time. In persistent forms, the palpitationsare ongoing and terminate only after adequate medicaltreatment. With regard to frequency, palpitations may occurdaily, weekly, monthly, oryearly.Types of palpitationsPatients report a wide range of sensations to describe their symptoms.The most common descriptions, and those most useful inclinical practice in differential diagnoses among the variouscauses of palpitations, enable palpitations to be classified accordingto the rate, rhythm, and intensity of heartbeat 5 – 9,59,60 : extrasystolicpalpitations, tachycardiac palpitations, anxiety-related palpitations,and pulsation palpitations (Table 2). It should, however, be stressedthat patients are not always able to describe the characteristics oftheir symptoms precisely. It may therefore be difficult to identifythe type of palpitation accurately, especially in the case of normalratepalpitations. 5,9,61Extrasystolic palpitations, due to ectopic beats, generally producefeelings of ‘missing/skipping a beat’ and/or a ‘sinking of the heart’interspersed with periods during which the heart beats normally;patients report that the heart seems to stop and then startagain, causing an unpleasant, almost painful, sensation of a blowto the chest. Linked to the presence of atrial or ventricular extrasystolicbeats, this type of palpitation is frequently encounteredeven in young subjects, often in the absence of heart disease,and generally has a benign prognosis. In extrasystolic palpitations,particularly if they are of ventricular origin, the sensation is dueto the increased strength of contraction of the post-extrasystolicDownloaded from http://europace.oxfordjournals.org/ at :: on December 6, 2011
924A. Raviele et al.Table 2 Types of palpitations and their clinical presentationsType of SubjectiveHeartbeatOnset and Trigger Possible associated symptomspalpitation descriptiontermination situations...............................................................................................................................................................................Extrasystolic ‘Skipping/missing a Irregular, interspersed with Sudden Rest —beat’, ‘sinking of the periods of normalheart’heartbeatTachycardiac‘Beating wings’ in thechestRegular or irregular,markedly acceleratedAnxiety-related Anxiety, agitation Regular, slightlyacceleratedSuddenGradualPhysical effort,cooling downStress, AnxietyattacksPulsation Heart pounding Regular, normal frequency Gradual Physical effort AstheniaSyncope, dyspnoea, fatigue, chestpainTingling in the hands and face, lumpin the throat, atypical chest pain,sighing dyspnoeaTable 3 Clinical characteristics of tachycardiac palpitationsType of arrhythmia Heartbeat Trigger situations Associated symptoms Vagal manoeuvres...............................................................................................................................................................................AVRT, AVNRT Sudden onset regular with periods of Physical effort, changes in Polyuria, frog signSudden interruptionelevated heart ratepostureAtrial fibrillation Irregular with variable heart rate Physical effort, cooling down,post meal, alcohol intakeAtrial tachycardia andatrial FlutterVentriculartachycardiasbeat, which accentuates the movement of the heart inside thechest, or to the post-extrasystolic pause, or to the altered activationof the heart. When the extrasystoles are particularly numerousand/or repetitive, it may prove difficult to make a differentialdiagnosis between extrasystolic and tachycardiac palpitations,especially those due to atrial fibrillation.In the case of tachycardiac palpitations, the sensation described bythe patient is that of a rapid fluctuation like ‘beating wings’ in thechest. The heartbeat is generally perceived to be very rapid (sometimeshigher than the maximum heart rate estimated on the basisof the 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 palpitationsare generally linked to supraventricular or ventriculartachyarrhythmias, which begin and usually end suddenly (sometimesthe termination is gradual due to the increase in sympathetictone during tachycardia that tends to persist and declines slowlyafter its interruption), or to sinus tachycardia due to systemiccauses or to the use of drugs or illicit substances (in these cases,palpitations begin and end gradually).Anxiety-related palpitations are perceived by the patient as a formof anxiety. The heartbeat is slightly elevated, but never higher thanthe maximum heart rate estimated on the basis of the patient’s age.These palpitations, whether paroxysmal or persistent, begin andPolyuriaRegular (irregular if A-V conduction isvariable) with elevated heart rateRegular with elevated heart rate Physical effort Signs/symptoms ofhaemodynamicimpairmentAVRT, atrio-ventricular reentrant tachycardia; AVNRT, atrio-ventricular node reentrant tachycardia; A-V, atrioventricular.Transitory reductionin heart rateTransitory reductionin heart rateNo effectend gradually, and patients describe numerous other associatedunspecific symptoms, such as tingling in the hands and face, alump in the throat, mental confusion, agitation, atypical chestpains, and sighing dyspnoea, that normally precede the palpitations.Anxiety-related palpitations are due to psychosomatic disordersand usually require exclusion of an arrhythmic cause of thesymptoms.Pulsation palpitations 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 palpitations areoften connected with the various causes of the palpitations 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 of atrioventricular nodal reentranttachycardia. The occurrence of syncope or other symptoms,such as severe fatigue, dyspnoea, or angina, in addition to palpitations,is much more frequent in patients with structural heartdisease. However, syncope may also occur at the onset of supraventriculartachycardia in patients with a normal heart, as the result ofthe triggering of a vasovagal reaction. 62,63Downloaded from http://europace.oxfordjournals.org/ at :: on December 6, 2011
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