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

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Managing patients with palpitations 925Polyuria, which is due to the hypersecretion of natriuretichormone, is typical of atrial tachyarrhythmias, particularly atrialfibrillation. By contrast, the sensation of a rapid, regular pulse inthe neck (usually associated with the ‘frog sign’) raises suspicionof supraventricular tachycardia, particularly atrioventricular nodalreentrant tachycardia. 64 It is the result of atria contracting againstclosed tricuspid and mitral valves. 9,65 An atrioventricular mechanicaldissociation may also occur in the case of ventricular extrasystoles.In this case, however, only one or few pulses are felt in theneck, and the rhythm is more irregular. In supraventricular tachycardiasinvolving the atrioventricular node, patients often learnto interrupt the episode by themselves by applying vagal stimulationthrough Valsalva’s manoeuvre or carotid sinus massage.Palpitations that arise in situations of anxiety or during panicattacks are generally due to episodes of more or less rapid sinustachycardia secondary to the mental disturbance. In some cases,however, the patient may have difficulty in discerning whetherthe palpitations precede or follow the onset of the anxiety orpanic attack, and may therefore be unable to suggest whetherthe palpitations are the cause or the effect of the psychologicaldistress.During physical exercise, due to an increase in the sympatheticdrive, patients may experience, in addition to the normal sensationof a rapid heart rate elicited by intense effort, palpitations due tovarious types of arrhythmia, such as right ventricular outflowtract tachycardia, atrioventricular node reentrant tachycardia, andpolymorphic catecholaminergic ventricular tachycardia. Finally, episodesof paroxysmal atrial fibrillation may occur in the phaseimmediately following the cessation of physical effort, duringDefinitive§ orsuspected diagnosishistory, physical examination, ECG, psychosomaticcounselling*which a sudden reduction in sympathetic tone is accompanied byan increase in vagal tone.Accuracy of clinical features for thediagnosis of arrhythmiasThe utility of the features on history for diagnosing an arrhythmiccause of palpitations has been examined in a recent systematicreview. 48 The likelihood ratio of each feature is, in general, lowand only a few features are really predictive. They include historyof cardiac disease, palpitations affected by sleeping, or while thepatient is at work. Other features such as underlying history ofpanic disorder and duration of palpitations less than 5 minappear to be useful for ruling out a clinically significant arrhythmia.47 However, data in this regard come from studies withsmall sample sizes.Diagnostic strategyIn patients with palpitations the diagnostic strategy should aim at:(i) distinguishing the mechanism of the palpitations; (ii) obtainingan electrocardiographic recording during symptoms; and (iii) evaluatingthe underlying heart disease. All patients suffering from palpitationsshould therefore 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 palpitationsDownloaded from 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 of patients with palpitations. *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 the palpitations are associated withphysical exertion (e.g. right ventricular outflow tract extrasystoles),in athletes and when coronary heart disease is suspected. The roleof echocardiography is of paramount importance to evaluate thepresence of structural heart disease. The need to conductfurther non-invasive cardiologic investigations (particularlycardiac magnetic resonance imaging to evaluate patients withstructural normal heart, palpitations, and frequent ventriculararrhythmias) or invasive investigations (coronary angiography,etc.) will depend on the nature of the heart disease suspectedor ascertained. Comparable to exercise-induced syncope,exercise-induced palpitations should raise suspicion for ischaemic,valvular, or other structural heart disease with the correspondingwork-up. Whenever a systemic or pharmacological cause of palpitationsis suspected, specific laboratory tests should be performedon the basis of the clinical presentation of the symptom and thepatient’s clinical characteristics (e.g. haemochrome, electrolytes,glycaemia, thyroid function, urinary catecholamines, detection ofillicit substances in the blood or urine). If, on the contrary, a psychosomaticcause is suspected, the patient’s mental state must beassessed either by means of specific questionnaires or through7,8,20 – 23referral for specialist examination.The initial clinical evaluation leads to a definitive or probablediagnosis of the cause of the palpitations in about half of patients,and excludes with reasonable certainty the presence of causes thathave an unfavourable prognosis. 47 Moreover, a thorough initialclinical evaluation will indicate which specific investigations, if any,are necessary.If the initial clinical evaluation proves completely unremarkable—which is more frequent in paroxysmal, short-lastingpalpitations—the palpitations are deemed to be of unknownorigin. In subjects with palpitations of unknown origin who have alow probability of an arrhythmic cause (i.e. patients with gradualonset of palpitations and without significant heart disease and thosewith anxiety-related or extrasystolic palpitations), further investigationsare often not required. The patient should be reassured and afollow-up clinical examination may be scheduled. It should be underlined,however, that, in the absence of electrocardiographic recordingduring an episode of palpitations, only a presumed or probablediagnosis can be made. 30 By contrast, in instances of subjects withpalpitations of unknown origin presenting with clinical features suggestiveof an arrhythmic cause 66 (Table 4), or when palpitations aresuspected to be related to atrial fibrillation in individuals with riskfactors for thromboembolism, 14,67 patients should be referred toTable 4 Clinical features suggestive of palpitations ofarrhythmic originStructural heart diseasePrimary electrical heart diseaseAbnormal ECGFamily history of sudden deathAdvanced ageTachycardiac palpitationsPalpitations associated with haemodynamic impairmentan arrhythmia centre, and second-level investigations should be considered;these include ambulatory ECG monitoring and electrophysiologicalstudy (EPS) (Figure 1). Finally, second-levelinvestigations should also be carried out in patients with palpitationsof unknown origin whose symptoms are frequent or associated withimpaired haemodynamic function or impaired quality of life or states ofanxiety. 9Initial clinical evaluationHistoryIt represents a major part of the initial examination as mostpatients at the time they visit a physician have no palpitationsand the diagnosis has to be performed retrospectively. 5 – 9,48 Thefirst step is to establish that symptoms described by the patientmatch to palpitations and are not confused with chest pain orother manifestations arising in the chest, but that do not correspondto the definition of palpitations described in this article.When this first step has been achieved several important questionshave to be asked, the most important of which are summarizedin Table 5. Answers to some of these questions may requireTable 5 Main questions to ask a patient withpalpitationsCircumstances prior to the beginning of palpitationsActivity (rest, sleeping, during sport or normal exercise, change inposture, after exercise)Position (supine or standing)Predisposing factors (emotional stress, exercise, squatting orbending)Onset of palpitationsAbrupt or slowly arisingPreceded by other symptoms (chest pain, dyspnoea, vertigo, fatigue,etc.)Episode of palpitationsType of palpitations (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 of the episodeAbrupt or slowly decreasing, end or perpetuation of accompanyingsymptoms, duration, urinationSpontaneously or with vagal manoeuvres or drug administrationBackgroundAge at the first episode, number of previous episodes, frequencyduring the last year or monthPrevious cardiac diseasePrevious psychosomatic disordersPrevious systemic diseasesPrevious thyroid dysfunctionFamily history of cardiac disease, tachycardia or sudden cardiacdeathMedications at the time of palpitationsDrug abuse (alcohol and/or others)Electrolytes imbalanceDownloaded from http://europace.oxfordjournals.org/ at :: on December 6, 2011
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