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

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Managing patients with palpitations 927inputs from other members of the family or from individuals whohave witnessed an episode of palpitations. Description of the typeof palpitations (regular or not, rapid or not) could help to determineits underlying mechanism (Table 2). It may be useful to askthe patient to mimic the perceived cardiac rhythm, either vocallyor by drumming with the fingers on a table.Circumstances during which palpitations have occurred are generallyhelpful to evaluate their cause. Some of these circumstancesare presented in Table 3. When, after this history-taking, itbecomes likely that palpitations are not related to arrhythmiabut rather to psychosomatic disorders, before starting moreextensive cardiovascular procedures, it is judicious to take thehelp of a mental health expert. 1,22,23,47,58It is naturally useless to perform this extensive history-taking ifthe patient has the feeling of palpitation even during the consultation.The first examination in these circumstances is to instantaneouslyrecord ECG.Physical examinationDuring palpitationsThe execution of the physical examination while the patient is stillsymptomatic is not the most frequent situation. However, whenthis occurs it is crucial to have some notions about frequencyand regularity of heart rhythm by listening to the patient’s chestor by palpation of the arterial pulse. The differential diagnosis ofvarious types of tachycardia may be guided by vagal manoeuvres 68such as carotid sinus massage: sudden interruption of the tachycardiais highly suggestive of a tachycardia involving the atrioventricularjunction whereas a temporary reduction of the frequency issuggestive of atrial fibrillation, flutter, or atrial tachycardia (Table 3).When this essential stage has been performed, examinationshould aim to evaluate the tolerance of a possible heart rhythmdisturbance (blood pressure, signs of cardiac failure, and so on),to assess the cardiovascular status (i.e. the presence of structuralheart disease), and, in case of a sinus rhythm or sinus tachycardia,to evaluate the presence of systemic diseases potentially responsiblefor palpitations.In the absence of palpitationsWhen the patient is examined in the absence of the culpritsymptom, the aim is to find signs of structural heart disease thatcould explain the occurrence of palpitations (cardiac murmur,hypertension, vascular diseases, signs of heart failure, and so on).It is also important to search for signs of systemic diseases.Standard electrocardiogramDuring palpitationsIf the patient is examined during palpitations, 12-lead ECG representsthe diagnostic gold standard. Thus, patients should beadvised to come as quickly as possible to an emergency departmentor a physician when an ECG has never been recordedduring symptoms. It allows the physician to analyse P and QRSmorphologies and the relationship between these two waves,and the frequency and regularity of the heart rhythm, and finallybrings an accurate diagnosis on the concordance between palpitationsand the presence or absence of arrhythmia. This distinctionbetween arrhythmic or non-arrhythmic palpitation is of paramountimportance for the future evaluation. 1,5 – 9,47 Furthermore, preciseanalysis of ECG during arrhythmia either provides the mechanismor gives important data that lead to this diagnosis. It should bestressed, however, that P waves during rapid tachycardia are notalways visible, making the diagnosis difficult. Vagal manoeuvresand pharmacological tests, such as intravenous adenosine or ajmaline,performed during ECG recording are of major interest as theycan unmask the atrial activity or interrupt suddenly the tachycardia,resulting in the diagnosis of the type of arrhythmia. 16,68 Alternatively,the possibility of taking a transoesophageal ECG duringtachycardia must be considered.Table 6 Electrocardiographic features recorded onstandard electrocardiogram in absence of palpitationsand suggestive of palpitations of arrhythmic originVentricular pre-excitationAtrioventricular reciprocating tachycardiaAtrial fibrillationP-wave abnormalities, supraventricular premature beats, sinusbradycardiaAtrial fibrillationLeft ventricular hypertrophyVentricular tachycardiaAtrial fibrillationFrequent ventricular premature beatsVentricular tachycardiaQ wave, signs of 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 of eletrocardiographic signs indicative ofprimary electrical heart diseasesECG signsSuspected disease................................................................................Corrected QT interval .0.46 sLong QT syndromeCorrected QT interval ,0.32 sShort QT syndromeRight bundle branch block with coved type/ Brugada syndromesaddle type ST segment elevation in theright precordial ECG leads (V1–V3) eitherspontaneous or provoked by flecainide orajmaline1-wave and/or T-wave inversion with QRSduration .110 ms in the right precordialECG leads (V1–V3); ventricular ectopicbeats with left bundle branch block andright-axis deviation morphologyHigh voltage in the precordial leads, Q wave,ST changesArrythmogenic rightventricularcardiomyopathyHypertrophiccardiomyopathyDownloaded from http://europace.oxfordjournals.org/ at :: on December 6, 2011
928A. Raviele et al.In the absence of palpitationsEven when the ECG is recorded in the absence of palpitations itprovides important data that can suggest the arrhythmic origin ofpalpitations (Tables 6 and 7). In some instances, for example incase of evident pre-excitation when the patient reports rapidregular palpitations, the diagnosis is formal even if tachycardiahas never been recorded.Ambulatory electrocardiogrammonitoringAmbulatory ECG monitoring serves to document the cardiacrhythm during an episode of palpitations if this cannot be doneby means of standard ECG, as in the case of short-lasting symptoms.Indeed, ambulatory ECG monitoring utilizes electrocardiographicrecorders that are able to monitor the patient’s cardiacrhythm for long periods of time or that can be activated by thepatient 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 patients at high risk of malignant arrhythmias),event recorders, external loop recorders, and, very recently,mobile cardiac outpatient telemetry. Implantable devices comprisepacemakers and ICDs equipped with diagnostic features (usedexclusively in patients requiring such devices for therapeutic purposes)and implantable loop recorders (ILRs).Event recorders or handheld patient-operated ECG systemshave been shown to improve the diagnosis of transient ECGchanges in patients with palpitations. 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. with no activation by the patient) and provide asignificantly higher yield than standard patient-activated loop recordersin patients with infrequent palpitations. 49,73 – 79 Another majorbenefit of the latest diagnostic systems is that many of them notonly allow automatic detection of the arrhythmias but also allowimmediate wireless transmission of pertinent ECG data to a centralmonitoring station via a mobile telephone line or the Internet.The alarms incorporated into the network providing telemetricdata to specialists improve the efficiency of patient management,since the physicians can check their patient’s data remotely withno delay. This permits greater emphasis on documentation andcharacterization of 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, theability to detect the onset of the episode provides valuable informationon the mechanism of the arrhythmias. The main technicalcharacteristics of the 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 palpitations and an electrocardiographicrecording. 69,70 In patients who do not developTable 8 Technical characteristics of the differentambulatory electrocardiogram monitoring devicesDeviceCharacteristics................................................................................Holter monitoring Utilizes external recorders connected to thepatient by means of skin electrodes; theserecorders are able to perform continuousbeat-to-beat electrocardiographicmonitoring via several leads (up to 12 inthe latest models).Event recorders Small, easy-to-use, portable devices that areapplied to the patient’s skin wheneversymptoms are experienced. They provideprospective one-leadelectrocardiographic recording for a fewseconds.External looprecordersMobile cardiacoutpatienttelemetryImplantable looprecordersPacemakers/ICDsIEGM, intracardiac electrogram.Connected continuously to the patient bymeans of skin electrodes and equippedwith a memory loop, these devicesprovide one to three-leadelectrocardiographic recording for a fewminutes before and after activation by thepatient when symptoms arise. The latestdevices are also able to self-activateautomatically when arrhythmic eventsoccur.Made up of an external loop recorderconnected to the patient by means of skinelectrodes, and of a portable receiver thatis able to transmit an electrocardiographictrace to a remote operating centre or to adedicated website via the telephone. Inthis way, the patient’s rhythm can bemonitored in real time.Similar in size to a pacemaker, these devicesare implanted beneath the skin through asmall incision of about 2 cm in the leftprecordial region. They are equipped witha memory loop and, once activated by thepatient through an external activator atthe moment when the symptoms arise,record one-lead electrocardiographictrace for several minutes before and afterthe event. They are also able to record anyarrhythmic event automatically (i.e. withno intervention by the patient). In general,monitoring lasts either until a diagnosis isreached or until the battery runs down.On completion of monitoring, the deviceis removed from the patient.Provided by an internal memory, they areable to detect and store an atrial andventricular IEGM separately (dualchamber devices), and to record anyarrhythmic events automatically. Somemodels may also be activated manually bythe patients when palpitations occur.symptoms during monitoring, therefore, this examination is oftennon-contributory. In some patients without palpitations on monitoring,the presence of clinically significant arrhythmias that areDownloaded from http://europace.oxfordjournals.org/ at :: on December 6, 2011
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