Clerking palpitations

Palpitations are defined as the abnormal awareness of one’s own heartbeat. A significant proportion of palpitations are due to non-life-threatening, treatable cardiac conditions. However, palpitations are occasionally a manifestation of potentially life-threatening conditions, especially in the setting of structural heart disease. Clerking palpitations includes a careful and directed history and physical examination and a 12-lead ECG. Further testing and treatment should be guided by this initial evaluation.

History

The following approach should be applied in history taking:

Greet the patient and establish rapport.

Obtain the biodata.

Characterise the palpitations, concentrating on the following:

  • Rate and degree of regularity of palpitations: sustained, rapid, irregular or regular rhythm.
  • Nature of palpitations: examples, a feeling of flip-flopping in the chest, often described as the heart stopping and then starting again, or as a skipped beat with the sensation of a pounding beat; or a feeling of rapid fluttering in the chest.
  • Timing: Palpitations on awakening (typically early in the morning) may be due to atrial fibrillation.
  • Precipitants: Exercise, emotional stress, positional changes.

Ask more direct questions based on possible differentials derived from the above:

  • Sinus tachycardia: 

history often vague; palpitations that just seem to fade away; hyperthyroidism-associated symptoms such as decreased weight despite increased appetite, emotional lability, oligomenorrhoea; associated breathlessness and fatigue due to anaemia; can be experienced in the setting of intense emotional episodes; associated headaches and flushing might be due to a phaeochromocytoma

  • Atrial tachycardia:

history of structural heart disease; association with acute illness; palpitations are often paroxysmal; fast and regular palpitations with sudden onset and termination; less specific symptoms such as fatigue and breathlessness can be present if atrial tachycardia is incessant

  • Atrial flutter:

fast and regular palpitations; seen in patients with normal hearts but is more often seen in patients with left ventricular dysfunction or rheumatic heart disease; commonly seen in conjunction with atrial fibrillation

  • Atrial fibrillation:

history of CHF, valvular heart disease, hypertrophic/dilated cardiomyopathy, pericarditis, thyroid disease, pulmonary disease, obstructive sleep apnoea, or atrial flutter; paroxysmal or persistent palpitations; often associated with other symptoms such as dyspnoea or fatigue; or can occur after binge drinking (holiday heart); common in older people (affects >10% of octagenerians)

  • Atrioventricular nodal re-entrant tachycardia:

can occur at any age; most commonly present in the late 20s or early 30s; [7]more common in women; palpitations typically have an abrupt initiation and termination, are fast and regular, described as being machine-like, and can be accompanied by a fullness in the throat due to right atrial contractions against a closed tricuspid valve; often terminated with Valsalva’s manoeuvres and sometimes associated with pre-syncope

  • Wolff-Parkinson-White syndrome (WPW):

rapid and regular palpitations that can be terminated with Valsalva’s manoeuvres; typically present in the teenage years; more frequently seen in males; associated with a slight increase in incidence of sudden cardiac death

  • Ventricular premature beat:

usually seen in normal hearts; palpitations are described as an early beat with a pause followed by an unusually strong or ‘pounding’ beat, or simply as a ‘flip-flop’; may be associated with caffeine intake

  • Atrial premature beat:

history of structural heart disease; palpitations described as a skipped beat often with a pause afterwards or a brief flip-flop, may be associated with caffeine intake

  • Anxiety and panic disorder:

palpitations may be preceded by a stressful event; tingling, paraesthesia, breathlessness may accompany the palpitations

  • Fever:

sweating, flushing, underlying illness, for example, influenza

  • Hyperthyroidism:

decreased weight despite increased appetite, emotional lability, oligomenorrhoea, heat intolerance

  • Excess alcohol use (binge drinking): 

significant alcohol intake, especially a history of binge drinking

  • Caffeine:

history of large caffeine consumption or direct correlation between caffeine intake and palpitations

  • Medications:

use of stimulants or medications that prolong the QT interval such as fluoroquinolone antibiotics or certain antipsychotics

  • Inappropriate sinus tachycardia:

exaggerated heart response to exercise, without an identifiable aetiology for the tachycardia such as pregnancy, anaemia, or hyperthyroidism; commonly seen in young women

  • Idiopathic ventricular tachycardia:

paroxysmal palpitations; often seen in the setting of catecholamine excess such as vigorous exercise; can be associated with near-syncope; typically no family history of arrhythmia

  • Long QT syndrome:

palpitations, often associated with syncope, can be triggered by exercise, fever, or emotional stress; drug history includes QT-prolonging drugs such as fluoroquinolone antibiotics or certain antipsychotics

  • Brugada syndrome:

patients can present between ages 22 and 65 years with palpitations due to episodes of non-sustained VT or ventricular fibrillation (VF); often associated with syncope

  • Hypertrophic cardiomyopathy:

family history of hypertrophic cardiomyopathy or sudden cardiac death: symptoms are associated with dyspnoea on exertion, near-syncope, and syncope, most often due to atrial fibrillation, but also VT

  • VT in the setting of other structural heart disease: 

history of coronary heart disease with MI, repaired congenital heart disease, mitral valve prolapse and/or regurgitation

  • Phaeochromocytoma:

headaches, flushing, diaphoresis, resistant HTN, family history of panic attack-like symptoms (but episodic rather than situational).

Physical examination

General examination: Pallor, fever, signs of hyperthyroidism such as warm and sweaty skin, thinning hair and skin, exophthalmos, eyelid lag, pretibial myxoedema.

CVS: Heart rate and rhythm; Blood pressure; Jugular venous pulse (cannon A waves, seen as a bulging in the neck when the atrium contracts against a closed tricuspid or mitral valve) as in atrioventricular dissociation.

Cardiac examination may show a laterally displaced and diffuse point of maximal impulse indicating dilated cardiomyopathy. Auscultation may reveal the mid-systolic click of mitral valve prolapse. A harsh holosystolic murmur heard along the left sternal border that increases with Valsalva’s manoeuvre indicates hypertrophic obstructive cardiomyopathy. There may be signs of CHF such as an S3. Mitral stenosis and regurgitation both lead to left atrial enlargement, which is associated with atrial fibrillation.

Other specific findings based on the differentials are as follows:

  • Sinus tachycardia: 

regular pulse >100 bpm; normal cardiac examination; signs and symptoms of hyperthyroidism (e.g., fine tremor, tachycardia, lid lag), anaemia (e.g., pallor) or phaeochromocytoma (episodic HTN)

  • Atrial tachycardia:

often normal; can see signs and symptoms of heart failure or pulmonary disease such as COPD or pneumonia

  • Atrial flutter:

fluttering of the venous jugular pulse may be seen; arterial pulse typically normal in intensity but ventricular rate is variable depending on the degree of AV block; signs of CHF and left ventricular dysfunction may be present

  • Atrial fibrillation:

irregularly irregular pulse; often rapid; if the patient is in a normal rhythm at the time of examination signs of CHF, rheumatic heart disease or thyroid disease should be sought

  • Atrioventricular nodal re-entrant tachycardia:

typically normal; during arrhythmia, the pulse is rapid and regular with a rapid fluttering of the jugular venous wave pulse

  • Wolff-Parkinson-White syndrome (WPW):

typically normal at baseline; during palpitations there is a rapid pulse that is regular, except in the case of atrial fibrillation in the setting of WPW, in which case the pulse is irregular

  • Ventricular premature beat:

typically normal; peripheral arterial pulse is regular except for occasional premature beats, often with a brief pause afterwards

  • Atrial premature beat:

typically normal; peripheral arterial pulse is regular except for occasional premature beats, often with a brief pause afterwards

  • Anxiety and panic disorder:

physical examination is non-specific

  • Fever:

elevated temperature

  • Hyperthyroidism:

weight loss, hyper-reflexia, tachycardia, atrial fibrillation, fine tremor, may be goitre

  • Excess alcohol use (binge drinking): 

atrial fibrillation may be evident, signs of alcohol intoxication

  • Caffeine:

physical examination is non-specific

  • Medications:

physical examination is non-specific

  • Inappropriate sinus tachycardia:

normal except for a fast and regular pulse >100 bpm

  • Idiopathic ventricular tachycardia:

typically normal except during palpitations when the patient may have salvos of non-sustained VT that manifest as a rapid regular pulse

  • Long QT syndrome:

typically normal

  • Brugada syndrome:

typically normal

  • Hypertrophic cardiomyopathy:

harsh crescendo-decrescendo murmur heard best in the right upper sternal border that gets louder with Valsalva’s manoeuvre, going from squatting to standing, or after a ventricular premature contraction (VPC); signs and symptoms of heart failure can be present, but typically not until later in the disease course

  • VT in the setting of other structural heart disease: 

signs of cardiomyopathy and/or CHF; diffuse and/or laterally displaced apical impulse consistent with left ventricular enlargement; gallop rhythm (S3); signs of atherosclerosis such as arterial bruits

  • Phaeochromocytoma:

hypertension, sinus tachycardia.