Palpitations

Patient presenting with history of palpitations

Clinical History:

• Circumstances prior to and during the episode of palpitations.
• Duration and frequency of palpitations.
• Description of the palpitations (patient to tap out rhythm if possible).
• Associated symptoms (breathlessness, chest pain, syncope or near syncope).
• History of heart disease or other medical conditions.
• Use of prescribed or over-the-counter drugs.
• Lifestyle factors.

Examination:

• Check heart rate and rhythym
• Check for murmurs suggestive of valvular disease
• Assess for signs heart failure - raised JVP, basal crepitations, peripheral oedema

Tests:

• FBC, U&E, TFT, LFT, HbA1c, Lipids.
• 12 lead ECG

AF on ECG

Manage via atrial fibrillation pathway

Normal ECG (or ectopics only and no risk factors*)

Manage potential lifestyle causes:

• Stress
• Caffeine
• Alcohol
• Smoking
• Drugs that can exacerbate palpitations
• Menopause

Low risk symptoms:

• Skipped beats
• Slow pounding
• Thumping beats
• Short episodes fluttering (< 20s)
• Single episode of palpitations

These are likely to respond to lifestyle modification and can generally be managed in primary care without further investigation.

Normal ECG - ongoing symptoms despite initial lifestyle management

• Arrange ECG Monitoring via SCI Gateway...DGRI...Cardiology...Palpitations Referral:

Physiologist will triage referral for appropriate investigation based on the referral information

• Daily symptoms - 24hr Holter ECG
• Several times a week - 48-72 hour monitor
• Weekly symptoms 7 day holter
• Less frequent - event recorder

If normal, holter results will be sent direct back to referrer.

If abnormal, holter results will be sent by the Physiologists to Cardiologist for review, a copy will be sent to GP.

Abnormal ECG and or risk factors*

• Refer cardiology

Urgent Referral to Cardiology:

• History of syncope or near syncope.
• Palpitations precipitated by exercise.
• Family history of sudden cardiac death under 40 years.
• Resting ECG abnormalities.
• Accompanying chest pain or lightheadedness.
• History or physical signs of structural heart disease, heart failure, or hypertension.
• Pregnant patients with palpitations.

Routine Referral to Cardiology:

• Recurrent sustained tachyarrhythmia, AF, or flutter.
• Symptoms consistent with paroxysmal supraventricular tachycardia.
• Ventricular ectopics if:
  • underlying heart disease is suspected from clinical assessment or ECG
  • ectopics are very frequent or ventricular tachycardia is suspected

• Patients with isolated palpitations, a normal ECG, and no associated risk factors or symptoms can be managed within primary care.