Palpitations in primary careInnovAit, July 2011
Aisha Bhaiyat
Aim
• Assessment
• Management
• ECG’s
Palpitations
• Prevalence – 16% of primary care
consultations
• 2nd commonest reason for gp referral to
cardiology
Assessment
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What does the patient mean by palpitation
Rate
Rhythm
Missed/extra beat
Associated symptoms
Onset/offset
Exacerbating/relieving
Timings
Assessments
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Past medical history
Drug history
Family history
Social history
Examination
Medical emergency
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Systolic BP less than 90 mmHg
Pulse less than 40 or greater than 150
Cardiac failure
Chest pain
Presyncope
Management
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ECG
Blood tests
Ambulatary ECG
Transthoracic echo – if structural cardiac
abnormality suspected
ECG abnormalities that may be
present in those with palpitations
Conduction abnormalities
• BBB
• Venricular pre-excitation
• Prolongue QTc
• Extreme 1st degree block
• 2nd/3rd degree block
• Other arrythmias eg AF
Structural heart disease related
• LVH
• T wave/ST changes
• Features of old MI
Red Flags/high risk-urgent referral to
cardiology
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Exercise related palpitations
Syncope/presyncope
FH of sudden cardiac death/inherited heart dx
ECG-high degree av block
High risk structural disease
Amber Flags/moderate risk-refer to
cardiology
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History suggestive of recurrent tachyarrythmia
Palpitation with associated symptoms
Abnormal ECG (other than high av block)
Structural heart disease
Low risk-manage in primary care
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Skipped or thumping beats
Slow pounding sensation
ECG normal
No structural heart disease
Management and referral pathway for patients presenting with palpitations.
Taggar J S , Hodson A, The assessment and management
of palpitations in primary care InnovAiT 2011;4(7):408-413,
By permission of oxford university press.
Further considerations
• Opportunistic health promotion
• Driving – must cease if arrythmia likely to
cause incapacity. Permitted once arrythmia
identified and controlled for 4/52. DVLA need
to be indentified only symptoms are disabling
• Occupation
• Genetics-HOCM, WPW, Brugada syndrome,
Long QTS
Key points
• Consider lifestyle/psychological/other
systemic medical causes
• After initial assessment, patients risk should
be stratified and managed appropriately
• Other considerations - health promotion/
driving/occupation/genetics
Useful websites
• Heart Rhythm UK [www.hruk.org.uk/]
• Arrhythmia Alliance
[www.heartrhythmcharity.org.uk/] (most
useful for patient information leaflets)
• Sudden Adult Death Trust [www.sadsuk.org/]
• Cardiac risk in the young [www.c-r-y.org.uk/]