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My approach to palpitations

February 17, 2024 Andrew To

Ventricular ectopics, outflow tract

The two top reasons for patients seeking medical attention for palpitations are

  • Symptoms being bothersome

  • Is there something wrong? Is there a risk of sudden death?

The top priority for physician though is

  • Is this benign or malignant?

Useful features on history

  • Onset - Sudden vs Gradual

  • Duration - Brief vs sustained

  • Frequency

  • Triggers

  • Irregular

  • HR >120bpm. Arrhythmia Alert on Smartwatch

  • Underlying heart disease

  • Family history of arrhythmia and sudden death, especially first degree

  • Associated symptoms

    • Breathlessness

    • Chest pain

    • Presyncope

    • Syncope

Key features from the history

  • Is the palpitations fast?

  • Is there any haemodynamic disturbances?

  • What is the likelihood of arrhythmia?

What are the rough categories of palpitations from history?

  • Extrasystole - Skipped beat, heart sinking, irregular interspersed, rest

  • Tachycardia - Beating wings, Butterfly feeling in the chest, fast heart rate, physical effort or cooling down, haemodynamic impairment

  • Anxiety - ………, slightly accelerated regular, stress, tinglings, atypical chest pain, signing dyspnea

  • Pulsation - heart pounding, physical effort, gradual onset and offset, fatigue (weakness and lack of strength)

Other useful investigations?

  • Thyroid function

  • Haemoglobin

What to look for on the ECG?

  • Measurements and numbers may actually be useful

  • Look out for

    • Heart rate

    • PR interval - WPW

    • QTc - long or short

  • Funny looking? Consider

    • Bubble branch block

    • Pre-excitation changes - WPW

    • T inversion V2 onwards, especially if deep

    • Brugada, repolarization

Extrasystoles

  • Premature ventricular contractions are extremely common

  • ARIC study - 2 minutes ECG - 5.5%

  • Framingham - 1 hour ECG - 12%

  • Risk of sinister outcome is rare

    • Patients may present with abrupt syncope or sudden arrhythmic death attributable to PVC-uinduced VF

    • PVC induced cardiomyopathy is also possible

  • Who are more at risk?

    • Abnormal ECG - indicates underlying abnormalities

    • High burden - could be based on symptoms of ectopics on resting ECG

  • Burden

    • No clear threshold or cut-off

      • Studies suggested that optimal test characteristics for PVC-induced cardiomyopathy occur at burdens of 16-24%

      • Most cases of PVC-induced cardiomyopathy occur in those at least >10%

  • Investigations

    • ECG

    • Echocardiogram

    • Holter monitor

  • Treatment

    • Medication should not necessarily be given for symptoms alone, as some only wanted reassurance.

    • Beta-blockers vs. Diltiazem vs. Verapamil

      • Beta-blockers have been effective specifically in outflow tract PVCs, sympathetically mediated, triggered PVCs

  • When to refer?

    • At risk features

    • Bothersome symptoms

    • Reassurance

Dr James Fu

In Cardiac Investigations Tags Palpitations, Ectopics, Premature ventricular contractions
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Copyright @2024 Cardiology Institute; All photos copyright @2024 Andrew To