Approach to palpitation family medicine case discussion 2010
Department of Family Medicine Case Discussion
Puan Rahimah a 54 years old Malay lady comes with her son to see you in the clinic with the
complaint of palpitation for the past 6 months.
She is married with 4 children and her husband is a pensioner
1) What question would you ask in assessing patient who presented with palpitation.
2) Based on safe diagnostic strategy, state differential diagnoses.
3) What is your diagnosis for this lady?
4) What investigation would you do for her?
5) How would you treat her?
What is Palpitation
An uncomfortable or abnormal awareness of the heart beat, are common in primary care patients.
In one study, recurrent symptoms occurred in 75% of patients and 33% reported lower quality of
life, but the 1-year mortality rate was 1.6% [Robert B. Taylor]
Usually felt over the precordium or in the throat or neck. The patient may describe them as
pounding, jumping, turning, fluttering, or flopping or as missing or skipping beats. Palpitations
may be regular or irregular, fast or slow, paroxysmal or sustained. [Handbook of Signs &
Symptoms 3rd ed]
Palpitation can be caused by cardiac and non cardiac origin. The most common cardiac causes of
palpitation is atrial fibrillation. However, less than half of the total patient presented to GP with
palpitation has significant cardiac problem. Others are benign and most of it are due to
psychological problem especially anxiety.
The initial task is to detect a life-threatening cause of the PPTs. Studies have shown a 7% to 40%
incidence of potentially serious arrhythmias in these patients, although the cause in up to 31% is
psychiatric [Robert B. Taylor]
In woman, palpitation occur at any age especially during the luteal phase of the menstrual cycle,
pregnancy and perimenopausal syndrome. In perimenapausal period, it is usually benign and
related to increased sympathetic activity caused by the menopause.
In order not to miss the causes of palpitation, a mnemonic VITAMIN CDE can be used.
Vascular - (aortic aneurysms, arteriovenous fistulas, anemia, postural hypotension, migraine,
and cardiac disorders such as aortic regurgitation, aortic stenosis, tricuspid insufficiency, CH)
Inflammation/infection - (fever, pericarditis, bacterial endocarditis, rheumatic fever.)
Trauma (due to increase release of catecholamines)
Anxiety / Autoimmune.
Metabolic – electrolyte disorder.
Idiopathic / intoxication - alcohol, tobacco, coffee, soft drinks, and tea
Neoplasm – rarely causes palpitation
Congenital – heart problem
Drugs – digitalis, aminophylline, sympathomimetics, ganglionic blocking agents, nitrates
Endocrine - thyrotoxicosis, pheochromocytoma, menopausal syndrome, and hypoglycemia.
Red Flag in palpitation
Like what have been written previously, most of the causes for palpitation are benign and less
than half of it are due to cardiac origin. However, once should pay an attention for Red flag of
2. Associated cardiac manifestation
Patient with high risk of cardiac etiology could be predicted based on few characteristic which
1. Male gender
2. Irregular heart beat
3. History of heart disease
4. Event duration more than 5
Since, cardiac arrhythmia is one of the causes for palpitation, one should look for cardinal sign of
unstable patient which includes
1. Altered Mental Status
2. On going chest pain
4. Acute Pulmonary Edema
Question to be asked in assessing patient who presented with palpitation
1) Characteristic of the palpitation
a) Rapid, irregular (AF, multifocal artrial tachycardia, artrial flutter)
b) Rapid, regular (supraventricular tachycardias, Sinus tachycardia and ventricular
c) A “stop-start,” “flip-flop,” or “turning over” sensation in the chest (premature
ventricular contractions or premature atrial contractions
d) Palpitation perceived at neck (AV nodal reentrant tachycardia, premature ventricular
e) Constant – suggest tachycardia, and that would suggest hyperthyroidism or overuse of
caffeine and other drugs. may also point out fever of unknown origin.
f) Intermittent palpitations -cardiac arrhythmia, particularly extrasystoles.
2) What patient did during the attack occur?
a) Anxiety or somatization disorders
b) Catecholamine release (exercise, emotional stress)
c) At rest - benign condition
d) In changes of posture - SVT or PVCs
3) Onset and termination
a) abrupt onset and termination of PPTs suggests PSVT
b) Anxiety can lead to sinus tachycardia following an arrhythmia, precluding the patient
from sensing an abrupt cessation.
4) Associated symptoms
a) Ruled out sustained or nonsustained VT if syncope, presyncope, or dizziness occurs
b) weight loss, increased appetite, and polyuria – hyperthyroidism
c) shortness of breath and pitting edema - congestive heart failure
5) Others relevant history
a) Occurs after taking some drugs or changing into another type of drugs
b) Association with food
c) Any known medical illness like Diabetes mellitus, thyroid problem,congenital heart
d) Menstrual history in woman.
Safe Diagnostic Strategy
A Safe Diagnostic strategy was designed by John Murtagh and the method was publish in
Australian Family Physician Journal, volume 19 in the year of 1990. It outlines a diagnostic
model applicable to all common problems encountered in general practice. It has an inbuilt
safety strategy to help the busy practitioner consider life threatening conditions and other serious
illnesses during the diagnostic process.
A health care personnel must bear in their mind that there are 5 questions need to be answered
when dealing with a patient who presented to them. The strategy is to demonstrate that you have
a logical and safe approach to making diagnoses.
What is the most likely
Case Study What serious disorders must
not be missed?
54 years old Malay lady with
complaint of palpitation for What conditions are often
the past 6 months missed?
Could the patient have a
masquerading illness? List at
Is the patient trying to say
1) Most likely diagnosis – Perimenopausal syndrome
2) Serious disorder not to miss – Unstable Atrial fibrillation
3) Condition often miss – Diabetes mellitus, hyperthyroidism, pheochromocytoma
4) Masquerading illness – alcohol intoxication, caffeine abuse, stess and anxiety
5) Is the patient try to say something – most likely related with psychological aspect.
What is your diagnosis for this lady?
The most probable diagnosis for this patient based on limited data given (age, sex, onset and
duration) is mainly benign and non cardiac related. I’m confidently say that based on data
provided by Hoefman E, et al
Therefore my most probable differential diagnosis would be
1. Perimenopausal syndrome
Palpitations associated with menopause and the perimenopausal period are usually related to
sinus tachycardia or to simple arrhythmias because of increased sympathetic drive. The
menopausal state is characterized by a marked decrease in ovarian estradiol production and an
associated increase in adrenergic activity. In menopausal women, cardiovascular control shifts
toward a sympathetic predominance. Estrogen replacement therapy improves this altered control
and can improve the cardiovascular symptoms such as hot flushes and papitations. Of note, some
progestins given in conjunction with estrogen replacement may trigger cardiac arrhythmias in
patients; however, this effect is usually remedied by decreasing the progestin dose or by using a
natural progestational agent. [Elizabeth R. Keeler et al]
2. Anxiety disorder.
Management for this patient
1) 12 lead ECG for cardiac problem screening
2) Re assurance for the patient.
3) Psychological councelling to relieve anxiety.
4) Severe anxiety may require further referral to psychiatrist for anti anxiety management.
Evidence Based Medicine
1) Relationship between pulse palpation and atrial fibrillation
Georga Cooke et al has analysed three studies by Morgan & Mant, Somerville et al and Sudlow
et all that compared pulse palpation with ECG. The estimated sensitivity of pulse palpation
ranged from 91% to 100%, while specificity ranged from 70% to 77%. Pooled sensitivity was
94% (95% confidence interval [CI], 84%–97%) and pooled specificity was 72% (95% CI, 69%–
75%). The pooled positive likelihood ratio was 3.39, while the pooled negative likelihood ratio
was 0.10. Therefore the author conluded that pulse palpation has a high sensitivity but relatively
low specificity for atrial fibrillation. It is therefore useful for ruling out atrial fibrillation. It may
also be a useful screen to apply opportunistically for previously undetected atrial fibrillation.
Assuming a prevalence of 3% for undetected atrial fibrillation in patients older than 65 years,
and given the test’s sensitivity and specificity, opportunistic pulse palpation in this age group
would detect an irregular pulse in 30% of screened patients, requiring further testing with ECG.
Among screened patients, 0.2% would have atrial fibrillation undetected with pulse palpation.
2) Goal standard in accessing cardiac arrhythmia
Obtaining a 12-lead echocardiogram (ECG) at the onset of symptoms is the gold standard in
diagnosing cardiac arrhythmias. The resting 12-lead ECG offers valuable information regarding
the presence of pre-existing conditions such as pre-excitation and ischaemic heart disease. Event
recorders used over a 2-week period offer an effective way to capture cardiac arrhythmias.
Holter monitors are also used in patients who have frequent symptoms. With the advent of new
transcatheter cardiac ablation techniques and depending on the rhythm disturbance, management
has become more successful (Ramzi YK & Mark D)
3) Differential diagnosis for palpitation
The majority of patients presenting with palpitations are suffering from either anxiety or ectopic
beats. In anxious patients, a recording of their ECG showing sinus rhythm while they have
symptoms is reassuring for patient and doctor alike. The majority of ectopics are also benign, but
in the case of ventricular ectopics it is important to ensure that there are not more serious
ventricular arrhythmias occurring at other times. Again a recording of the rhythm while the
patient is symptomatic is very helpful.Palpitations can be a reflection of dangerous cardiac
arrhythmias. In one study of 190 patients with palpitations, 1.6% died and 1.1% had a stroke
within 1 year of presentation (Ramzi YK & Mark D)
4) Accurate prediction by GPs of the presence of a (relevant) arrhythmia in patients
presenting with palpitations and/or lightheadedness
This study by Emmy Hoefman et al confirmed that an accurate prediction by GPs of the presence
of a (relevant) arrhythmia in patients presenting with palpitations and/or lightheadedness and an
inconclusive standard ECG is not possible at this moment. GPs do not have an accurate
instrument at hand to predict which patients might profit from further diagnostic evaluation. As
our sample was small, further research is needed to develop accurate triage rules.
In cases where a standard ECG does not lead to a diagnosis, evidence suggests that a continuous
event recording (CER) might be very helpful in the decision to treat or refer a patient. Reassuring
a patient without using this diagnostic test might be premature.Therefore, a low threshold for
further diagnostic testing seems adequate.
5) Non-cardiac chest pain and benign palpitations in the cardiac clinic in 94 consecutive
referrals by general practitioners to a cardiac clinic with the presenting disorder of
chest pain or palpitations.
Fifty one patients were given no major physical diagnosis. Although all were new referrals to the
clinic, many had already received considerable medical care for their symptoms.
Conclusion: A substantial proportion of the consecutive referrals continued to describe
symptoms and disability throughout the three years after clinic attendance. Outcome was poor
for those who had negative investigations and were reassured that they had no cardiac disorder or
other serious physical finding. These results have implications for defining the role of
psychological assessment and for the formulation of cost effective clinical measures to (a)
minimise disability associated with cardiac disorder; and (b) prevent and treat handicaps in those
without major physical diagnoses [Richard Mayou et al]
6) Characteristics of patients presenting to a cardiac clinic with palpitation
Most patients presenting to secondary care with palpitation do not have serious underlying
cardiovascular conditions. Concurrent psychological problems are common and persistent.
Aetiology may be seen as an interaction of pathology, awareness of normal physiology, and
psychological variables. Few patients require specialist cardiological treatment, but simple
reassurance is of limited effectiveness. A stepped care approach may improve outcomes and
needs rigorous evaluation.[R. Mayou et al]
7) Laboratory Evaluation of palpitation based on article by Elizabeth R. Keeler et al
A few basic hematological and chemistry studies should be performed to assess for anemia,
hyperthyroidism, electrolyte disturbances (especially in patients taking digitalis), and
hypoglycemia. If there is evidence suggesting a pheochromocytoma, a 24-hour urine assessment
for vanillylmandelic acid is helpful
All patients complaining of palpitations should have an electrocardiogram to distinguish
supraventricular from ventricular tachycardias and to help to identify the type of SVT during the
If the history, physical examination, and a 12-lead electrocardiogram fail to point to an etiology
of the palpitations, further investigation should be performed.
If palpitations occur on a daily basis, 24-hour continuous ambulatory electrocardiographic
monitoring may be helpful (Holter monitors)
When palpitations are associated with exertion, an exercise stress testing should be done because
ventricular tachycardia may be uncovered
An echocardiogram should be done when the history, physical exam, or EKG raise suspicion of
valvular disease or cardiomyopathy
Electrophysiological studies (EPS), either via the transesophageal or intracavitary route, are able
to identify some arrhythmias. Because this technique is invasive, EPS should be limited to
individuals who have asymptomatic nonsustained VT and either evidence of underlying heart
disease or a reduced ejection fraction (< 40%)
8) Prevalence of palpitations, cardiac arrhythmias and their associated risk factors in
ambulant elderly, by Lok NS, Lau CP, Int J Cardiol. 1996 Jun;54(3):231-6.
To determine the prevalence of palpitations, cardiac arrhythmias and associated cardiovascular
risk factors in an ambulatory elderly population, 1454 ambulatory elderly people (219 men and
1235 women, age range 60-94 years) were assessed in a territory-wide health survey including
anthropometric measurements, biochemical blood tests, questionnaire interview and resting
surface ECG examination. Prevalence of palpitations and ECG abnormalities were determined
and correlated with coronary risk factors and biochemical blood tests. Palpitations were present
in 121 subjects (8.3%) and cardiac arrhythmias were found in 183 subjects (12.6%). Conduction
abnormalities and sinus bradycardia were the commonest findings (9.8%). Premature beats
(atrial 2.3%; ventricular 1%) were the next most frequent arrhythmia. Atrial fibrillation was the
commonest sustained arrhythmia that was present in 19 subjects (1.3%). Compared with those