1. The document provides an overview of four patient cases presenting with palpitations. It reviews the approach to evaluating patients with palpitations, including obtaining a history, ECG, Holter monitor or event monitor depending on symptom frequency. 2. For Case 1, a Holter monitor showed ventricular tachycardia, indicating a need for an ICD. Case 2's Holter demonstrated SVT, leading to ablation. Case 3's normal Holter did not explain symptoms but an event monitor was ordered due to underlying cardiomyopathy. Case 4 required further workup. 3. The document emphasizes correlating rhythms to symptoms to make a diagnosis, and considering risk of malignant arrhythmias to guide management.

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Palpitations and Holters 101
A quick review in 25 minutes for the Family Physician
Jonathan Tang
UBC Division of Cardiology
BCCFP 2014 Spring Family Medicine Conference
June 8, 2014
Disclosures
Relationships with commercial interests:
Received financial support:
In-kind support:
Conflict of interest:

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Objectives
1. To develop an approach to the care of
patients with palpitations
2. To become familiar with the Holter report
Case 1. The case of Willy Maykit.
You see Mr. Maykit, a 70 year old chap, in your office.
He is a gentleman with known ischaemic cardiomyopathy,
with a 4-vessel CABG 5 years ago, and an LVEF 40%.
He comes to your office today because he had sudden onset
of “heart racing” in his chest, which was associated with
lightheadedness, and after a minute, he lost consiousness.
He came to after a few minutes, and is now back to
normal.
This has occurred once before, about 6 months ago.

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Case 2. The case of Tak Ekardya.
You see Mr. Ekardya, a 28 year old chap, in your office.
He is an otherwise well young athletic individual, who has
noted palpitations over the last 6 months.
What he notes is that every 10 weeks or so, he will have,
with utter randomness, a feeling of “rapid heart
beating”, associated with lightheadedness, but without
ever having had loss of consiousness. This will last 10
minutes, and just as abruptly as it started, it will stop.
Case 3. The case of Earl E. deMyse.
You see Mr. deMyse, a 58 year old chap, in your office.
He came to the attention of cardiologists 3 years ago, when
he underwent an ECG for insurance purposes
demonstrating LVH. A subsequent echocardiogram and
cardiac MRI demonstrated findings consistent with
hypertrophic cardiomyopathy.
He now has symptoms of “heart pounding hard”, which
occurs once every 3 weeks or so, lasts a few seconds at
most, and is not associated with lightheadedness or
chest pain. He has never had syncope.

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Case 4. The case of Terry Fyde.
You see Miss Fyde, a 26 year old, in your office.
She is an otherwise healthy lady who comes to your
attention after having had a syncopal spell.
On this occasion, she was at work at the counter of her
university library. She had missed her lunch and the
room was full of students. She felt unwell,
lightheaded, and after a few minutes, proceeded to go
to get a drink of water but lost consciousness at the
water cooler.
This type of scenario has occurred a few times before,
and she has lost consciousness all times, thankfully
without much more than a bruised ego.
Her ECG is normal.
Palpitations - the second most common cardiac symptom

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Definition
an awareness of heart beat
a disagreeable sensation of pulsation in the chest and/
or adjacent areas
rapid fluttering, irregular
“flip flop”
sudden pause - then a “boom”
rapid, regular, fluttering
associated with neck pounding
sudden on/off “like a switch”
Palpitations - historical features
Substrate risk:
• known structural or ischaemic heart disease
hypertension, valvular heart disease, previous MI, decreased EF,
congenital heart disease, hypertrophic cardiomyopathy, etc.
• known electrical substrate
Wolff-Parkinson-White, prolonged QT, Brugada, etc.
• family history of possible inherited heart disease
hypertrophic cardiomyopathy, long QT syndrome, Brugada, ARVC, dilated
cardiomyopathy, Fabry’s, unexplained sudden cardiac death in young
family member, etc.
Important features to establish

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Palpitations - historical features
Characteristics of palpitations:
regularity, rate, onset and termination
triggers (ie. exercise) and aggravating/alleviating factors
Burden of symptoms
• frequency and duration of symptoms
• other associated symptoms (ie. chest pain, nausea, sweating, etc.)
• haemodynamic impairment (syncope or pre-syncope)
Important features to establish
What is your next step?
a. Get an ECG
b. Get a Holter
c. Send him to ER
d. Tell him to get a will
Case 1. The case of Willy Maykit.
You see Mr. Maykit, a 70 year old chap, in your office.
He is a gentleman with known ischaemic cardiomyopathy, with a 4-vessel
CABG 5 years ago, and an LVEF 40%.
He comes to your office today because he had sudden onset of “heart racing”
in his chest, which was associated with lightheadedness, and after a minute, he
lost consiousness. He came to after a few minutes, and is now back to
normal.
This has occurred once before, about 6 months ago.

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Why do we worry about palpitations?
The management strategy depends on:
• the suspected arrhythmic diagnosis
• the ability to obtain definitive ECG diagnosis
• the risk of a malignant arrhythmia
• the impairment in quality of life
Manifestations of possible death
What is the cause of his syncope?
a.Ventricular tachycardia
b. Can’t be sure
c. SVT
d. Vasovagal (from pretty GP)
Case 1. The case of Willy Maykit.
Mr. Maykit is seen in the Emergency. His ECG demonstrates sinus rhythm with
a prior inferior infarct. He is admitted to a monitored bed.
He is asymptomatic and reading his book, when the telemetry alarm bells go
off. The strip shows the following:

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Diagnosis: the need for rhythm-symptom correlation
The only means to achieve a definitive diagnosis
behind a patient’s symptoms is to obtain an ECG at
the time of palpitations.
However, in the absence of a diagnosis, one can infer
the likely cause of symptoms, and the risk associated
with the suspected arrhythmia.
Risk: what to look for on monitoring
the word “normal”
narrow-complex
not too fast
short
infrequent
wide-complex
fast
sustained
frequent
associated with syncope
THE BAD

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Diagnosis: what method to choose?
HOLTER
IMPLANTABLE
LOOP
RECORDER
Easily available
Limited duration
(24 - 48 hrs)
Useful for frequent
symptoms
Diagnostic yield:
up to 10%
EVENT/LOOP
RECORDER
Longer duration
(1 to 4 weeks)
Useful for less
frequent symptoms
Needs patient self-
activation
Diagnostic yield:
25%
Longest duration
(up to 3 years)
For infrequent but
debilitating symptoms
with suspected cardiac
cause
Diagnostic yield:
70%
Case 1. The case of Willy Maykit.
Mr. Maykit was referred to a cardiologist for further
management for his high-risk palpitations/syncope
with ventricular tachycardia suspected to be the
underlying cause.
A dual-chamber ICD was placed.

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What is your next step?
a. Get an ECG
b. Get a Holter
c. Get an event monitor
d. Tell him to stop whining
Case 2. The case of Tak Ekardya.
You see Mr. Ekardya, a 28 year old chap, in your office.
He is an otherwise well young athletic individual, who has noted palpitations
over the last 6 months.
What he notes is that every 10 weeks or so, he will have, with utter
randomness, a feeling of “rapid heart beating”, associated with lightheadedness,
but without ever having had loss of consiousness. This will last 10 minutes, and
just as abruptly as it started, it will stop.
Case 2. The case of Tak Ekardya.
His ECG is interpreted as normal.
You are cognizant that it will be difficult to obtain a
diagnosis for this gentleman as his symptoms are
relatively short and infrequent.
While a diagnosis is not possible at this time, with a normal
history, examination, and ECG, you attempt to reassure
him that his symptoms do not confer any high-risk
features. You give him instructions to seek medical
attention and get an ECG if his symptoms become
protracted.
He looks at you with a doubtful face, but duly states that he
will do as instructed.

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Case 2. The case of Tak Ekardya.
You see him back in the office after 3 months.
He tells you know that with his examinations, his
symptoms are occurring longer and more frequently
(once every few days, 30 minutes each time now). You
note that he is drinking more coffee as well.
You arrange for a Holter monitor.

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Case 2. The case of Tak Ekardya.
HOLTER REPORT
NAME: TAK EKARDYA
DOB: 04/31/1986
REPORT:
Predominant sinus rhythm with frequent PACs
Runs of regular, narrow complex, long RP tachycardia, possible atypical AVNRT or atrial
tachycardia; longest run 551 beats at 185 bpm
Symptoms of “palpitations” correlated with runs of SVT
IMPRESSION:
Symptomatic SVT; long RP tachycardia, atypical AVNRT or atrial tachycardia
HOLTER MONITOR PATIENT DIARY
TIME ACTIVITY SYMPTOMS TIME ACTIVITY SYMPTOMS
0920 Eating
0950 Watching TV
1000 Bathroom
1030 Driving to work
1055 Meeting
1100 Sitting at desk
1130 Coffee
1200 Lunch
1300 Angry
1320 Feel better
1350 Coffee
1500 Email
1600 Leaving work
1730 In accident
1750 Bathroom
1800 Making dinner
1850 Sitting
1910 Bus to friends
1920 Watching TV
2000 Chatting
2100 Talking to mom
2200 Going to sleep
0800 Breakfast
0900 Return Holter
None
None
None
None
Pounding heart
“Blip”
Heart racing
None
Heart racing
None
Heart racing
Tired
Happy
Chest pain
None
None
None
None
None
None
None
None
None

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Going through a Holter report
HOLTER REPORT
NAME: TAK EKARDYA
DOB: 04/31/1986
REPORT:
Predominant sinus rhythm with frequent PACs
Runs of regular, narrow complex, long RP tachycardia, possible atypical AVNRT or atrial
tachycardia; longest run 551 beats at 185 bpm
Symptoms of “palpitations” correlated with runs of SVT
IMPRESSION:
Symptomatic SVT; long RP tachycardia, atypical AVNRT or atrial tachycardia
NAME
HEART RATES
TYPES OF ECTOPICS
SUBDIVISIONS OF ECTOPY
Isolated, Couplets, Runs, Duration, Rate
REPORT
Predominant sinus rhythm with frequent PACs
Runs of regular, narrow complex, long RP tachycardia, possible atypical AVNRT or atrial
tachycardia; longest run 551 beats at 185 bpm
Symptoms of “palpitations” correlated with runs of SVT
IMPRESSION:
Symptomatic SVT; long RP tachycardia, atypical AVNRT or atrial tachycardia
Bare facts:
Diagnostic Holter with rhythm symptom
correlation
Diagnosis: SVT
Non-lethal
Significant impairment in quality of life
Case 2. The case of Tak Ekardya.
Mr. Ekardya’s Holter report was reviewed.
He was reassured that his new diagnosis of SVT was not
life-threatening.
The possible management options were discussed. Given
that he had significant impairment in quality of life, a
referral was made for him to undergo an
electrophysiology study and ablation.
He underwent ablation for AVNRT and has not had any
further episodes since.

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What is your next step?
a. Get an ECG
b. Get a Holter
c. Get an event monitor
d. Send him to a cardiologist
Case 3. The case of Earl E. deMyse.
You see Mr. deMyse, a 58 year old chap, in your office.
He came to the attention of cardiologists 3 years ago, when he underwent an
ECG for insurance purposes demonstrating LVH. A subsequent echocardiogram
and cardiac MRI demonstrated findings consistent with hypertrophic
cardiomyopathy.
He now has symptoms of “heart pounding hard”, which occurs once every 3
weeks or so, lasts a few seconds at most, and is not associated with
lightheadedness or chest pain. He has never had syncope.
Patients with hypertrophic cardiomyopathy are at
increased risk of sudden cardiac death
Therefore, suspicion of any possible arrhythmic symptoms
should come to the attention of a cardiologist
The cardiologist reviews Mr. deMyse and feels that on
history and review of his recent tests, there are no high risk
features to suggest a further increased risk of a ventricular
arrhythmia.
However, to further delineate his risk, Mr. deMyse undergoes
a Holter.
Case 3. The case of Earl E. deMyse.

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Case 3. The case of Earl E. deMyse.
HOLTER REPORT
NAME: EARL DEMYSE
DOB: 13/30/1956
REPORT:
Sinus rhythm throughout
Only one PAC noted
No arrhythmias. No symptoms noted.
IMPRESSION:
Normal Holter
Bare facts:
This is a reassuring Holter (ie. favourable prognosis)
He is still at increased risk of sudden cardiac death
given his known diagnosis of hypertrophic
cardiomyopathy
However, there are no high-risk features to suggest
that he is at further increased risk
We still don’t know the actual etiology behind his
“heart pounding” given the lack of rhythm-symptom
correlation
In patients with hypertrophic cardiomyopathy, the
presence of nonsustained ventricular tachycardia, even
if asymptomatic, would be considered to be a feature
of increased risk for sudden cardiac death
The cardiologist reviews Mr. deMyse again. He is still
concerned that his “heart pounding” could still represent a
ventricular dysrhythmia (ie. PVC).
He arranges for an event monitor.
Before the event monitor is arranged, Mr. deMyse notes
that he is under more financial stress and that he is now
having these “heart pounding” almost daily. Therefore, his
cardiologist arranges for a Holter.
Case 3. The case of Earl E. deMyse.

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Case 3. The case of Earl E. deMyse.
HOLTER REPORT
NAME: EARL DEMYSE
DOB: 13/30/1956
REPORT:
Sinus rhythm throughout
Frequent, isolated PVCs. No runs.
Symptoms of “heart pounding” corresponded to sinus rhythm
IMPRESSION:
Sinus rhythm with frequent PVCs. No rhythm symptom correlation.
PVCs: what to do about them?
In the presence of a reassuring history and physical
examination, normal ECG, and normal cardiac
structure, PVCs are considered to be benign.
That means:
• reassuring history:
• no family history of sudden cardiac death
• no genetic predisposition (ie. no family history of hypertrophic
cardiomyopathy, Brugada, etc.)
• no history to suggest angina or syncope
• normal physical examination:
• normal ECG:
• no evidence of WPW, LVH, long QT, Brugada, etc.
• normal echocardiogram:
• no significant ventricular or valvular disease

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PVC-induced cardiomyopathy: a new entity
Do the number of PVCs matter?
“PVC-induced cardiomyopathy” as a diagnosis is still a new
entity in its infancy and more is still yet to be known
The higher the PVC burden, the further the risk of
depressed EF
PVCs: in a nutshell
1. PVCs are extremely common, and in the majority of cases,
considered to be benign.
2. In the setting of isolated PVCs without sinister findings (on history,
examination, and ECG), all that is needed is reassurance.
3. In the setting of suspected frequent PVCs, then in addition to the
history, examination, and ECG, a Holter (to demonstrate PVC
burden) and echocardiogram is valuable.
Definitions of frequent PVCs vary: > 60/hr, > 1% of total QRS complexes, > 1000 per 24
hours
4. There is a new entity of “PVC-induced cardiomyopathy”
5. A cardiology referral should be considered for patients who are:
a) symptomatic, or;
b) if they have frequent PVCs, to delineate the best management
strategy for further serial evaluation

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The cardiologist determines that Mr. deMyse has “heart
pounding” palpitations that is non-arrhythmic in origin.
He has frequent PVCs, but these are asymptomatic. There
is no evidence of nonsustained ventricular tachycardia on
his Holter monitor reports.
Given that Mr. deMyse has hypertrophic cardiomyopathy, the
cardiologist decides to follow Mr. deMyse closely, and
informs him of possible symptoms that would warrant
urgent evaluation.
A followup visit is arranged for 3 month’s time.
Case 3. The case of Earl E. deMyse.
What is your next step?
a. Get a Holter
b. Get an event monitor
c. Reassure her, it’s vasovagal
d. Tell her to stop working
Case 4. The case of Terry Fyde.
You see Miss Fyde, a 26 year old, in your office.
She is an otherwise healthy lady who comes to your attention after having had a
syncopal spell.
On this occasion, she was at work at the counter of her university library. She
had missed her lunch and the room was full of students. She felt unwell,
lightheaded, and after a few minutes, proceeded to go to get a drink of water
but lost consciousness at the water cooler.
This type of scenario has occurred a few times before, and she has lost
consciousness all times, thankfully without much more than a bruised ego.

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Case 4. The case of Terry Fyde.
HOLTER REPORT
NAME: TERRY FYDE
DOB: 02/30/1986
REPORT:
Sinus rhythm throughout
Episodes of sinus slowing and junctional escape rhythm
One episode occurred during daytime hours, with associated “dizziness and nausea”, suggesting
intrinsic sinus node disease
IMPRESSION:
Sinus node dysfunction. Abnormal Holter.
A referral was made to have Terry see a cardiologist.
The cardiologist agreed that her symptoms were most likely
vasovagal. Further understudy of the Holter was taken.
Case 4. The case of Terry Fyde.
It turns out that she had both a Holter and lab work
requested. Her labs were drawn while Holter on. Being
terrified of needles, she felt vagal at the time of her needle
puncture. Her Holter was consistent with high vagal tone.

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Terry was reassured of the benign nature of her vasovagal
syncope and the reassuring Holter results.
She was advised of the conservative treatment measures
with regards to her vasovagal events.
She has continued working in the library and while a few
more episodes of “feeling unwell” have occurred, these are
self-limiting and she has not had any further syncope.
Case 4. The case of Terry Fyde.
Summary
1. Many people have palpitations.
2. An assessment of palpitations includes a detailed history,
physical examination, and ECG, to determine the
underlying risk of a possible sinister arrhythmia.
3. The need for further investigations, and the type of
ambulatory ECG monitoring, is aimed towards achieving
a definitive diagnosis and assessment of prognosis.
4. This depends on the frequency of symptoms, the need
for diagnosis, and the underlying perceived risk.
5. Remember that your friendly neighbourhood cardiologist
is always available!

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Thank you