Skips, thumps and bumps‌ should I worry? By Dr Tim Gattorna, Cardiologist, Subiaco, Midland, Northam & Kalgoorlie Palpitations are a common, subjective symptom resulting in frequent presentations in the primary health care setting. Although generally benign, they can occasionally be a manifestation of a potentially life-threatening arrhythmia. Appropriate evaluation is therefore required. Cardiac or arrhythmic causes are the most common aetiology. Other causes include medical conditions (e.g. endocrine and metabolic abnormalities), psychiatric disorders, medication effects, and drug or other substances. It is important not to label a patient’s palpitations as secondary to panic/anxiety without
Key messages Palpitations are frequent in the community History, examination and basic investigations can determine cause in many patients Case finding and management of AF is critical as is awareness of red flags. a proper evaluation, as around 50% of this group will be diagnosed with an arrhythmic cause. A targeted and thorough history is required given the majority of patients present in sinus rhythm,
Table: Risk stratification
Skipped beats Thumping beats Short fluttering Slow pounding AND Normal ECG AND No Family History AND No Structural Heart Disease Low Risk Manage in Primary Care
History suggests recurrent tachyarrhythmia Palpitations with associated AND/OR symptoms Abnormal ECG AND/OR Structural Heart Disease Refer to cardiology
Palpitations during exercise Palpitations with syncope/ near syncope High risk of structural heart disease Family history of inheritable heart disease/SADS High degree AVblock Refer to cardiology with urgency
Table published with permission of Primary Care Cardiovascular Journal
38 | APRIL 2020
between episodes of palpitation. The description of skips, jumps and thumps may represent ectopic beats (atrial or ventricular); rapid onset/onset of racing heart may be consistent with a supraventricular tachycardia. Ask about onset and offset (sudden or gradual), duration (momentary or sustained), frequency of episodes, triggers, any associated symptoms (e.g. syncope, breathlessness or chest pain), pre-existing cardiac issues and any family history of sudden cardiac death or cardiac conditions.
Which investigations? This depends on the history, frequency and duration of episodes. A 12-lead ECG (if symptomatic at the time) is the gold standard. Ambulatory (Holter) monitoring is useful if frequent symptoms, whilst an event monitor is useful in less frequent symptoms. Loop recording (for recurrent syncope), echocardiography to evaluate heart structure and stress testing (if exercise induced or suspected IHD) can be helpful. Smart phone monitoring/apps may be the future. continued on Page 39
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