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At the heart of general practice since 1960

How to diagnose and treat childhood food allergies

Palpitations are among the

most common symptoms in general practice

­ Dr Mark O'Neill

and Dr Wyn Davies explain how to manage five different presentations

Case 1

Sudden short palpitations

A 23-year-old presents to his GP with a four-year history of recurrent palpitations. He describes a 'rapid pounding' in his chest, which both begins and terminates suddenly. There is no specific precipitant, and episodes last from five minutes to up to two hours, occurring approximately once every two months. There is occasionally some associated chest tightness, but he has never collapsed or lost consciousness as a result of his palpitations.

Once, while on holiday in France, he attended a casualty department during a prolonged episode where he was given 'an injection' and his palpitations stopped immediately. There is no other history of note and physical examination is entirely normal.

His 12-lead electrocardiogram shows a short PR interval and a delta wave, that is, slurred upstroke of the QRS complex, suggesting the presence of an accessory atrioventricular electrical communication other than the atrioventricular (AV) node and the diagnosis of WPW syndrome.

Discussion

This young man gives a typical history for a supraventricular tachycardia as the cause of his palpitations.

Delta waves are visible on the surface ECG in 0.15-0.25 per cent of the general population. The incidence of sudden cardiac death in patients with the WPW syndrome is estimated at 0.15-0.39 per cent over a 10-year follow-up period1.

In 90 per cent of WPW patients the tachycardia circuit involves anterograde conduction down the AV node, and retrograde conduction up the accessory pathway. The accessory pathway is therefore critical for perpetuation of the circuit.

Patients with WPW syndrome should all be referred for electrophysiological risk assessment and consideration for curative ablation of the accessory pathway. Successful ablation can be achieved in 95 per cent of patients with an overall procedural risk of serious complications of 1-2 per cent1.

Patients should be instructed in how to use vagal manoeuvres to terminate symptomatic episodes. The Valsalva manoeuvre, carotid sinus massage and facial immersion in cold water may all terminate a tachycardia involving the AV node.

Pharmacological therapy may be appropriate for the patient with very infrequent symptoms or who is reluctant to undergo ablation therapy. Agents that may be used include diltiazem,

?-blockers, flecainide and propafenone; however, this decision is best left to a cardiologist.

Case 2

A 'fluttering'

in the chest

A 39-year-old presents with a two-week history of palpitations. She describes a 'fluttering' in the chest approximately three times per week lasting up to 30 seconds, but no specific precipitant and no exacerbating features. She is otherwise fit and well, and physical examination is entirely normal. The

12-lead ECG shows normal sinus rhythm.

At the end of the consultation she mentions that her daughter has recently left home to go to university.

Discussion

This patient is extremely unlikely to have a cardiac arrhythmia as the cause of her palpitations. The description of fluttering is often given for episodes of paroxysmal AF, and for this reason an ambulatory monitor together with a thyroid function test is worthwhile here.

With palpitations occurring only three times per week,

24-hour ambulatory is likely to be of little use, and so a patient-activated event recorder is the most appropriate device with two weeks being adequate to achieve a diagnostic recording in up to 80 per cent of patients2.

Case 3

Loss of

consciousness

A 30-year-old presents to his GP following an episode of loss of consciousness earlier that day while lifting some building bricks in his back garden.

He recalls the sudden onset of severe, regular palpitations with associated chest tightness and dizziness for approximately 30 seconds before blacking out.

This was his first episode, though he mentions that his

father died suddenly at the age of 34, for which no cause was found.

Physical examination reveals a harsh mid-systolic murmur at the left sternal border. The electrocardiogram shows evidence of left ventricular hypertrophy.

Discussion

There are important clues to the diagnosis in this patient. The first is the history of syncope associated with exertion, the second is the family history of unexplained death and the third is the physical finding of a murmur suggesting structural cardiac disease.

The likelihood of this patient having a cardiac cause for his palpitations is extremely high, and he should therefore be referred urgently to a consultant cardiologist.

Based on the information available from the initial consultation, the diagnosis of hypertrophic cardiomyopathy is likely. The diagnosis and management of hypertrophic cardiomyopathy are beyond the scope of this article;

however, the reader is referred to a recent excellent review

of the subject3.

Case 4

Recurrent

dizziness

A 72-year-old with stable NYHA Class II heart failure secondary to ischaemic heart disease presents to the surgery with a one-week history of recurrent episodes of dizziness, but no worsening of her angina. The episodes occur two or three times daily, and although she has never lost consciousness, she has felt 'close to it' on a few occasions.

They are not related to posture and she has not noticed any palpitations with her episodes. The heart rate is 58 beats/min and the remainder of the physical examination reveals no evidence of fluid overload.

Her medication comprises aspirin, a ?-blocker, an angiotensin-converting enzyme inhibitor and a statin.

A recent electrolyte profile was normal. The 12-lead ECG shows sinus rhythm with left bundle branch block.

She is referred for an open-access 24-hour tape, which shows recurrent episodes of regular broad complex tachycardia up to 45 seconds in duration at a rate of 150 beats/min, which correlate well with her symptoms as reported on the patient diary.

Discussion

This patient presents with what may be symptomatic ventricular tachycardia or a supraventricular tachycardia with aberrant conduction. Interestingly, she does not specifically complain of palpitations. However, the patient history is the most important feature here and the index of suspicion for a cardiac arrhythmia must be high in a patient with structural heart disease (see box right).

Case 5

Heartbeat

'out of control'

A 66-year-old comes to the surgery complaining of palpitations over the past two weeks. He describes his heart beat as being 'completely out of control'. He has noticed that he is breathless on exertion over the same period of time, though before that he was swimming 10 lengths daily without difficulty.

On examination the patient is euthyroid. The blood pressure is 160/94mmHg. The radial pulse rate is 120 beats/min and irregularly irregular. The apex beat is not displaced and there is no apical radial deficit.

Both heart sounds are normal. There is no third heart sound and no audible cardiac murmur. The chest is clear to percussion and auscultation.

The 12-lead ECG confirms AF with a ventricular response rate of 90-120 beats/min.

Discussion

This is a typical presentation for a patient with new-onset AF, which remains the most common arrhythmia in the general population and can lead to a three-fold increased risk of developing heart failure and a five-fold risk of stroke4.

The physical examination searches for potential precipitants, for example, mitral valve disease, hypertension and thyrotoxicosis, to name but a few.

The management of atrial fibrillation is two-pronged: the risk of thromboembolism must be addressed, and there is now very clear evidence that warfarin is the agent of choice in patients over the age of 65 with AF. The decision of rate versus rhythm control remains a controversial one and should be tailored to the individual; however, in the present case a

?-blocker would be the most appropriate drug given the co-existing hypertension, in conjunction with warfarin anticoagulation and referral to the local cardiology service for further evaluation.

Urgent referral to a consultant

cardiologist is appropriate...

...where evaluation will include:

·Transthoracic echocardiography to assess left ventricular function and to estimate the ejection fraction

·Coronary angiography to exclude a coronary stenosis, which may be amenable to revascularisation

·Assessment of suitability for an implantable cardioverter defibrillator

There is an increasingly robust evidence base for the prophylactic use of ICDs in the management of patients with cardiac failure5.

Assessment for an ICD will include an electrophysiological study to assess the likelihood of a supraventricular versus a ventricular origin for the patient's palpitations.

References

1 Blomstrom-Lundqvist C et al. ACC/AHA/ESC Guidelines for the Management of Patients with Supraventricular Arrrhythmias ­ Executive Summary. A report on the American College of Cardiology/ American Heart Association Taskforce on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias).

J Am Coll Cardiol 2003;42(8):

1493-1531

2 Zimetbaum PJ, Josephson ME. The evolving role of ambulatory arrhythmia monitoring in general clinical practice. Ann Intern Med 1999;130:848-56

3 Elliot P, McKenna WJ. Hypertrophic cardiomyopathy.

Lancet 2004;363:1881-91

4 Martins JL et al. Rapid access arrhythmia clinic for the diagnosis and management of new arrhythmias presenting in the community:

a prospective, descriptive study.

Heart 2004;90:877-81

5 Bardy GH et al. For the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart Failure.

NEJM 2005;352:225-37

Find the full version of this article in The Practitioner, free with your copy of Pulse next week

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