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Palpitations

Dr Puneet Kakar and Professor Gregory Lip answer GP Dr Kathryn Griffith's questions on potentially dangerous cardiac rhythms

Dr Puneet Kakar and Professor Gregory Lip answer GP Dr Kathryn Griffith's questions on potentially dangerous cardiac rhythms

1. Which are the most important questions we should ask when taking the history to help us decide if the symptoms are significant?

Palpitations can be a manifestation of a number of diseases and illnesses including anxiety, hyperventilation, thyrotoxicosis and cardiac conduction disorders or arrhythmias, to name just a few. In any history, it is essential to ask about relevant facets of presentation and suspected causes. For palpitations as such, a probing approach into frequency, onset, aggravation, relief, duration, regularity and association with other sinister symptoms such as chest pain, syncope and dizziness will be valuable in determining the investigative approach.

2. What is a positive family history in this context?

Without knowing the exact diagnosis and cause of palpitations it is hard to pinpoint a positive family history to the presenting complaint. However, a positive diagnosis of certain conduction disorders in the family significantly increases the chances that the patient's palpitations have a serious cause. For example, a patient with a family history of sudden cardiac death who presents with palpitations must be referred immediately to a specialist and sinister causes ruled out.

3. What are the red flag symptoms that make you recommend urgent referral to a cardiologist?

Palpitations secondary to cardiac conduction disorders may be entirely benign or have potential catastrophic consequences. Although symptoms alone are not enough to gauge the entire picture, certain telltale symptoms such as syncope or pre-syncope, draining of facial colour, onset with exercise, shortness of breath and chest pain may indicate an abnormal and dangerous rhy-thm and should be referred to a specialist.

4. Which features should we look for on the ECG of an asymptomatic patient to help make the diagnosis in a patient with palpitations?

Palpitations may or may not be associated with ECG changes. Often the ECG may look normal. In certain rare conditions such as Brugada syndrome and Wolff-Parkinson-White syndrome there may be characteristic resting ECG changes but these are relatively rare conditions and in the majority of patients there are no ECG changes at rest while asymptomatic. In the event of a patient experiencing palpitations, a concurrent ECG is useful in making a diagnosis but this is often difficult as the timing of palpitations may not coincide with the ECG recording.

5. Which blood tests should we arrange in primary care?

An electrolyte and blood profile check in every patient is particularly important so as to ensure that there are no electrolyte disorders, which can be a common cause of palpitations. Apart from these, thyroid function tests are useful. Hyperthyroidism may be associated with palpitations.

6. What are the methods you use to monitora patient over 24 hours or more, and how doyou decide which method to use?

Where a 12-lead ECG or a rhythm strip is unable to determine the underlying abnormal rhythm, we employ a 24- or 48-hour ECG recording, seven-day ECG recording or an event recorder according to the frequency of symptoms. For example, in a patient who experiences palpitations once or twice a day it may be enough to use a 24-hour tape while those with fewer or unpredictable recurrences may require an event recorder, which has the advantage of correlating symptoms and abnormal rhythms.

7. If we find a patient has persistent atrial fibrillation how do we decide who to referfor consideration of cardioversion?

Cardioversion is generally preferred for patients with persistent AF who are symptomatic, younger (under 65), who present for the first time with lone AF, those with AF secondary to a treated/corrected precipitant (for example; postoperative AF) and in those with congestive heart failure. These patients have a higher chance of returning to sinus rhythm after cardioversion. Of course, every decision on cardioversion is decided on an individual basis.

8. Do you think a non-specialist could chemically cardiovert a patient in primary care?

It is recommended that cardioversion be carried out in hospital. Chemical cardioversion requires administration of amiodarone or flecainide and in most cases there are no complications. However sometimes cardioversion may not be successful and may even precipitate an abnormal rhythm which may require the use of a cardiac defibrillator or external cardiac pacing. For these reasons it is recommended that cardioversion be carried out in hospitals, where emergency care is available.

9. How long should a patient be anticoagulated for before they have cardioversion?

Cardioversion increases the risk of thromboembolism if there is inadequate anticoagulation. A safe and well adopted measure is to maintain a therapeutic INR for at least three weeks before cardioversion and at least four weeks after. In the event of an emergency cardioversion, heparin should be administered immediately, cardioversion should be performed and anticoagulation continued for four weeks after cardioversion. Where patients have stroke risk factors or are considered at high risk of AF relapse, long-term anticoagulation should be considered.

10. Should patients with atrial flutter have the same management as those with AF?

While anticoagulation recommendations for atrial flutter are broadly similar to those of atrial fibrillation, the medical management of the rhythm itself differs slightly. Atrial flutter is usually more resistant to cardiac rhythm control drugs and also to pharmacological cardioversion. Hence, the major thrust of management is towards electrical cardioversion while providing adequate anticoagulation cover, or using an atrioventricular node blocker, such as digoxin, which may convert atrial flutter to AF, which may be easier to manage. Atrial flutter is also frequently amenable to a cure with an ablation procedure.

11. Is there still a role for digoxin in the management of atrial fibrillation?

Digoxin is less effective than ß-blockers and rate-limiting calcium antagonists for rate control. It is no better than placebo for cardioversion and may even exacerbate paroxysmal AF. Digoxin is now recommended only as an 'add-on' treatment to either a ß-blocker or a calcium antagonist regime for rate control. However, digoxin monotherapy may suffice for older sedentary patients.

12. How should we manage intermittent AF?

The aim of treatment is to reduce AF frequency, prevent complications and alleviate symptoms of intermittent atrial fibrillation. Treatment may vary depending on the frequency of symptoms. The first line is generally with standard ß-blockers. Certain selected patients (those with no structural or ischaemic heart disease) may be suitable for self-treatment with flecainide – a strategy known as the 'pill in the pocket' approach. Amiodarone is a second-line agent and is used where ß-blockers and other drugs such as flecainide are ineffective or contraindicated. As an alternative to amiodarone, some patients with paroxysmal AF achieve a cure with an ablation procedure. As regards anticoagulation, the same approach that is used to treat permanent AF should be adopted for intermittent AF as the frequency of stroke and thrombotic complications are comparable between the two types.

13. Which patients would a general cardiologist refer to an electrophysiology (EP) specialist?

In general there is no specific group of patients who always need referral to an EP specialist. This decision is decided on a case to case basis. Good reasons to refer to an EP specialist are:

• poorly controlled symptoms on medical treatment

• cardiac arrhythmias with syncope

• pre-excitation syndromes such as Wolff-Parkinson-White syndrome and suspected ventricular tachycardias

• family history of sudden cardiac death

• sustained supraventricular tachycardias .

14. If a relative has had a premature sudden death possibly related to an arrhythmia, which family members do we need to refer and who to?

In general, first-degree relatives under 40 with a family history of sudden cardiac death must be investigated. Other conditions to consider are congenital prolonged QT syndrome and hypertrophic cardiomyopathy, as these may predispose to sudden cardiac death. It would be appropriate to refer these patients to the cardiologist.

Dr Puneet Kakar is research fellow and Professor Gregory Lip is professor of cardiovascular medicine at the Haemostasis, Thrombosis and Vascular Biology Unit at the University Department of Medicine, City Hospital, Birmingham

Competing interests None declared

Take-home points

Take-home points

• Symptoms such as syncope or pre-syncope, draining of facial colour, onset with exercise, shortness of breath and chest pain may indicate an abnormal and dangerous rhythm and should be referred.
• Cardioversion is preferred for patients with persistent atrial fibrillation (AF) who are symptomatic, under 65; present for the first time with lone AF; those with AF secondary to a treated/corrected precipitant and in those with congestive cardiac failure. These patients have a higher chance of returning to sinus rhythm.

• Atrial flutter is usually more resistant to rhythm control drugs and pharmacological cardioversion. Consider electrical cardioversion or an atrioventricular node blocker, which may convert atrial flutter to AF. Atrial flutter might be 'cured' with ablation.

What I will do now What I will do now

What i will do now

Dr Griffith responds to the answers to her questions

• I will urgently refer patients who have palpitations and who had a family member who suffered a sudden cardiac death under the age of 40.

• I will recognise the increased likelihood of significant arrhythmia in patients with palpitations associated with exercise, syncope, breathlessness or chest pain.

• I will accept the limited conclusions to draw from ECG measurement; most patients with palpitations will have a normal ECG at rest when they are asymptomatic.

• If the medical history suggests that symptoms occur daily, my patients may benefit from 24-hour ECG recording.

• Because cardioversion increases thromboembolic risk, I will expect patients to have a good INR control at least three weeks before and four weeks after successful cardioversion.

• I will expect most patients with atrial flutter to receive electrical cardioversion, as they respond to it better than to medical cardioversion.

• I will prescribe digoxin sparingly, as an add-on for rate control unless the patient is sedentary.

Dr Kathryn Griffith is a GP in York and cardiovascular and renal lead for North Yorkshire PCT

An ECG concurrent with palpitations may help make a diagnosis, but usually there are no changes at rest. An ECG concurrent with palpitations may help make a diagnosis, but usually there are no changes at rest.

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