Palpitations in primary care- InnovAit, July 2011

Aisha Bhaiyat

Aim

• Assessment• Management• ECG’s

Palpitations

• Prevalence – 16% of primary care consultations

• 2nd commonest reason for gp referral to cardiology

Assessment

• What does the patient mean by palpitation• Rate • Rhythm • Missed/extra beat • Associated symptoms • Onset/offset• Exacerbating/relieving• Timings

Assessments

• Past medical history • Drug history• Family history • Social history• Examination

Medical emergency

• Systolic BP less than 90 mmHg• Pulse less than 40 or greater than 150• Cardiac failure• Chest pain• Presyncope

Management

• ECG• Blood tests • Ambulatary ECG• Transthoracic echo – if structural cardiac

abnormality suspected

ECG abnormalities that may be present in those with palpitations

Conduction abnormalities• BBB • Venricular pre-excitation• Prolongue QTc• Extreme 1st degree block• 2nd/3rd degree block• Other arrythmias eg AF

Structural heart disease related

• LVH• T wave/ST changes• Features of old MI

Red Flags/high risk-urgent referral to cardiology

• Exercise related palpitations• Syncope/presyncope• FH of sudden cardiac death/inherited heart dx• ECG-high degree av block• High risk structural disease

Amber Flags/moderate risk-refer to cardiology

• History suggestive of recurrent tachyarrythmia• Palpitation with associated symptoms• Abnormal ECG (other than high av block)• Structural heart disease

Low risk-manage in primary care

• Skipped or thumping beats• Slow pounding sensation• ECG normal• No structural heart disease

Management and referral pathway for patients presenting with palpitations.

Taggar J S , Hodson A, The assessment and management of palpitations in primary care InnovAiT 2011;4(7):408-413,By permission of oxford university press.

Further considerations

• Opportunistic health promotion• Driving – must cease if arrythmia likely to

cause incapacity. Permitted once arrythmia identified and controlled for 4/52. DVLA need to be indentified only symptoms are disabling

• Occupation• Genetics-HOCM, WPW, Brugada syndrome,

Long QTS

Key points

• Consider lifestyle/psychological/other systemic medical causes

• After initial assessment, patients risk should be stratified and managed appropriately

• Other considerations - health promotion/ driving/occupation/genetics

Useful websites

• Heart Rhythm UK [www.hruk.org.uk/] • Arrhythmia Alliance [

www.heartrhythmcharity.org.uk/] (most useful for patient information leaflets)

• Sudden Adult Death Trust [www.sadsuk.org/] • Cardiac risk in the young [www.c-r-y.org.uk/]