APPROACH TO PALPITATION
History taking in cardiology contd…
Palpitation is a common symptom in cardiac patients as well as in patients with a variety of other diseases, sometimes even without diseases. History taking represents a major part of evaluation of patients with palpitation as most patients by the time they visit a physician have no palpitation and the diagnosis has to be made retrospectively.
Before embarking on the understanding of palpitation we should know what palpitation is. As defined by EHRA (European heart rhythm association) “Palpitations are a symptom defined as awareness of the heartbeat and are described by patients as a disagreeable sensation of pulsation or movement in the chest and/or adjacent areas.”
Even though palpitation is a very common symptom it is a difficult problem to evaluate and to make a definitive diagnosis.
Below is given a list of the possible etiologies of palpitation. Take a careful look into the list so that you understand what we are looking for while taking history of palpitation.
Etiologies of palpitation:
- Cardiac arrhythmias
Bradyarrhythmias: severe sinus bradycardia, sinus pauses, second and
third-degree atrioventricular block
Anomalies in the functioning and/or programming of pacemakers and ICDs
- Structural heart diseases
Mitral valve prolapse
Severe mitral regurgitation
Severe aortic regurgitation
Congenital heart diseases with significant shunt
Cardiomegaly and/or heart failure of various aetiologies
Mechanical prosthetic valves
- Psychosomatic disorders
Anxiety, panic attacks
Depression, somatization disorders
- Systemic causes
Hyperthyroidism, hypoglycaemia, postmenopausal syndrome, fever,
anaemia, pregnancy, hypovolaemia, orthostatic hypotension,
postural orthostatic tachycardia syndrome, pheochromocytoma,
- Effects of medical and recreational drugs
Sympathicomimetic agents in pump inhalers, vasodilators,
Recent withdrawal of b-blockers
Alcohol, cocaine, heroin, amphetamines, caffeine, nicotine, cannabis,
Weight reductions drugs
Now lets go to the history taking proper. Here we will have our standard step-wise approach to history taking and analysis (as mentioned in approach to chest pain)
Step 1: describe the symptom in detail
Step2: localize the symptom to an anatomical system
Step 3: localize the palpitation to an organ/mechanism
Step 4: etiology of palpitation
As described in history taking in cardiology , always begin by noting down the premorbid functional status of the patient. Any change in functional status should be noted.
Step 1.Recording the history of palpitation:
Given here is a scheme of question to ask while taking history of palpitation
- Circumstances prior to the beginning of palpitations
Activity (rest, sleeping, during sport or normal exercise, change in
posture, after exercise)
Position (supine or standing)
Predisposing factors (emotional stress, exercise, squatting or
- Onset of palpitations
Abrupt or slowly arising
Preceded by other symptoms (chest pain, dyspnoea, vertigo, fatigue,
- Episode of palpitations
Type of palpitations (regular or not, rapid or not, permanent or not)
Associated symptoms (chest pain, syncope or near syncope,
sweating, pulmonary oedema, anxiety, nausea, vomiting, etc.)
- End of the episode
Abrupt or slowly decreasing, end or perpetuation of accompanying
symptoms, duration, urination
Spontaneously or with vagal manoeuvres or drug administration
Age at the first episode, number of previous episodes, frequency
during the last year or month
Previous cardiac disease
Previous psychosomatic disorders
Previous systemic diseases
Previous thyroid dysfunction
Family history of cardiac disease, tachycardia or sudden cardiac
Medications at the time of palpitations
Drug abuse (alcohol and/or others)
Once the history of palpitation has been recorded, next step is to localize whether it is cardiac or noncardiac in origin (please refer to the Etiology list for cardiac and noncardiac causes). It may be less reliable to differentiate a cardiac from noncardiac cause of palpitation based on history only. For that associated symptoms really help. Someone who has other symptoms of cardiac disease has more likelihood of having cardiac cause of palpitation.
Among cardiac cause of palpitation our aim is to differentiate arrhythmic from nonarrhythmic causes.
Features which suggest arrhythmic palpitations are
Structural heart disease
Primary electrical heart disease
Family history of sudden death
Palpitations associated with haemodynamic impairment
Below are listed description of some common types of palpitation.
|Type ofpalpitation||Subjectivedescription||Heartbeat||Onset andtermination||Triggersituations||Possible associated symptoms|
|Extrasystolic||‘Skipping/missing a beat’, ‘sinking of the heart’||Irregular, interspersed withperiods of normal heartbeat||Sudden||Rest||–|
|Tachycardiac||‘Beatingwings’ in the chest||Regular or irregular, markedly accelerated||Sudden||Physical effort, cooling down||Syncope,dyspnoea,fatigue,chestpain|
|Anxiety-related||Anxiety, agitation||Regular,slightly accelerated||Gradual||Stress,Anxiety attacks
|Tingling in the hands and face, lump in the throat,atypical chest pain,sighing dyspnoea|
|Pulsation||Heart pounding||Regular,normal frequency||Gradual||Physicaleffort||Asthenia|
Some features also help to differentiate the different types of arrhythmic palpitations:
|Type of arrhythmia||Heartbeat||Trigger situation||Associated symptoms||Vagal manoeuvres|
|AVRT, AVNRT||Sudden onset regular with periods of elevated heart rate||Physical effort, changes in posture||Polyuria, frog sign||Sudden interruption|
|Atrial fibrillation||Irregular with variable heart rate||Physical effort, cooling down,post meal, alcohol intake||Polyuria||Transitory reduction in heart rate|
|Atrial tachycardia and atrial flutter||Regular (irregular if A-V conduction is variable) with elevated heart rate||Transitory reduction in heart rate|
|Ventricular tachycardia||Regular with elevated heart rate||Physical effort||Signs/symptoms of hemodynamic impairment||No effect|
These tables will help to delineate the cardiac cause of palpitation.
This the final step where all the above discussion culminates in a list of differential diagnosis. The differential diagnosis will look something like this
- Arrhythmic palpitation
- Structural heart disease e.g.
- Valvular regurgitation
- Congenital or acquired shunt lesions
- Heart failure etc..
In the exams it is a bit difficult to make differential diagnoses based on palpitation only. There evaluate other cardiac symptoms very carefully. Once all the cardiac symptoms have been analysed then forming differential diagnoses is a bit easy. Yes one more thing read the natural history of cardiac diseases. I will post articles on natural history of cardiac diseases once this discussion on history taking is over.
This outlines the approach to palpitation. I hope it fulfils your purpose. All these articles are intended for medical students and exam goings. For professional there are a few references listed below for further reading.
- Weber BE, Kapoor WH. Evaluations and outcomes of patients with palpitations.
Am J Med 1996;100:138–48.
- Thavendiranathan P, Bagai A, Khoo C, Dorian P, Choudhry NK. Does this patient
with palpitations have a cardiac arrhythmia? JAMA 2009;302:2135–43.
- Hoefman E, Boer KR, van Weert HCPM, Reitsma JN, Koster RW, Bindels PJE.
Predictive value of history taking and physical examination in diagnosing arrhythmias
in general practice. Fam Pract 2007;24:636–41.
- Managing patients with palpitation. Europace (2011) 13, 920–934