Palpitations: Evaluation in the Primary Care Setting

 

Am Fam Physician. 2017 Dec 15;96(12):784-789.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/heart-palpitations.html.

Author disclosure: No relevant financial affiliations.

Palpitations are a common problem in the ambulatory primary care setting, and cardiac causes are the most concerning etiology. Psychiatric illness, adverse effects of prescription and over-the-counter medications, and substance use should also be considered. Distinguishing cardiac from noncardiac causes is important because of the risk of sudden death in those with an underlying cardiac etiology. A thorough history and physical examination, followed by targeted diagnostic testing, can distinguish cardiac conditions from other causes of palpitations. Persons with a history of cardiovascular disease, palpitations at work, or palpitations that affect sleep have an increased risk of a cardiac cause. A history of cardiac symptoms, a family history concerning for cardiac dysrhythmias, or abnormal physical examination or electrocardiography findings should prompt a more in-depth evaluation for heart disease. Ischemic symptoms may signal coronary heart disease and associated ventricular premature contractions that may warrant exercise stress testing. Exertional symptoms accompanied by elevated jugular venous pressure, rales, or lower extremity edema should raise concern for heart failure; imaging may be required to assess for functional and structural heart disease.

Patients often present to family physicians with a “flopping” sensation in the chest or an awareness of palpitations that may be fast, slow, regular, or irregular. Cardiac causes are classified as structural or arrhythmic, with testing guided by clinical suspicion.18

WHAT IS NEW ON THIS TOPIC: PALPITATIONS

Supraventricular premature complexes, which can be distinguished from ventricular premature contractions when nonsinus atrial depolarizations are followed by narrow QRS complexes, are associated with significant increases in atrial fibrillation, stroke, cardiovascular disease, and death, even if asymptomatic.

In addition to cocaine, methamphetamine, and 3,4-methylenedioxymethamphetamine (MDMA or Ecstasy), marijuana use can cause arrhythmias and should be assessed in patients presenting with palpitations.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

All patients presenting with palpitations should be evaluated for an ischemic cause.

C

3, 5, 16

Nonspecific ST-segment and T-wave changes in symptomatic patients should not be considered normal and should prompt further evaluation for a cardiac cause.

C

25

Patients who have syncope associated with palpitations should undergo tilt-table testing.

C

15, 17, 19

Transthoracic echocardiography should be considered to evaluate for heart failure or structural heart disease in patients with palpitations accompanied by elevated jugular venous pressure, rales, or lower extremity edema.

C

3


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

All patients presenting with palpitations should be evaluated for an ischemic cause.

C

3, 5, 16

Nonspecific ST-segment and T-wave changes in symptomatic patients should not be considered normal and should prompt further evaluation for a cardiac cause.

C

25

Patients who have syncope associated with palpitations should undergo tilt-table testing.

C

15, 17, 19

Transthoracic echocardiography should be considered to evaluate for heart failure or structural heart disease in patients with palpitations accompanied by elevated jugular venous pressure, rales, or lower extremity edema.

C

3


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Pathophysiology

Ordinary cardiac transmission involves the spontaneous discharge of an electrical impulse at the sinoatrial node. The impulse is then propagated down the wall of the right atrium to the atrioventricular node, then disseminated via the His-Purkinje system to depolarize the ventricles. Disturbance of the electrical impulse anywhere along these pathways may produce an arrhythmia. Noncardiac factors (e.g., thyroid disease, pheochromocytoma, psychiatric disorders, medications) may affect this process. Hyperthyroidism and hypothyroidism can affect cardiac function by impairing cardiac pliability and oxygen demand, resulting in arrhythmia.9,10 Panic attacks, anxiety, and somat

The Authors

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RANDELL K. WEXLER, MD, MPH, is an associate professor in the Division of Family Medicine at The Ohio State University Wexner Medical Center, Columbus....

ADAM PLEISTER, MD, is an assistant professor in the Division of Cardiovascular Medicine at The Ohio State University Wexner Medical Center.

SUBHA V. RAMAN, MD, MSEE, is a professor in the Division of Cardiovascular Medicine at The Ohio State University Wexner Medical Center.

Address correspondence to Randell K. Wexler, MD, MPH, The Ohio State University, 2231 N. High St., Columbus, OH 43201 (e-mail: randy. wexler@osumc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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