Make the Diagnosis: Does This Patient With Palpitations Have a Cardiac Arrhythmia?
About 16% of general medical patients report that they have palpitations.1 Within this group of symptomatic patients, the pretest probability of any cardiac arrhythmia is 39%. Important risk factors are age, sex, family history of palpitations, history of panic disorder, and history of prior cardiac disease. Medications should be reviewed for all patients with palpitations. Having the patient tap out his or her perceived rhythm or to choose from cadences tapped out by the physician may help in identifying the regularity and speed of the palpitations.
Population in Whom Palpitations Suggest Cardiac Arrhythmia
Most demographic and historical features do not have a substantial impact on the likelihood of cardiac arrhythmia as the cause of palpitations. To complicate the evaluation, most patients have episodic symptoms and are asymptomatic during their visit to the physician. This chapter addresses patients who present with palpitations without an underlying medical condition (eg, hyperthyroidism) or known structural heart disease.
Assessing the Likelihood of Cardiac Arrhythmia
Symptoms have been studied more than physical findings since most patients do not present for an evaluation while they are having palpitations (Table 74-1). Because most findings have only been evaluated in a few studies or not at all, physicians must consider other factors such as the patient's medications, frequency of palpitations, the severity of associated symptoms, and their overall impression without knowing for certain the value of these findings. When patients do present with palpitations, a 12-lead electrocardiogram during the event can often provide information for an immediate diagnosis.
Table 74-1Clinical Findings for Identifying Cardiac Arrhythmias in Patients With Palpitations ||Download (.pdf) Table 74-1 Clinical Findings for Identifying Cardiac Arrhythmias in Patients With Palpitations
|Finding ||LR+ (95% CI) ||LR- (95% CI) |
| ||Likelihood Ratio of Any Arrhythmiaa |
|Affected by sleeping ||2.3 (1.3-3.9) ||0.70 (0.53-0.93) |
|Occur at work ||2.2 (1.2-4.0) ||0.76 (0.60-0.98) |
|Prior cardiac disease ||2.0 (1.3-3.1) ||0.71 (0.57-0.88) |
|Duration >5 min ||1.5 (1.3-1.9) ||0.38 (0.22-0.63) |
|Panic disorder ||0.26 (0.07-1.0) ||1.3 (1.1-1.5) |
| ||Arrhythmias |
|Regular, rapid pounding in the neck with palpitationsb ||177 (25-1251) ||0.07 (0.03-0.19) |
|Abnormal heart rate <60/min or >100/min ||3.0 (1.3-7.1) ||0.78 (0.60-1.0) |
|Visible neck pulsations ||2.7 (1.3-5.8) ||0.87 (0.76-1.0) |
|Vasovagal symptoms (pale and/or sweaty) ||1.7 (1.1-2.7) ||0.63 (0.39-1.0) |
Acceptable reference standards are clinical event monitors, intermittent event recorders, implantable loop recorders, in-hospital telemetry, 12-lead electrocardiographic monitoring during symptoms, or electrophysiological study. Event monitors pair the patient's report of palpitations with an ambulatory recording of the rhythm. An important ...