Assessment of the Patient with Palpitation
| Description | See Table 8.2. |
| Positional factors | Extrasystoles may be felt on lying down in the left lateral decubitus or supine positions. AV nodal re-entrant tachycardia may be precipitated by bending over and then standing up and may terminate on lying down. |
| Syncope | Syncope during palpitation is a sign of haemodynamic compromise, either from ventricular tachycardia (VT) or occasionally SVT. VT must be excluded. |
| Relation to exercise | Exercise can trigger right ventricular outflow tract ventricular tachycardia, catecholaminergic polymorphic ventricular tachycardia (CPVT) and some forms of congenital long QT syndrome (LQTS). Atrial fibrillation (AF) can also be triggered by the onset or offset of exercise. Inappropriate sinus tachycardia may follow physical or emotional stress. |
| Emotional stress | Most likely to induce sinus tachycardia, but can occasionally trigger SVT or VT. |
| Anxiety | A quick screening question is: ‘Have you experienced brief periods, for seconds or minutes, of an overwhelming panic or terror that was accompanied by racing heartbeats, shortness of breath, or dizziness?’ Other causes should be considered before attributing to anxiety. |
| Drug history | Caffeine, illicit drugs (e.g. cocaine, amphetamines, ‘ecstasy’) and alcohol can trigger arrhythmias. |
| Prescribed drugs | Arrhythmias can be caused by anti-arrhythmics, thyroxine, theophyllines, beta-adrenoreceptor agonists, antidepressants and antipsychotics.* |
| Cardiac history | Symptoms or signs of cardiac disease may suggest specific arrhythmias. Ischaemic heart disease and cardiomyopathies raise the possibility of ventricular arrhythmias. Mitral valve disease predisposes to atrial fibrillation. |
| Medical history | Thyrotoxicosis, anaemia and phaeochromocytoma may result in palpitations and arrhythmias. Pregnancy may also result in palpitations and arrhythmias. |
| Family history | Ischaemic heart disease, early-onset atrial fibrillation, channelopathies and cardiomyopathies have a genetic component. |
*For a full list see: http://www.sads.org.uk/drugs-to-avoid/