Management of patients with palpitations: a position paper from the European Heart Rhythm Association

In the paper

“Low cost”

In the paper

“Low cost; easy to use”

In the paper

“Invasiveness”

In the paper

“poor ECG records”

In the paper

“high costs”

In the paper

“Invasiveness”

In the paper

“Low cost; easy to use”

In the paper

“This gives rise to some uncertainty in establishing a cause -effect relationship between any anomalies that may be detected and the palpitations themselves.”

In the paper

“It is important to underline the fact that, although cardiac rhythm disorders generally give rise to palpitations (or other related symptoms, such as fatigue, dyspnoea, dizziness, syncope, and angina), in some subjects, for reasons not entirely known but probably linked to some clinical characteristics (long-standing arrhythmias with relatively low maximum ventricular rate, male sex, absence of”

What the sources say

• Not checked yetcites [11] Sugishita, 2003, Diabetes influences the cardiac symptoms related to atrial fibrillation, Circ J source
• Not checked yetcites [13] Kirchhof, 2007, Outcome parameters for trials in atrial fibrillation, Europace source
• Not checked yetcites [14] Camm, 2010, Guidelines for the management of atrial fibrillation. The task force for the management of atrial fibrillation of the European Society of Cardiology, Eur Heart J
• Not checked yetcites [15] Flaker, 2005, Asymptomatic atrial fibrillation: demographic features and prognostic information from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study, Am Heart J source

In the paper

“Indeed, in many cases a definitive, or at least probable, diagnosis of the cause of palpitations is not reached and no specific therapy is initiated.5,6”

What the sources say

• Not checked yetcites [5] Zimetbaum, 1998, Evaluation of patients with palpitations, New Engl J Med source
• Not checked yetcites [6] Giada, 2004, Diagnostic management of patients with palpitations of unknown origin, Ital Heart J

In the paper

“Moreover, as palpitations may be caused by a wide range of different physiological and pathological conditions, clinicians tend to apply a number of instrumental investigations, laboratory tests, and specialist examinations, which are both time-consuming and costly.”

In the paper

“This means that many patients continue to suffer recurrences of their symptoms, which impair their quality of life and mental balance, lead to the potential risk of adverse clinical events, and induce continual recourse to healthcare facilities.”

In the paper

“Electrocardiographic documentation of a rhythm disorder during spontaneous symptoms provides the strongest evidence of causality; whenever this proves possible, therefore, the palpitations are classified as being of arrhythmic origin.”

In the paper

“It is not uncommon, however, for the patient to have more than one potential cause or type of palpitation.”

In the paper

“Psychosomatic disorders that are most frequently associated with palpitations include anxiety, panic attacks, depression, and somatization, which can either induce sinus tachycardia or modify the patient's subjective perception of a heartbeat that is otherwise normal or presents minimal irregularities.20 -23”

What the sources say

• Not checked yetcites [20] Chignon, 1993, Panic disorder in cardiac outpatients, Am J Psychiatry source
• Not checked yetcites [21] Barsky, 1994, Psychiatric disorders in medical outpatients complaining of palpitations, J Gen Intern Med source
• Not checked yetcites [22] Barsky, 1994, Panic disorder, palpitations and awareness of cardiac activity, J Nerv Ment Dis source
• Not checked yetcites [23] Jeejeebhoy, 2000, Panic disorder and the heart: a cardiology perspective, J Psychosom Res source

In the paper

“By contrast, they are considered to be of non-arrhythmic origin when the underlying heart rhythm exhibits sinus rhythm or sinus tachycardia.”

In the paper

“Indeed, in the last few years, some studies investigating the correlation between anxiety syndrome and the appearance of arrhythmias have suggested that anxiety exerts a facilitating effect on arrhythmogenesis 28 as well as on the patient's perception of the arrhythmia.29”

What the sources say

• Not checked yetcites [28] Tavazzi, 1986, The role of psychologic stress in the genesis of lethal arrhythmias in patients with coronary artery disease, Eur Heart J
• Not checked yetcites [29] Domschke, 2010, Coincidence of paroxysmal supraventricular tachycardia and panic disorders: two case reports, Ann Gen Psych source

In the paper

“A sensation of palpitation may stem from sinus tachycardia and/or increased cardiac contractility, both of which may have various causes: fever, anaemia, orthostatic hypotension, hyperthyroidism/ thyreotoxicosis, postmenopausal syndrome, pregnancy, hypoglycaemia, hypovolaemia, pheochromocytoma, arteriovenous fistula, postural orthostatic tachycardia syndrome, among others.31 -39”

What the sources say

• Not checked yetcites [31] Cryer, 1985, Glucose counterregulation, hypoglycemia, and intensive insulin therapy in diabetes mellitus, N Engl J Med source
• Not checked yetcites [32] Klein, 1990, Thyroid hormone and the cardiovascular system, Am J Med source
• Not checked yetcites [33] Bravo, 1984, Pheocromocitoma: diagnosis, localization and management, N Engl J Med source
• Not checked yetcites [34] Rosenthal, 1992, Hematological–oncological disorders and heart disease
• Not checked yetcites [35] Elkayam, 1992, Pregnancy and cardiovascular disease
• Not checked yetcites [36] Dinardello, 1990, Fever
• Not checked yetcites [37] Holman, 1966, Abnormal arteriovenous communications. Great variability of effects with particular reference to delayed development of cardiac failure, Circulation source
• Not checked yetcites [38] Moya, 2009, Guidelines for the diagnosis and management of syncope. The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Developed in collaboration with European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), and Heart Rhythm Society (HRS), Eur Heart J source
• Not checked yetcites [39] Thomas, 1981, Orthostatic hypotension, Mayo Clin Proc source

In the paper

“Finally, in a study conducted on patients with documented supraventricular tachycardia, it was found that two-thirds had previously been wrongly diagnosed as suffering from panic attack disorder, and that the diagnosed 'psychosomatic disease' could be cured by catheter ablation in most of these patients.30”

What the sources say

• Not checked yetcites [30] Lessmeier, 1997, Unrecognized paroxysmal supraventricular tachycardia. Potential for misdiagnosis as panic disorder, Arch Intern Med source

In the paper

“The prevalence of palpitations is dependent on definitions and diagnostic methods used and varies substantially in different populations.”

In the paper

“In studies in primary care settings, palpitations account for 16% of the symptoms that prompt patients to visit their general practitioner, and are second only to chest pain as the presenting complaint for specialist cardiologic evaluation.1,3,4”

What the sources say

• Not checked yetcites [1] Mayou, 1998, Chest pain, palpitations and panic, J Psychosom Res source
• Not checked yetcites [3] Kroenke, 1990, The prevalence of symptoms in medical outpatients and the adequacy of therapy, Arch Intern Med source
• Not checked yetcites [4] Knudson, 1987, The natural history of palpitations in a family practice, J Fam Pract

In the paper

“In such cases, palpitations may be linked to sinus tachycardia; drugs involved include sympathomimetics, anticholinergics, vasodilators, and hydralazine.40”

What the sources say

• Not checked yetcites [40] Naranjo, 1981, A method for estimating the probabilty of adverse drug reaction, Clin Pharmacol Ther source

In the paper

“Nevertheless, there is evidence that palpitations are a very frequent symptom in the general population 2,9 and, in particular, in patients suffering from hypertension or heart disease.”

What the sources say

• Not checked yetcites [2] Messineo, 1989, Ventricular ectopic activity: prevalence and risk, Am J Cardiol source
• Not checked yetcites [9] Abbott, 2005, Diagnostic approach to palpitations, Am Fam Physician

In the paper

“In a prospective study by Weber and Kapoor 47 in 190 patients presenting with a complaint of palpitations at an university medical centre, palpitations were due to arrhythmias in 41% of these patients (16% of whom had atrial fibrillation/flutter, 10% had supraventricular tachycardia, and 2% had ventricular tachycardia), to structural heart disease in 3%, to psychosomatic disorders in 31% (mainly”

What the sources say

• Not checked yetcites [47] Weber, 1996, Evaluations and outcomes of patients with palpitations, Am J Med source

In the paper

“Indeed, it is not always possible to establish a definite cause of palpitations; often, only a likely cause can be given, and, in some cases, several possible causes have to be taken into consideration.8,42”

What the sources say

• Not checked yetcites [8] Pickett, 2005, Palpitations: a proper evaluation and approach to effective medical therapy, Curr Cardiol Rep source
• Not checked yetcites [42] Lange, 2001, Cardiovascular complications of cocaine use, N Engl J Med source

In the paper

“In general, however, older patients and men are more likely to have an arrhythmic cause of palpitations and younger patients and women a psychosomatic cause.47 -51”

What the sources say

• Not checked yetcites [47] Weber, 1996, Evaluations and outcomes of patients with palpitations, Am J Med source
• Not checked yetcites [48] Thavendiranathan, 2009, Does this patient with palpitations have a cardiac arrhythmia?, JAMA source
• Not checked yetcites [49] Hoefman, 2007, Predictive value of history taking and physical examination in diagnosing arrhythmias in general practice, Fam Pract source
• Not checked yetcites [50] Summerton, 2001, New-onset palpitations in general practice: assessing the discriminant value of items within the clinical history, Fam Pract source
• Not checked yetcites [51] Mayou, 2003, Characteristics of patients presenting to a cardiac clinic with palpitations, Q J Med source

In the paper

“In athletes, palpitations are not uncommon.”

In the paper

“However, even in patients without severe heart disease, palpitations may be due to significant arrhythmias, such as atrial fibrillation, atrial flutter, or ventricular ectopic beats, all of which require adequate investigation and treatment.”

In the paper

“In the study by Weber and Kapoor, 47 77% of patients experienced at least one recurrence of palpitations, and the effect on their quality of life was unfavourable: one-third of patients reported an impairment of their ability to attend to household chores, 19% claimed that their working capacity had diminished, and 12% said that they had taken days off work.”

What the sources say

• Not checked yetcites [47] Weber, 1996, Evaluations and outcomes of patients with palpitations, Am J Med source

In the paper

“Sudden death, in particular in younger athletes, is rare and mostly associated with underlying structural heart disease or primary arrhythmic disorders, and palpitations may be the initial clinical symptom or an incidental finding possibly leading to the recognition of a previously undiagnosed relevant heart disease.55,56”

What the sources say

• Not checked yetcites [55] Pelliccia, 2005, Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology, Eur Heart J source
• Not checked yetcites [56] Delise, 2005, Cardiological guidelines for competitive sports eligibility, Ital Heart J

In the paper

“Although palpitations display a low mortality rate, the recurrence of symptoms is, however, very frequent.”

In the paper

“It should, however, be stressed that patients are not always able to describe the characteristics of their symptoms precisely.It may therefore be difficult to identify the type of palpitation accurately, especially in the case of normalrate palpitations.5,9,61”

What the sources say

• Not checked yetcites [5] Zimetbaum, 1998, Evaluation of patients with palpitations, New Engl J Med source
• Not checked yetcites [9] Abbott, 2005, Diagnostic approach to palpitations, Am Fam Physician
• Not checked yetcites [61] Leitch, 1991, Can patients discriminate between atrial fibrillation and regular supraventricular tachycardia?, Am J Cardiol source

In the paper

“In many respects, palpitations seem to behave like a chronic disorder that has a favourable prognosis, but with periodic attacks followed by transitory remission.3,4”

What the sources say

• Not checked yetcites [3] Kroenke, 1990, The prevalence of symptoms in medical outpatients and the adequacy of therapy, Arch Intern Med source
• Not checked yetcites [4] Knudson, 1987, The natural history of palpitations in a family practice, J Fam Pract

In the paper

“Frequent and recurrent palpitations, therefore, can impair the patient's quality of life, giving rise to anxiety and frequent visits to the emergency department.3”

What the sources say

• Not checked yetcites [3] Kroenke, 1990, The prevalence of symptoms in medical outpatients and the adequacy of therapy, Arch Intern Med source

In the paper

“They tend to be persistent and are generally linked to structural heart diseases, such as aortic regurgitation, or to systemic causes involving a high stroke volume, such as fever and anaemia.”

In the paper

“These palpitations are generally linked to supraventricular or ventricular tachyarrhythmias, which begin and usually end suddenly (sometimes the termination is gradual due to the increase in sympathetic tone during tachycardia that tends to persist and declines slowly after its interruption), or to sinus tachycardia due to systemic causes or to the use of drugs or illicit substances (in these”

In the paper

“Finally, episodes of paroxysmal atrial fibrillation may occur in the phase immediately following the cessation of physical effort, during which a sudden reduction in sympathetic tone is accompanied by an increase in vagal tone.”

In the paper

“Palpitations that arise in situations of anxiety or during panic attacks are generally due to episodes of more or less rapid sinus tachycardia secondary to the mental disturbance.”

In the paper

“During physical exercise, due to an increase in the sympathetic drive, patients may experience, in addition to the normal sensation of a rapid heart rate elicited by intense effort, palpitations due to various types of arrhythmia, such as right ventricular outflow tract tachycardia, atrioventricular node reentrant tachycardia, and polymorphic catecholaminergic ventricular tachycardia.”

In the paper

“Polyuria, which is due to the hypersecretion of natriuretic hormone, is typical of atrial tachyarrhythmias, particularly atrial fibrillation.”

In the paper

“Palpitations arising after sudden changes in posture are frequently due to intolerance to orthostatis or to episodes of atrioventricular nodal reentrant tachycardia.”

In the paper

“Linked to the presence of atrial or ventricular extrasystolic beats, this type of palpitation is frequently encountered even in young subjects, often in the absence of heart disease, and generally has a benign prognosis.”

In the paper

“Anxiety-related palpitations are due to psychosomatic disorders and usually require exclusion of an arrhythmic cause of the symptoms.”

In the paper

“The initial clinical evaluation leads to a definitive or probable diagnosis of the cause of the palpitations in about half of patients, and excludes with reasonable certainty the presence of causes that have an unfavourable prognosis.47”

What the sources say

• Not checked yetcites [47] Weber, 1996, Evaluations and outcomes of patients with palpitations, Am J Med source

In the paper

“Moreover, a thorough initial clinical evaluation will indicate which specific investigations, if any, are necessary.”

In the paper

“The likelihood ratio of each feature is, in general, low and only a few features are really predictive.They include history of cardiac disease, palpitations affected by sleeping, or while the patient is at work.”

What the sources say

• Not checked yetcites [48] Thavendiranathan, 2009, Does this patient with palpitations have a cardiac arrhythmia?, JAMA source

In the paper

“Another major benefit of the latest diagnostic systems is that many of them not only allow automatic detection of the arrhythmias but also allow immediate wireless transmission of pertinent ECG data to a central monitoring station via a mobile telephone line or the Internet.”

In the paper

“ILRs have been successfully used to study syncope, in which they have shown a better cost/effectiveness ratio than the conventional tests, 86,87”

What the sources say

• Not checked yetcites [86] Krahn, 1999, The high cost of syncope: cost implications of a new insertable loop recorder in the investigation of recurrent syncope, Am Heart J source
• Not checked yetcites [87] Krahn, 2001, Randomized assessment of syncope trial: conventional diagnostic testing versus a prolonged monitoring strategy, Circulation source

In the paper

“By contrast, in patients in whom the symptoms are quite frequent (i.e.daily or weekly), external loop recorders and event recorders have shown both a higher diagnostic value (66 -83%) and a better cost/effectiveness ratio than Holter devices.71,83”

What the sources say

• Not checked yetcites [71] Scherr, 2008, Prospective comparison of the diagnostic utility of a standard event monitor versus a ‘leadless’ portable ECG monitor in the evaluation of patients with palpitations, J Interv Card Electrophysiol source
• Not checked yetcites [83] Zimetbaum, 1998, Diagnostic yield and optimal duration of continuous-loop event monitoring for the diagnosis of palpitations, Ann Intern Med source

In the paper

“Finally, ambulatory ECG monitoring requires the patient to experience a recurrence of symptoms.This delays the diagnosis and, should the palpitations be due to malignant arrhythmias, exposes the patient to the potential risk of adverse events.”

In the paper

“However, it must be underlined that once atrial fibrillation has been diagnosed as a cause of palpitations, there is up to now only limited data on the importance of assessing atrial fibrillation burden for the evaluation of thromboembolic risk, and more information is still needed.67,91”

What the sources say

• Not checked yetcites [67] Botto, 2009, Presence and duration of atrial fibrillation detected by continuous monitoring: crucial implications for the risk of thromboembolic events, J Cardiovasc Electrophysiol source
• Not checked yetcites [91] Glotzer, 2009, The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk. The TRENDS Study, Circ Arrhythm Electrophysiol source

In the paper

“Finally, while EPS enables a diagnosis to be made and specific therapy to be initiated immediately, ambulatory ECG monitoring requires the patient to experience a recurrence of symptoms.”

In the paper

“It allows the physician to analyse P and QRS morphologies and the relationship between these two waves, and the frequency and regularity of the heart rhythm, and finally brings an accurate diagnosis on the concordance between palpitations and the presence or absence of arrhythmia.”

In the paper

“In some instances, for example in case of evident pre-excitation when the patient reports rapid regular palpitations, the diagnosis is formal even if tachycardia has never been recorded.”

In the paper

“Furthermore, precise analysis of ECG during arrhythmia either provides the mechanism or gives important data that lead to this diagnosis.”

In the paper

“Circumstances during which palpitations have occurred are generally helpful to evaluate their cause.”

In the paper

“It should be stressed, however, that P waves during rapid tachycardia are not always visible, making the diagnosis difficult.”

In the paper

“The differential diagnosis of various types of tachycardia may be guided by vagal manoeuvres 68 such as carotid sinus massage: sudden interruption of the tachycardia is highly suggestive of a tachycardia involving the atrioventricular junction whereas a temporary reduction of the frequency is suggestive of atrial fibrillation, flutter, or atrial tachycardia (Table 3).”

What the sources say

• Not checked yetcites [68] Brembilla-Perrot, 2010, Pharmacological testing in the diagnosis of arrhythmias, Minerva Cardioangiol