🩺 Palpitations

Palpitations are the sensation of an abnormal, fast, or irregular heartbeat. While frequently caused by anxiety or ectopic beats, they can be the presenting symptom of serious arrhythmias or underlying structural heart disease. The clinical challenge lies in capturing the arrhythmia during the symptomatic period. UK guidelines focus on risk-stratifying the patient to decide who needs ambulatory monitoring or echocardiography.

Identify the onset, duration, and frequency. Ask the patient to 'tap out' the rhythm to differentiate between fast/regular (SVT) and irregular (AF/ectopics). Ask about 'thumping' or 'skipped beats' (ectopics). Crucially, screen for associated symptoms: lightheadedness, syncope, chest pain, or dyspnoea. Review medications (salbutamol, caffeine, sympathomimetics) and social drug use. A family history of sudden cardiac death is a major risk marker.

Focus on the cardiovascular system and thyroid. Assess the heart rate, rhythm (regular vs irregular), and character of the pulse. Listen for murmurs (e.g., mitral stenosis or HOCM) that may predispose to arrhythmias. Look for signs of hyperthyroidism like tremor, lid lag, or goitre. Assess the JVP for 'cannon a-waves' which may be seen in complete heart block or certain tachycardias. Check BP for orthostatic changes.

Premature Atrial/Ventricular Contractions (ectopics), Atrial Fibrillation/Flutter, Supraventricular Tachycardia (SVT), Ventricular Tachycardia (VT), Sinus Tachycardia (Anxiety/Fever/Anaemia).

Syncope or near-syncope during palpitations; palpitations triggered by exercise; family history of sudden cardiac death; evidence of structural heart disease on exam; persistent tachycardia or chest pain.

A 12-lead ECG is the baseline but often captured when the patient is in sinus rhythm. If symptoms are frequent (daily), use a 24-hour Holter monitor; if infrequent, use a 7-day monitor or an 'event recorder/patient-activated device'. Bloods should include FBC (anaemia), U&Es (electrolyte disturbances like low K+ or Mg++), and TFTs (thyrotoxicosis). Echocardiography is indicated if there is a suspected structural heart disease or an abnormal ECG.

Most palpitations are benign, but red flags must be identified. Palpitations during exercise or those associated with syncope are high-risk for ventricular arrhythmias. Coffee, alcohol, and stress are common triggers, but always screen for hyperthyroidism. A 'regularly irregular' pulse usually suggests ectopics, while 'irregularly irregular' suggests Atrial Fibrillation. If the patient is asymptomatic during the review, the 12-lead ECG is often normal.

Focuses on the interpretation of ECGs (AF, SVT, Heart Block) as per the MLA content map. Emphasises the distinction between benign causes and those requiring urgent specialist referral (Cardiology/Electrophysiology).