Palpitations in primary care- InnovAit, July 2011 Aisha Bhaiyat

Aim Assessment Management ECG’s

Palpitations Prevalence – 16% of primary care consultations 2 nd commonest reason for gp referral to cardiology

Assessment What does the patient mean by palpitation Rate Rhythm Missed/extra beat Associated symptoms Onset/offset Exacerbating/relieving Timings

Assessments Past medical history Drug history Family history Social history Examination

Medical emergency Systolic BP less than 90 mmHg Pulse less than 40 or greater than 150 Cardiac failure Chest pain Presyncope

Management ECG Blood tests Ambulatary ECG Transthoracic echo – if structural cardiac abnormality suspected

ECG abnormalities that may be present in those with palpitations Conduction abnormalities BBB Venricular pre-excitation Prolongue QTc Extreme 1 st degree block 2 nd /3 rd degree block Other arrythmias eg AF Structural heart disease related LVH T wave/ST changes Features of old MI

Red Flags/high risk-urgent referral to cardiology Exercise related palpitations Syncope/presyncope FH of sudden cardiac death/inherited heart dx ECG-high degree av block High risk structural disease

Amber Flags/moderate risk-refer to cardiology History suggestive of recurrent tachyarrythmia Palpitation with associated symptoms Abnormal ECG (other than high av block) Structural heart disease

Low risk-manage in primary care Skipped or thumping beats Slow pounding sensation ECG normal No structural heart disease

Management and referral pathway for patients presenting with palpitations. Taggar J S, Hodson A, The assessment and management of palpitations in primary care InnovAiT 2011;4(7): , By permission of oxford university press.

Further considerations Opportunistic health promotion Driving – must cease if arrythmia likely to cause incapacity. Permitted once arrythmia identified and controlled for 4/52. DVLA need to be indentified only symptoms are disabling Occupation Genetics-HOCM, WPW, Brugada syndrome, Long QTS

Key points Consider lifestyle/psychological/other systemic medical causes After initial assessment, patients risk should be stratified and managed appropriately Other considerations - health promotion/ driving/occupation/genetics

Useful websites Heart Rhythm UK [ Arrhythmia Alliance [ (most useful for patient information leaflets) Sudden Adult Death Trust [ Cardiac risk in the young [