Palpitations
Cardiology
Introduction
Taking a history from a patient with palpitations involves exploring the characteristics of the palpitations, including onset, duration, frequency, and triggers such as stress, caffeine, or exercise. Ask the patient to describe the sensation (e.g., fluttering, pounding, or skipping beats) and whether symptoms occur suddenly or gradually. Inquire about associated symptoms like chest pain, dizziness, shortness of breath, or fainting, which may indicate a more serious cause. Past medical history should cover conditions like heart disease, anxiety, or thyroid disorders. Review medications, including stimulants or recreational drugs, and family history of heart conditions. This comprehensive approach helps differentiate between benign causes (like anxiety) and more serious arrhythmias.
WIPER
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Presenting Complaint
1. Onset:
When did the palpitations begin?
Was the onset sudden or gradual?
2. Frequency and Duration:
Is it continuous or intermittent?
How long does it last (seconds, minutes, hours)?
3. Character of Palpitations:
Can the patient describe the sensation? (e.g., pounding, racing, irregular, fluttering, skipped beats)
Can they tap out the rhythm?
4. Triggers:
Are there any identifiable triggers? (e.g., exercise, stress, caffeine, alcohol, medications, recreational drugs)
5. Associated Symptoms:
Cardiovascular:
Chest pain, shortness of breath, dizziness, syncope, sweating.
Systemic:
Fatigue, fever, weight loss.
Neurological:
Headache, visual disturbances, focal neurological symptoms.
6. Relieving Factors:
What stops the palpitations? (e.g., rest, Valsalva manoeuvre, specific medications)
7. Exacerbating Factors:
What makes the palpitations worse? (e.g., exertion, anxiety, lying down)
8. Impact:
Does it affect with daily life, sleep, or physical activity?
9. Severity:
How distressing are the episodes on a scale (1-10) (e.g., mild, moderate,
severe)?
ICE: Ideas, Concerns, Expectations
Ideas: Does the patient has any ideas what might be causing this?
Concerns: Are they worried about anything?
Expectations: What outcomes do they hope for?
Past Medical History
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Medications
Current medications and recent changes:
Beta-blockers, calcium channel blockers, diuretics, or stimulants.
Recreational drug use (e.g., cocaine, amphetamines)
Family History
Family history of arrhythmias, sudden cardiac death, or inherited conditions
(e.g., Long QT syndrome, hypertrophic cardiomyopathy).
Social History
Smoking: Calculate pack-years history
Alcohol Intake: How many units per week
Recreational Drugs: Especially stimulants
Lifestyle: High stress levels, poor sleep, or physical inactivity
Explore risk Factors for palpitations including:
Caffeine, alcohol, stress, thyroid problems, anaemia, and dehydration
Differential Diagnosis
Palpitations may arise from the following causes:
Cardiac Causes:
Arrhythmias (e.g., atrial fibrillation, supraventricular tachycardia, ventricular tachycardia), ectopic beats, structural abnormalities, heart failure.
Endocrine/Metabolic Causes:
Hyperthyroidism, hypoglycaemia, pheochromocytoma, electrolyte
imbalances
Systemic Causes:
Fever, infection, anaemia, hypovolaemia
Psychological Causes:
Anxiety, panic attacks, or stress
Medication-Induced Causes:
Bronchodilators, stimulants, or withdrawal from beta-blockers
Management
Bedside:
Physical examination to check for
Assess pulse rate, rhythm, and volume
Blood pressure measurement
Jugular venous pressure (JVP)
Examine for signs of thyroid dysfunction (e.g. tremor)
Laboratory:
Blood Tests:
Full blood count (FBC) – anaemia or infection
Thyroid function tests (TFTs) – hyperthyroidism
Electrolytes – potassium, magnesium, calcium imbalances
Blood glucose – rule out hypoglycaemia
Imaging and Special Tests:
ECG – look for arrhythmias, QT interval abnormalities, or evidence of structural disease.
Echocardiogram – assess structural abnormalities (e.g., valve disease, hypertrophic cardiomyopathy)
Management Plan
Tailor based on underlying cause:
Address modifiable risk factors (e.g., reduce caffeine, manage stress).
Consider referral to a cardiologist for further investigation or treatment if required.
Provide reassurance and advice for benign cases (e.g., ectopic beats without structural heart disease)