Palpitation is an awareness of the heartbeat; although benign in the vast majority, palpitations are occasionally a manifestation of a life-threatening disorder. Cardiac Arrhythmia • Premature ventricular contractions (ventricular ectopic beats)* • Premature atrial contractions (atrial ectopic beats)* • Atrial fibrillation* (Fig. 50) • Supraventricular tachycardia Figure 50 ECG of atrial fibrillation. *Indicates causes that tend to present as irregular palpitations. A variety of symptoms is used to describe palpitations and this includes ‘fluttering’, ‘pounding’ and ‘skipping a beat’. Symptoms may also be experienced in the neck. Important aspects are the frequency, regularity of palpitation (e.g. fast and irregular) and precipitating factors. Asking the patient to tap the rate and rhythm of the palpitation (on a table for example) can be very informative. Arrhythmias associated with irregular palpitations are listed above. Knowledge of precipitating factors is important. Palpitations can be a normal manifestation of anxiety or panic reactions. However, it is vitally important that an organic cause is excluded as it is common for anxiety disorders to co-exist in a patient with supraventricular tachycardia. Exercise is associated with excess catecholamines and also a precipitator of arrhythmia (supraventricular tachycardia, atrial fibrillation and ventricular tachycardia usually originating from the right ventricle). Excessive caffeine, smoking and alcohol intake are also thought to be precipitators of arrhythmia. A history of any underlying heart disorder is important, as arrhythmia is associated with ischaemic heart disease (ventricular arrhythmia), hypertensive heart disease (atrial fibrillation), heart failure (ventricular arrhythmia), heart valve disease. Early age of onset of arrhythmia (childhood or teenage years) suggests the presence of a congenital abnormality such as a bypass tract that can lead to supraventricular tachycardia. The reader should consult a cardiology textbook for further details. Dizziness or syncope (p. 443) is usually associated with serious arrhythmia such as ventricular tachycardia and occasionally supraventricular tachycardia.
Palpitations
Causes
The irregularly irregular QRS complexes occur in the setting of a saw-tooth baseline of uncoordinated atrial activity.
History
Additional features
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