OVERVIEW
- Palpitations can be managed as a medically unexplained symptom by the GP where the clinical picture is very low risk or investigations show only sinus tachycardia
- Chest pain, although a common medically unexplained symptom always warrants careful assessment
- Breathlessness often has mixed physical and behavioural components—simple breathing control techniques are helpful for many patients
- Palpitations, chest pain and breathlessness are commonly associated with anxiety and panic disorders. Consider these in patients with unexplained symptoms at any age
Introduction
Palpitations, chest pain and breathlessness are three common symptoms that patients present to GPs. All three are common medically unexplained symptoms (MUS) but all can be manifestations of life-threatening disease. Palpitations, chest pain and breathless are commonly associated with anxiety or panic and when assessed as low risk can be explained and managed as variations in autonomic function, often with secondary amplification. Although they commonly overlap, this chapter will deal with each of the three separately.
Palpitations
Epidemiology in primary care
Around 0.5% of patients consult a GP with some form of palpitations (awareness of possible abnormality of the heart beat) per year. Around one-third of these will have a detectable arrhythmia—although not all of these will be clinically important. The probability of significant arrhythmia increases with age.
GP assessment
The aim of GP assessment of new onset palpitations is to decide whether further investigation is warranted or whether the patient should be managed as having innocent palpitations—a medically unexplained symptom. Investigation should include history, examination, electrocardiogram (ECG) and tests for anaemia and thyroid disorder.
Typical features of functional symptoms
Functional palpitations (either sinus tachycardia or heightened awareness of physiological variations in rhythm) may be reported as a fast heart rate, missed heartbeats or as pounding. Very brief (one or two beats) disturbances of rhythm or a regular rate less than 100, particularly if associated with a sense of pounding are strong pointers to functional symptoms.
‘John’ is a 28-year-old factory worker who regularly works out. He has noticed that sometimes when at home his heart pounds. It never occurs at work or in the gym and he tends to notice it especially when he’s falling asleep. He demonstrates a regular heart rate during episodes of 80/min and recognises the feeling of his heart pounding out of his chest.
Typical features of organic symptoms and red flag symptoms
In many cases the history and examination between episodes are of little value in differentiating organic tachycardia from innocent palpitation. Table 7.1 lists the likelihood ratios for various features as predictors of organic tachycardia. Although no feature on its own is sufficiently predictive, co-occurrence of several (for instance short episodes of pounding that do not occur during sleep or at work) strongly suggests a functional cause.
Table 7.1 Probability of arrythymia associated with clinical features in patients with palpitation.
| Characteristic of palpitations | Likelihood ratio for arrhythmia |
| Epidemiology | |
| Presence of cardiac disease | 2.0 |
| Panic disorder | 0.3 |
| History | |
| Palpitations during sleep (not before sleep) | 2.3 |
| Palpitations at work | 2.2 |
| Palpitations lasting <5 min | 0.4 |
| Pounding sensation in chest | 0.1 |
| Examination | |
| Visible neck pulsation | 2.7 |
Interpreting likelihood ratios: likelihood ratio >1 indicates increased probability of organic tachycardia; likelihood ratio <1 indicates reduced probability.
Palpitations associated with exercise, and with collapse are both alarm symptoms (for cardiomyopathy and ventricular arrhythmias in particular) as is palpitation associated with typical ischaemic chest pain. Any of these features should lead to referral, possibly urgently.
History and examination tips
The ideal is to examine the patient, and obtain an ECG, when they have their symptoms but this is usually not possible. If, during the consultation, the patient suddenly appears concerned it is worth asking if their symptoms are present and checking the pulse. When taking the pulse, if you notice a missed beat, then ask the patient if they noticed it—increased awareness of minor variants such as ectopics is associated with anxiety disorders. If the pulse is normal then get the patient to tap out their abnormal rhythm and check whether it was regular—‘could you tap your foot to it?’ If in doubt it can help to demonstrate a regular rhythm at 90 beats/min, and at 150 and an irregular rhythm to give the patient a choice.
Even though you know it will probably be normal, you should examine the heart properly. Emphasise to the patient that you are being thorough. Arrange an ECG, either within the consultation or in the near future and a clear plan for review. Arrange blood tests for anaemia and thyroid function, explaining that you expect them to be normal but are checking in order to be thorough.
It is worth considering anxiety (or less likely depression) in association with palpitations. Ask about sleep and concentration, listen for other symptoms commonly associated with anxiety or for patient-volunteered concerns.
Clinical decision
By the time you have completed the history and examination you should be able to classify the patient as having either low or increased probability of tachycardia.
Referral and Investigations
Patients with very low risk (episodes lasting less than 5 min, strong pounding, not occurring at work or when asleep) do not usually warrant further investigation. There is some evidence that a normal ambulatory ECG monitoring test does not increase reassurance.
Other patients warrant some form of continuous or episodic monitoring. Explain when referring patients that tachycardias are often physiological and that the test may show normal variations in heart rate with no sign of disease.
Explanation
Low probability of palpitations
The key aim of explanation is to normalise the potentially threatening symptom. Three component mechanisms are appropriate here: normal ectopic beats; variable autonomic control and symptom awareness.
Normal ectopic beats warrant a simple but clear explanation (Box 7.1).
The variable autonomic control explanation accepts that the heart rate is continually changing under ‘autopilot’ control. Sometimes when resting, there are short bursts of unexpected activity. The key point is that when the system needs to respond it does so (everything is healthy, it works fine when exercising) but sometimes when resting or settling down at night, there are noticeable changes.
Symptom awareness links to variable autonomic control by amplifying the unexpected (but normal) changes in heart rate at rest. It makes sense that if something unexpected happens then the body will keep an eye out to see if it happens again. Sometimes this leads to a vicious circle of amplification and awareness (see Chapters 1 and 15).
Normal ambulatory ECG/event monitoring
Assuming the patient had symptoms associated with no rhythm disturbance then it is important to rationalise the patient’s genuine awareness of the heartbeat and not imply that they were imagining it. This explanation will probably involve elements of variable autonomic control and symptom awareness as described above.
Specific treatment
Patients with disruptive but harmless awareness of their heartbeat may benefit from a low-dose beta-blocker. There have been only a few small studies in specialist care of brief cognitive-behavioural interventions for patients with palpitations, these suggest benefit but do not provide definitive evidence.
Chest pain
This section addresses two particular problems with chest pain: assessment of new chest pain and management of patients with angina-like pain after normal cardiac investigations.
Epidemiology in primary care
Chest pain symptoms are relatively common in primary care (lifetime incidence 20–40%, annual incidence around 1%). Although many cases are either obviously due to disease—most commonly coronary heart disease (CHD) or oesophageal reflux—many are not. Observational studies suggest that around 5% of patients with undifferentiated chest pain (no clear diagnosis within 2 weeks) are subsequently found to have heart disease: thus, some patients initially thought to have medically unexplained chest pain do have, or develop, heart disease. A smaller number also turn out to have cancer or another serious illness. Even when initial assessment confers low risk, it is important for the GP to watch for changes in the clinical picture that point to disease.
GP assessment of new chest pain
The aim of the GP assessment of chest pain should be to assess the probability of cardiac or pulmonary disease and plan management accordingly. Low-risk chest pain tends to be either intense but very transient, lasting only a few seconds, or persistent over several days with little variation. In contrast to stable ischaemic pain it has no consistent relationship to effort or rest.
Table 7.2 shows a recently validated risk score for use in primary care for new patients presenting with chest pain. Using a cut-off score of three or more out of five it has a sensitivity of 86% and specificity of 75% for coronary heart disease.
Table 7.2 Score for risk of heart disease in primary care patients with chest pain.
| Characteristic of chest pain | Points |
| Epidemiology | |
| Male aged ≥55 or female ≥65 | 1 |
| Any prior clinical vascular disease (coronary, peripheral or cerebrovascular) | 1 |
| History | |
| Worse during exercise | 1 |
| Patient ‘concerned that the pain is cardiac’ or ‘feeling very concerned about the pain’ | 1 |
| Examination | |
| Pain not reproduced by palpation | 1 |
Total score: ≥3 probability of coronary heart disease (CHD) at least 33%; ≤2 probability of CHD <3%.
History and examination tips
Take your time with a chest pain history. Listen while the patient describes the pain. Ask what it feels like—and leave the patient room to answer: you might get a description such as ‘sharp’, a simile (‘like a knife going in)’, an attribution (‘I think it might be my heart’) or an emotional response (‘It’s worrying’). These latter responses are particularly important in view of the patient attribution question in Table 7.2. Ask about relationship to exercise, breathing and rest. If necessary be specific: ‘of the last 10 times it’s come on, how many times were you sitting at home’.
In patients with chest pain you need to examine the heart. Although this is unlikely to yield information (although symptomatic aortic stenosis needs urgent referral) it is necessary and demonstrates that you are being thorough. It also means you can test for palpation tenderness (Table 7.2). In low-risk patients explain that you have listened carefully to the heart and that it sounds OK (don’t say this if you suspect disease, you may promote false reassurance).
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