Palpitations Practice Station

Opening statement:

• You woke up in the middle of the night feeling your heart racing in your chest. You were extremely worried, so your wife called an ambulance and brought you here. The fluttering has now stopped but you don’t want it to happen again.

History of presenting complaint

• What do you mean by fluttering? - Feeling my heart beating fast and irregularly in my chest.
• Onset: The first time you experienced this was 2 months ago. You were helping your wife do some dishes when you suddenly felt your heart beating rapidly in your chest with an unusual pattern. It went away but occurred again last night. This is only the second time you have experienced this.
• Duration and frequency: last for around 3 minutes continuously. You have only had this once before. The first time it occurred when you were doing the dishes, and the second time (last night) when you were sleeping.
• Progression: fluttering doesn’t get worse or better but is the same intensity as when they begin.
• Character- heart pounds very fast and irregularly. There is no specific pattern to the heartbeat.
• Rhythm-feels irregular
• Timing: The fluttering lasts for 3 minutes
• Exacerbating/relieving factors: you have not found anything to help stop the palpitations. The palpitations go away on their own, but you usually sit down and put your head between your legs to stop feeling dizzy. No associations with caffeine, alcohol, or exercise.
• Severity: The palpitations stop you from the task you are doing. You usually sit down and wait for them to go.
• Ask the patient to tap out the beat: tap out a racing irregular heart beat

ICE:

• Ideas-You are worried you have had a heart attack.
• Concerns-None
• Expectations-you just want to find out what’s going on and how to stop it from happening again as it is becoming scary.

Systems Review

• Cardiac: Chest pain: Site: centre of the chest. Onset: a few moments after the fluttering has begun. Character: squeezing or tightening of the chest. Radiation: upper back. Timings: You also suffered a similar chest pain in your first palpitations episode. Exacerbations: nothing. The pain only comes on during the palpitations. Severity: 6/10
• You do get light-headed during the episodes but you have not suffered from any  loss of consciousness.
• You also feel weak during the episodes and for a while afterwards.
• Respiratory-No breathlessness. No cough.
• Gastrointestinal: No nausea or vomiting associated with the palpitations. No changes in bowel
• Psychiatry: You have been feeling slightly more stressed these few weeks, but you have never had episodes of panic or anxiety. No trembling. No dry mouth.
• Endocrine: you haven’t had any changes in body temperature or changes in weight. No flushing. No paraesthesia in body or mouth
• No neurological symptoms
• Anaemia symptoms: no fatigue, no headaches, no pallor
• Red flags: No fevers recently, no night sweats, no changes in weight.

Past Medical History:

• Nil
• Excellent candidates will ask specifically about diabetes and thyroid problems.

Medications:

• Excellent candidates will ask about OTC antihistamines?
• None

Past Surgical History

• Nil

Allergies

• NKDA

Family History:

• No family history of sudden unexpected deaths below 50

Social History

• Smoker: you only smoke socially, around 2-3 cigarettes every fortnight
• No recreational drug uses.
• You drink around 15 units of alcohol per week.
• You drink caffeinated coffee around 4-5 times a day.
• You are a stockbroker, so your job is very stressful.

General exam:

• Inspection -Patient appears pale but comfortable.
• Observations:
  • Temperature 37 °C
  • HR: 95, rhythm regular, normal volume and character.
  • RR: 16
  • BP: 100/80
  • O₂ saturations: 99%

Cardiology exam:

• Inspection-no scars
• Hands-normal CRT, no clubbing, no cyanosis
• Normal S1 + S2
• Vesicular breath sounds bilaterally.
• No radial-radial delay

No peripheral stigmata of disease

What is the differential diagnosis?

• Atrial fibrillation -the most common cardiac arrhythmia. This patient has paroxysmal atrial fibrillation, where episodes of palpitations occur and terminate spontaneously. It is paroxysmal because they terminate, whereas in persistent AF the palpitations never terminate.
• Atrial flutter -another arrhythmia, less common than atrial fibrillation but can also lead to palpitations.
• Anxiety-palpitations are usually preceded by a stressful event. There may also be accompanying breathlessness. Although this patient has stated he is under more stress than usual, this would accompany some breathlessness, tingling or paraesthesia.
• Hyperthyroidism -is less likely as there is no history of weight loss, decreased appetite, or heat intolerance. However, it should always be considered.
• Caffeine or Medications – caffeine is known to stimulate palpitations, as this patient is consuming a large amount of caffeine a day, it would be beneficial to ask him to try and decrease his coffee intake to see if it has any effect on the palpitations.
• Phaeochromocytoma -unlikely, additional symptoms such as resistant hypertension, headaches, flushing, diaphoresis would point more to phaeochromocytoma as a cause.

What investigations would you like to order? ⁽¹⁾

• General observations to ensure patient is stable.
• 12-lead ECG is gold-standard to assess cardiac rhythm. Consider 24 hour cardiac monitor if ECG is normal.
• FBC-used to detect non-cardiac factors that may be causing AF, eg, anaemia, and infection.
• Clotting profile to assess for bleeding risk, as immediate cardioversion may be required.
• Electrolytes, urea, and creatinine-to assess for electrolyte disturbances and chronic kidney disease which is a risk factor for AF.
• Thyroid function-to exclude thyrotoxicosis which can cause palpitations
• Chest x ray-to exclude for lung pathology that may precipitate atrial fibrillation
• Transthoracic echocardiography-to assess for heart failure which may cause atrial fibrillation.

In the middle of the night, Mr Brown woke up with fluttering in his chest. A nurse performed an ECG and has asked you to review. Please interpret this ECG.

MICHAEL BROWN AGE: 42

HOSPITAL NUMBER 123456

ECG from²: Ed Burns and Robert Buttner, Atrial Fibrillation, Life in the Fast Lane

Creative Commons Licence: CC BY-NC-SA 4.0

• This is the ECG of Mr Michael Brown (hospital number and date of birth correct).
• Mr Brown’s heart rate= 102
• The ECG shows absent p waves and an irregularly irregular rhythm. This suggests he is currently in atrial fibrillation.
• Other things to mention: Normal cardiac axis, no changes in ST segment, no signs of any bundle branch blocks.
• A summary of systematic approach to interpreting ECGs can be found in the ECG Interpretation Guide tab

What is the acute management of atrial fibrillation?⁽¹⁾⁽³⁾

• Unstable: Emergency electrical cardioversion
• Stable:
  • <48 hours

1. 1. • Rate control or rhythm control:

• • • • Rate control: beta blockers (eg. atenolol) or rate limiting calcium channel blockers, eg. verapamil). If elderly or sedentary lifestyle consider digoxin.
      • Rhythm control: Electrical or pharmacological cardioversion.
      • Treat underlying cause
      • Consider longer-term anticoagulation therapy via HASBLED/ORBIT
  • >48 hours:
    • Rate control: beta blockers (eg. atenolol) or rate limiting calcium channel blockers, eg. verapamil). If elderly or sedentary lifestyle consider digoxin.
    • If AF persists after rate control offer
    • Rhythm control (electrical cardioversion preferred) can be offered electively only if: patient has been maintained on anticoagulation for a minimum of 3 weeks or transoesophageal echo has excluded a thrombus in the left atrial appendage.

What is the long-term management of atrial fibrillation? ⁽⁴⁾

• Atrial fibrillation places patients at a higher risk of developing a stroke in the future. Therefore, after rate or rhythm control, patients should be assessed for the risk of stroke using the CHA₂DS₂-VASc score and the risk of bleeding using the ORBIT score.
• A score of 1 for males suggests anticoagulation should be considered.
• A score of 2 for males or females suggests anticoagulation should be given. The first line anticoagulation to be offered are direct oral anticoagulants (DOACs).

What is the pill in pocket approach for paroxysmal AF?

As Mr Brown is suffering from paroxysmal atrial fibrillation (intermittent episodes of atrial fibrillation) he will benefit from a pill in the pocket approach. This means he will take a pill to terminate his episodes of atrial fibrillation only when the symptoms start. Flecainide is the anti-arrhythmic drug of choice but this must not be used in patients with structural or ischaemic heart disease. Alternatives include calcium channel blockers or beta blockers^3,4.

What is the difference between defibrillation and cardioversion? ⁽⁵⁾

• Defibrillation is a shock given to patients who do not have a pulse. It usually gives the shock with a greater amount of energy and at a different part of the cardiac cycle than a cardioversion shock.
• Synchronised cardioversion delivers the shock with a lower amount of energy and at synchronised R waves during the cardiac cycle. 

Summary of a Systematic approach to interpreting ECGs:

1. Confirm details of patient

• • Name and DOB of patient
  • Date and time that ECG was produced.

2. Calculate heart rate

• • Number of Q waves multiplied by 6

3. Calculate heart rhythm

• • Regular rhythm: p wave before QRS complex
  • Irregular rhythm: absent p waves
  • Count the number of large boxes between every Q wave (consistent number of boxes suggests regular, inconsistent number suggests irregular).

4. Comment on cardiac axis

• • Normal, left cardiac axis or right cardiac axis

5. P-waves

• • Present? Appearance (normal or Saw tooth)?

6. PR interval

• • Between 3-5 small squares (120-200ms) is normal

7. QRS complex

• • Width, height, morphology

8. ST segment

• • Normal height or elevated or depressed?

9. T waves

• • Normal/Inverted/tall

10. Document interpretation.