New-onset palpitations in general practice: assessing the discriminant value of items within the clinical history

Palpitation referrals from primary care to a secondary care cardiology outpatient clinic: assessing adherence to guidelines

BACKGROUND AND AIMS

Palpitations are a common presentation in primary care. Guidelines have been developed to identify patients with palpitations who require further assessment by a cardiologist in secondary care. However, patients that do not meet guideline thresholds for referrals are still referred to secondary care services. This audit evaluated the adherence to referral guidelines at our trust and assessed the characteristics of patients who were referred appropriately versus those referred without meeting guideline referral thresholds (inappropriate referral).

RESULTS

Palpitation referrals to a single cardiology outpatient clinic were assessed (n = 66). Half the patients referred for palpitations were referred inappropriately (n = 34, 51.5%). Patients referred inappropriately were more likely to have a benign diagnosis after assessment (91.2%). These patients also had significantly fewer investigations [mean difference of 1.1 (confidence interval: 0.6-1.6)]. Specialist investigations, such as cardiac event recorders (P < 0.05) and cardiac magnetic resonance imaging (P < 0.05) were less likely to be used in inappropriately referred patients.

CONCLUSIONS

The results from this audit provide early evidence that there are a significant number of patients who are being referred that could be managed in primary care. Further studies are needed to confirm our findings in larger cohorts and to establish the underlying reasons for inappropriate referrals.

Evidence-Based Approach to Palpitations

Palpitations are a common presenting symptom in primary care, yet their cause can be difficult to diagnose due to their intermittent and sometimes infrequent nature. All patients presenting with a chief complaint of palpitations should undergo a detailed history, physical examination, and electrocardiogram (ECG). This alone can yield a probable diagnosis. Limited laboratory testing, ambulatory ECG monitoring, and cardiology referral are sometimes indicated. This article reviews current data and guidelines on how to evaluate palpitations in the primary care setting.

Evidence-based Recommendations for the Evaluation of Palpitations in the Primary Care Setting

Palpitations are a symptom of many cardiac and noncardiac conditions. The patient's history, physical examination, appropriately directed laboratory tests, and basic electrocardiogram are helpful in evaluating palpitations and may be essential to finding a diagnosis. There are many outpatient options for the evaluation of palpitations caused by a presumed cardiogenic cause. These evaluation tools include Holter monitor, event monitor, transtelephonic electrocardiographic monitor, treadmill exercise stress test, echocardiography, and electrophysiologic studies. Most patients can be evaluated as an outpatient, but there are reasons, such as hemodynamic compromise, that may require admission to an inpatient setting to complete the diagnostic workup.

Relationship Between Palpitation and Mental Health

Background:

‘Palpitation’ is one of the most common complaints in patients referring to cardiologists. In modern medicine era, these patients suffer from much distress and some cases are known to be difficult to treat. Although the clinician’s first duty is obviously to search for an organic basis for this symptom, the diagnostic evaluation is frequently unrevealing. However, clinical experience suggests that psychiatric causes are relatively common.

Objectives:

This research aimed to screen for mental disorders in patients complaining of palpitation and healthy persons in order to perform a preliminary comparison between them.

Patients and Methods:

This is a case-control study to screen mental disorders. The target population consisted of adult volunteers with benign palpitation and their matched healthy persons. They were referred during a 10-month-period to the cardiology outpatient’s clinic of Mostafa Khomeini hospital in Tehran, Iran. Sampling was accidental and eventually 110 participants comprised the sample size. The measuring tool was GHQ-28 (28-item general health questionnaire) and the main variable was the questionnaire score obtained from the Likert scoring method.

Results:

Comparing two groups showed that the number of participants with the scores more than cut-off point in palpitation group was significantly more than healthy person group (85.4% vs. 43.6% with P < 0.001). Also the total score of GHQ-28 and scores of its subscale (somatization, anxiety, and social dysfunction) in patients complaining of palpitation were significantly more than those of the healthy participants (34.2 vs. 25.7, 8.9 vs. 6.4, 9.4 vs. 6.4, and 12.3 vs. 10.8, respectively with P < 0.001, P = 0.001, P < 0.001, and P < 0.007, respectively).

Conclusions:

Palpitation is the most common symptom in psychiatric disorders such as anxiety and somatization disorders. According to the results of this study, psychiatric causes have an important role in Iranian patients complaining of palpitations (benign form). Considering this fact may lead to a more effective treatment of benign palpitations.

The use of external event monitoring (web-loop) in the elucidation of symptoms associated with arrhythmias in a general population

Objective

To correlate arrhythmic symptoms with the presence of significant arrhythmias through the external event monitoring (web-loop).

Methods

Between January and December 2011, the web-loop was connected to 112 patients (46% of them were women, mean age 52±21 years old). Specific arrhythmic symptoms were defined as palpitations, pre-syncope and syncope observed during the monitoring. Supraventricular tachycardia, atrial flutter or fibrillation, ventricular tachycardia, pauses greater than 2 seconds or advanced atrioventricular block were classified as significant arrhythmia. The association between symptoms and significant arrhythmias were analyzed.

Results

The web-loop recorded arrhythmic symptoms in 74 (66%) patients. Of these, in only 14 (19%) patients the association between symptoms and significant cardiac arrhythmia was detected. Moreover, significant arrhythmia was found in 11 (9.8%) asymptomatic patients. There was no association between presence of major symptoms and significant cardiac arrhythmia (OR=0.57, CI95%: 0.21-1.57; p=0.23).

Conclusion

We found no association between major symptoms and significant cardiac arrhythmia in patients submitted to event recorder monitoring. Event loop recorder was useful to elucidate cases of palpitations and syncope in symptomatic patients.

Analysis of emergency department visits for palpitations (from the National Hospital Ambulatory Medical Care Survey)

Palpitations is a common complaint in patients who visit the emergency department (ED), with causes ranging from benign to life threatening. We analyzed the ED component of the National Hospital Ambulatory Medical Care Survey for 2001 through 2010 for visits with a chief complaint of palpitations and calculated nationally representative weighted estimates for prevalence, demographic characteristics, and admission rates. ED and hospital discharge diagnoses were tabulated and categorized, and recursive partitioning was used to identify factors associated with admission. An estimated 684,000 visits had a primary reason for visit of "palpitations" representing a national prevalence of 5.8 per 1,000 ED visits (0.58%, 95% confidence interval 0.52 to 0.64). Women and non-Hispanic whites were responsible for most visits. A cardiac diagnosis made up 34% of all ED diagnoses. The overall admission rate was 24.6% (95% confidence interval 21.2 to 28.1), with higher rates seen in the Midwest and Northeast compared with the West. Survey-weighted recursive partitioning revealed several factors associated with admission including age >50 years, male gender, cardiac ED diagnosis, tachycardia, hypertension, and Medicare insurance. In conclusion, palpitations are responsible for a significant minority of ED visits and are associated with a cardiac diagnosis roughly 1/3 of the time. This was associated with a relatively high admission rate, although significant regional variation in these rates exists.

Efficacy of diagnostic tools for detecting cardiac arrhythmias: systematic literature search

BACKGROUND/OBJECTIVES

Symptoms suggestive of cardiac arrhythmias are a challenge to the diagnosis. Physical examination and a 12-lead ECG are of limited value, as rhythm disturbances are frequently of a paroxysmal nature. New technologies facilitate a more accurate diagnosis. The objective of this study was to review the medical literature in an effort to define a guide to rational diagnostic testing.

METHODS

Primary studies on the use of a diagnostic tool in the evaluation of palpitations were searched in MEDLINE, and EMBASE with an additional reference check.

RESULTS

TWO TYPES OF STUDIES WERE FOUND: descriptive and experimental studies, which compared the yield of two or more devices or diagnostic strategies. Holter monitors seemed to have less diagnostic yield (33 to 35%) than event recorders. Automatically triggered recorders detect more arrhythmias (72 to 80%) than patient-triggered devices (17 to 75%). Implantable devices are used for prolonged monitoring periods in patients with infrequent symptoms or unexplained syncope.

CONCLUSION

The choice of the device depends on the characteristics of the symptoms and the patient. Due to methodological shortcomings of the included studies no evidence-based diagnostic strategy can be proposed. (Neth Heart J 2010;18:543-51.).

Diagnostic yield of patient-activated loop recorders for detecting heart rhythm abnormalities in general practice: a randomised clinical trial

BACKGROUND

Because palpitations and light headedness often occur paroxysmally these complaints are difficult to diagnose. The hazards for a GP are too many diagnostic interventions for worried well and too few diagnostics for potentially life threatening complaints.

OBJECTIVES

Patient-activated memo event recorders have proved to be successful in diagnosing episodes of cardiac arrythmias in secondary care. We tested the diagnostic yield of these devices in general practice.

METHODS

A randomized clinical trial in general practice. Consecutive patients with complaints of palpitations or light-headedness were randomized to either usual care or usual care plus event-recorder. The main outcome was the difference in explained episodes. Secondary outcomes were the differences in the number and character of cardiac diagnoses and the feasibility of the event-recorder.

RESULTS

There were fewer patients without a diagnosis in the intervention group (17% vs 38%; RR = 0.5, 95% CI 0.3 to 0.7) and more patients with a cardiac diagnosis (67% vs. 27%: RR 2.5, CI 1.8 to 3,5). More relevant cardiac arrhythmias were detected (22% vs 7%) with event recording than with usual care (RR 3.2, 95% CI 1.5 to 6.8).

CONCLUSION

Patient-activated loop recorders are feasible and effective diagnostic tools in patients with palpitations or light-headedness in primary care. More research into patient characteristics and selection criteria is needed to fine-tune the use of these devices in primary care.

Occurrence of symptoms and depressive mood among working-aged coronary heart disease patients

BACKGROUND

The typical symptoms of coronary heart disease (CHD), chest pain and breathlessness, are well-known. They are considered quite dramatic, and can thus be fairly reliably mapped by a survey. However, people might have other clearly unpleasant symptoms impairing quality of life. The aim of this study is to evaluate the appearance of these complaints of working-aged people with self-reported CHD.

METHODS

The study consists of a postal questionnaire of randomly selected Finns in age groups 30-34, 40-44 and 50-54, a response rate of 39% (N = 15,477). The subjects were asked whether or not a doctor had told them that they had angina pectoris or had had myocardial infarction. Four randomly selected age and sex matched controls were chosen for every patient. The occurrence of self-reported dyspnoea, chest pain during anger or other kind of emotion, palpitation and perspiration without physical exercise, irregular heartbeats, flushing, trembling of hands and voice, jerking of muscles, depression and day-time sleepiness were examined. Odds ratios (OR) with 95% confidence intervals (CI), between occurrence of symptoms and CHD with and without heart infarction, were computed by multivariate logistic regression analysis.

RESULTS

The sample eventually comprised 319 CHD patients. Dyspnoea, chest pain during anger or other kind of emotion, palpitation, perspiration without physical exercise, irregular heartbeats daily or almost daily, trembling of hands and voice, and jerking of muscles occurred statistically significantly more frequently among CHD patients than among controls. The CHD patients also reported more depressive mood according to Beck's inventory scores and poorer sleep and more frequent day-time sleepiness than controls. In the multivariate logistic regression analysis chest pain during anger or other kind of emotion (ORs 4.12 and 3.61) and dyspnoea (ORs 2.33 and 3.81) were the symptoms most associated with CHD.

CONCLUSIONS

Working-aged people with self-reported coronary heart disease evince a number of symptoms limiting the quality of their every day life. This aspect should be paid attention to when evaluating functional capacity of these patients.