palpitations in primary care- innovait, july 2011 aisha bhaiyat
TRANSCRIPT
Palpitations in primary care- InnovAit, July 2011
Aisha Bhaiyat
Aim
• Assessment• Management• ECG’s
Palpitations
• Prevalence – 16% of primary care consultations
• 2nd commonest reason for gp referral to cardiology
Assessment
• What does the patient mean by palpitation• Rate • Rhythm • Missed/extra beat • Associated symptoms • Onset/offset• Exacerbating/relieving• Timings
Assessments
• Past medical history • Drug history• Family history • Social history• Examination
Medical emergency
• Systolic BP less than 90 mmHg• Pulse less than 40 or greater than 150• Cardiac failure• Chest pain• Presyncope
Management
• ECG• Blood tests • Ambulatary ECG• Transthoracic echo – if structural cardiac
abnormality suspected
ECG abnormalities that may be present in those with palpitations
Conduction abnormalities• BBB • Venricular pre-excitation• Prolongue QTc• Extreme 1st degree block• 2nd/3rd degree block• Other arrythmias eg AF
Structural heart disease related
• LVH• T wave/ST changes• Features of old MI
Red Flags/high risk-urgent referral to cardiology
• Exercise related palpitations• Syncope/presyncope• FH of sudden cardiac death/inherited heart dx• ECG-high degree av block• High risk structural disease
Amber Flags/moderate risk-refer to cardiology
• History suggestive of recurrent tachyarrythmia• Palpitation with associated symptoms• Abnormal ECG (other than high av block)• Structural heart disease
Low risk-manage in primary care
• Skipped or thumping beats• Slow pounding sensation• ECG normal• No structural heart disease
Management and referral pathway for patients presenting with palpitations.
Taggar J S , Hodson A, The assessment and management of palpitations in primary care InnovAiT 2011;4(7):408-413,By permission of oxford university press.
Further considerations
• Opportunistic health promotion• Driving – must cease if arrythmia likely to
cause incapacity. Permitted once arrythmia identified and controlled for 4/52. DVLA need to be indentified only symptoms are disabling
• Occupation• Genetics-HOCM, WPW, Brugada syndrome,
Long QTS
Key points
• Consider lifestyle/psychological/other systemic medical causes
• After initial assessment, patients risk should be stratified and managed appropriately
• Other considerations - health promotion/ driving/occupation/genetics
Useful websites
• Heart Rhythm UK [www.hruk.org.uk/] • Arrhythmia Alliance [
www.heartrhythmcharity.org.uk/] (most useful for patient information leaflets)
• Sudden Adult Death Trust [www.sadsuk.org/] • Cardiac risk in the young [www.c-r-y.org.uk/]