Does This Patient With Palpitations Have a Cardiac Arrhythmia?

Abstract

Context Many patients have palpitations and seek advice from general practitioners. Differentiating benign causes from those resulting from clinically significant cardiac arrhythmia can be challenging and the clinical examination may aid in this process.Objective To systematically review the accuracy of historical features, physical examination, and cardiac testing for the diagnosis of cardiac arrhythmia in patients with palpitations. MEDLINE (1950 to August 25, 2009 and EMBASE (1947 to August 2009) searches of English-language articles that compared clinical features and diagnostic tests in patients with palpitations with a reference standard for cardiac arrhythmia. Of the 277 studies identified by the search strategy, 7 studies were used for accuracy analysis and 16 studies for diagnostic yield analysis. Two authors independently reviewed articles for study data and quality and a third author resolved disagreements. Data Source, Study Selection, and Data ExtractionData Synthesis Most data were obtained from single studies with small sample sizes. A known history of cardiac disease (likelihood ratio [LR], 2.03; 95% confidence interval [CI], 1.33-3.11), having palpitations affected by sleeping (LR, 2.29; 95% CI, 1.33-3.94), or while the patient is at work (LR, 2.17; 95% CI, 1.19-3.96) slightly increase the likelihood of a cardiac arrhythmia. A known history of panic disorder (LR, 0.26; 95% CI, 0.07-1.01) or having palpitations lasting less than 5 minutes (LR, 0.38; 95% CI, 0.22-0.63) makes the diagnosis of cardiac arrhythmia slightly less likely. The presence of a regular rapid-pounding sensation in the neck (LR, 177; 95% CI, 25-1251) or visible neck pulsations (LR, 2.68; 95% CI, 1.25-5.78) in association with palpitations increases the likelihood of a specific type of arrhythmia (atrioventricular nodal reentry tachycardia). The absence of a regular rapid-pounding sensation in the neck makes detecting the same arrhythmia less likely (LR, 0.07; 95% CI, 0.03-0.19). No other features significantly alter the probability of clinically significant arrhythmia. Diagnostic tests for prolonged periods of electrocardiographic monitoring vary in their yield depending on the modality used, duration of monitoring, and occurrence of typical symptoms during monitoring. Loop monitors have the highest diagnostic yield (34%-84%) for identifying an arrhythmia.Conclusions While the presence of a regular rapid-pounding sensation in the neck or visible neck pulsations associated with palpitations makes the diagnosis of atrioventricular nodal reentry tachycardia likely, the reviewed studies suggest that the clinical examination is not sufficiently accurate to exclude clinically significant arrhythmias in most patients. Thus, prolonged electrocardiographic monitoring with demonstration of symptom-rhythm correlation is required to make the diagnosis of a cardiac arrhythmia for most patients with recurrent palpitations.

Ambulatory Cardiac Monitoring for Discharged Emergency Department Patients with Possible Cardiac Arrhythmias

“…ED management is driven by risk assessment and current guidelines 1–5. Admission rates, however, remain high and inpatient management is expensive 6.…”

“…The gold standard for diagnosing an arrhythmia as the etiology for the patient’s symptoms is electrocardiogram (ECG) documentation of a rhythm disturbance at the time of symptoms 1–5. The optimal device for ambulatory cardiac monitoring is based on the frequency of symptoms.…”

Psychiatric Disorder and Incessant Tachyarrhythmia in a Child

“…“Shirt flapping” or regular rapid neck pulsations may be associated with PSVT, especially those types that are associated with contraction of the atria against a closed AV valve resulting in reflux of blood into the SVC [6]. Among the various physical exam findings, it has been shown that regular rapid pounding neck sensation or visible neck pulsation is one of the most sensitive and specific for PSVT and should not be ignored [7]. …”

Panic attacks and supraventricular tachycardias: the chicken or the egg?

“…In addition, regular rapid-pounding sensations as well as visible neck pulsations increased the likelihood of AVNRT. Duration of palpitations of less than five minutes or a known history of panic disorder decreased the likelihood of veritable arrhythmias [9]. However, clinical examination on its own is not sufficient to precisely diagnose or to exclude an underlying tachycardia.…”

“…However, clinical examination on its own is not sufficient to precisely diagnose or to exclude an underlying tachycardia. Therefore, a correlation of symptoms with Holter monitoring is crucial for a precise diagnosis [9].…”