Practice Rational Testing

Investigating palpitations: the role of Holter monitoring and loop recorders

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3123 (Published 27 July 2017) Cite this as: BMJ 2017;358:j3123
  1. Charbel Abi Khalil, assistant professor of medicine and genetic medicine and consultant in cardiology1 2 3,
  2. Fadi Haddad, associate professor of clinical medicine and internal medicine specialist4,
  3. Jassim Al Suwaidi, associate professor of clinical medicine and consultant in cardiology1 3
  1. 1Department of medicine and genetic medicine, Weill Cornell Medicine Qatar. Doha-Qatar
  2. 2Department of medicine and genetic medicine. Weill Cornell Medicine, New York, USA
  3. 3Adult cardiology department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
  4. 4Hôtel-Dieu de France medical center, Saint-Joseph University, Beirut, Lebanon
  1. Correspondence to Charbel Abi Khalil cha2022{at}med.cornell.edu

What you need to know

  • Palpitations are a common presentation in primary care, but more than half of cases are harmless (eg, extrasystoles)

  • Assess frequency and severity of symptoms, perform a physical examination and a 12 lead resting electrocardiogram (ECG), and order blood tests

  • Refer the patient to a cardiologist if an arrhythmia or a conduction disorder is diagnosed on the resting ECG, if the patient is known to have a cardiac disease, or if palpitations are associated with chest pain, syncope, or lightheadedness

  • Offer Holter monitoring to patients if the resting ECG is normal, and adapt its duration to the frequency of symptoms

A 62 year old man complains of palpitations four times in the last week. He felt his heart beating very fast and was short of breath. Symptoms were variable in their timing and duration, however two episodes followed alcohol intake. On direct questioning, he did not have chest pain or syncope. He is on amlodipine for hypertension. On examination, his blood pressure is 160/90 mm Hg; his heart rate is regular at 82 beats/ min. Heart sounds and respiratory examination are normal.

Palpitations are a common presentation in primary care and can be distressing. In a patient presenting with palpitations, note the type and severity of symptoms, the timing of palpitations, and comorbid medical conditions. Suggestions for history and examination are in box 1.

Box 1: What to consider in history and examination for palpitations

  • Frequency and regularity—Palpitations that last for a few seconds and occur randomly and episodically are often due to premature beats. Rapid and irregular palpitations are commonly reported in atrial fibrillation

  • Associated symptoms—Ask about dizziness and loss of consciousness, which might suggest idiopathic ventricular tachycardia in patients with structurally normal hearts1

  • Precipitating factors—Ask if palpitations are precipitated by exercise or substances such as caffeine, alcohol, or cocaine. Supraventricular arrhythmias can be induced by exercise …

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