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Palpitations in primary care- InnovAit, July 2011. Aisha Bhaiyat. Aim. Assessment Management ECG’s. Palpitations. Prevalence – 16% of primary care consultations 2 nd commonest reason for gp referral to cardiology. Assessment. What does the patient mean by palpitation Rate Rhythm

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Presentation Transcript
slide2
Aim
  • Assessment
  • Management
  • ECG’s
palpitations
Palpitations
  • Prevalence – 16% of primary care consultations
  • 2nd commonest reason for gp referral to cardiology
assessment
Assessment
  • What does the patient mean by palpitation
  • Rate
  • Rhythm
  • Missed/extra beat
  • Associated symptoms
  • Onset/offset
  • Exacerbating/relieving
  • Timings
assessments
Assessments
  • Past medical history
  • Drug history
  • Family history
  • Social history
  • Examination
medical emergency
Medical emergency
  • Systolic BP less than 90 mmHg
  • Pulse less than 40 or greater than 150
  • Cardiac failure
  • Chest pain
  • Presyncope
management
Management
  • ECG
  • Blood tests
  • Ambulatary ECG
  • Transthoracic echo – if structural cardiac abnormality suspected
ecg abnormalities that may be present in those with palpitations
ECG abnormalities that may be present in those with palpitations

Conduction abnormalities

Structural heart disease related

LVH

T wave/ST changes

Features of old MI

  • BBB
  • Venricular pre-excitation
  • Prolongue QTc
  • Extreme 1st degree block
  • 2nd/3rd degree block
  • Other arrythmias eg AF
red flags high risk urgent referral to cardiology
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
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
Low risk-manage in primary care
  • Skipped or thumping beats
  • Slow pounding sensation
  • ECG normal
  • No structural heart disease
slide12

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
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
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
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/]