Palpitations and Atrial Fibrillation

Primary Care Knowledge Boost Podcast 6 Palpitations

Hello and welcome to Primary Care Knowledge Boost. I'm Dr Sarah McDermott and I'm Dr Lisa Adams and today we're going to be talking to consultant cardiologist Dr Karthik about palpitations. So hello and welcome back to Primary Care Knowledge Boost. Today we have Dr Karthik back with us to talk about palpitations. It's nice to see you again, Dr Karthik. Would you mind introducing yourself again for everyone?

Thank you once again. I'm Dr. Karthik and I'm one of the cardiology consultants working at Wigan Infirmary and with Insure Hospital Manchester. Perhaps we can start with defining what palpitations actually are.

Okay, I'm not going to give you the Oxford textbook of medicine definition of palpitations, but palpitations could mean anything, right from someone just being aware of the heartbeat to someone actually having fast... forceful beating of the heart which they are aware about and palpitations again for some patients could mean a forceful sensation in the chest like they describe it as the heart jumping out and some for some it's it's just ringing in the ears a pulse style ringing in the ear so

It's a very variable presentation in terms of symptoms for palpitations. Right, okay. So if we've got someone that comes in and says to us, oh, I've got palpitations, doctor, what sort of questions and features are important for us to ask about? So palpitors, the first thing is, it's best to ask if they're just aware of the heartbeat or if they actually feel the heart beating fast.

And then the patients can come up and say, oh, my heart isn't beating fast, but I can feel that it's forceful and I can feel my heart going boom, boom, boom. And some patients tend to have a fast heartbeat and where it's useful to ask them whether it's fast and regular. fast and irregular. I even tap on the table and ask them if it's regular or visit.

if it's irregular and all over the place. And it helps to determine that. And with palpitations, obviously, we ask for associated symptoms, including dizziness, lightheadedness, breathlessness, chest tightness, chest pains. And it's important to ask them what brings the palpitations on, how long do they last for, what makes them better. And if there is any sort of regular feature in terms of a precipitating cause, you know.

binge drinking every Friday and palpitational Saturday morning and also relation to food intake to physical activity exercise and also in women if it's around the menstrual cycles and stuff like that. Because that could begin hormonal changes causing...

tachycardia and palpitations. What examination should we be carrying out after the first appointment of seeing somebody? So once you have your history about the palpitations, again it's important to ask about family history, family history of any tachycardiast. trachyarithmias, parents having ablation procedures when they were young, parents having pacemaker procedures because of falling ablations, and also history of sudden cardiac death in the young. Again, if there's a family history of...

I'd say long QT syndromes and palpitations related to cardiac conduction disturbances. Physical examination, the usual, make sure they're clinically euthyroid, examine their thyroid status. Check their pulse and blood pressure. A 20 DCG is a good start. To look for simple things like sinus rhythm or an atrial tachycardia of any sort, AF or flutter. Look for QT intervals. An echocardiogram would also be useful to look for any structural heart disease if somebody has had congenital heart disease.

well you'll be aware of it anyway but because they would have been picked up and investigated for that yeah and again look for valvular heart disease atrial sorry aortic stenosis aortic regurgitation mitral stenosis quite commonly yeah And then you go on to request things like a 24-hour halter monitor and prolonged recording as required. Okay.

Fabulous. And with that first history and examination, would there be any signs or symptoms that be worrying in these patients? If these patients are getting a significant amount of palpitations, fast heart rates, that is making them feel dizzy, lightheaded. lose consciousness, syncope, that would be worrying. Or if they have symptoms that are associated with significant amount of chest pain, especially in older patients where tachycardia and palpitations.

can have an effect on the myocardial demand supply for oxygen and nutrition. In this case, it could be an angina symptom because of the increased heart rate. So it's important to rule that out. So these are some of the features which would be worth looking for. You're lovely. And what are just generally the first-line investigations that you go about doing? I would have thought by the time The Reach has, I mean...

They would have had routine blood investigations like haemoglobin to load anemia, thyroid function tests to assess for hyperthyroidism. And again, depending upon their physical examination. Look for things like raised cortisol levels in Cushing's. And if you're worried about things like fair chromocytoma, obviously direct investigations.

towards looking for feochromocytoma in these patients. If they have symptoms like flushing with palpitations, that is again useful. So these investigations should be directed depending upon the clinical presentation. So just as an aside here, we looked into tests looking for pheochromocytoma. It's always an interesting one that perhaps in primary care we don't always come across very much, but we just had a look about the diagnostic tests available.

Yeah, so the BMJ best practice have produced some guidance on the area, which was last reviewed in May 2019. And they state that if the patient has a low pre-test probability for the condition, then the best test for us to do is the 24-hour urine collection of catecholium.

means they suggest that the blood test for serum-free metanephrines and normetanephrines would be appropriate if your clinical suspicion is high i've got a link to the um the best practice article so we'll also include that in the episode description for anyone to have a read if they're interested And now back to the podcast.

And if everything, say, comes back on all of those first-line investigations, where would we go next? Particularly, I guess, if the person's not had any event or anything with the monitor on. So when they've not had any event, while wearing the monitor on, and if everything is normal... and they still have persistent palpitations, then the next step would be to probably go for prolonged monitoring. As I said, 48-hour tape, 72-hour tape, or even a two-week event recorder.

And finally, considering an implantable loop recorder if the symptoms are debilitating enough for the patients that they are unable to carry on with the daily activities. or have associated symptoms like loss of consciousness, syncope with the palpitations. I remember in my ST3 practice, one of the patients went and bought something that they could put their thumb on to record their heart and one of those kind of home things.

Do you recommend anything like that? You get a lot of commercial gadgets nowadays that will look at your heart rate and rhythm and in fact there's one that you stick onto your phone and which will detect or which is meant to detect abnormal heart rhythms including atrial fibrillation and flutter. And yeah, why not? And nowadays we have had a lot of referrals and increase in referrals because patients are picking up fast heart rates on their Fitbits and the Apple Watches.

yeah i had recently a man in with af yeah yeah um lovely um so What are the significant findings on a 24-hour ECG? So the significant findings on a 24-hour ECG would be a very high burden of atrial or ventricular ectopics. When I say high burden, maybe over 10%, 15%. But again...

Mind you, if somebody's got only one or two percent, but then they are so aware of those ectopics, that's significant for that particular patient. Yeah. And then there are also situations where you tend to come across runs of... supraventricular tachycardia, narrow complex tachycardia including atrial flutter, fibrillation or just plain SVT and even ventricular tachycardia.

So that would be the worrying things we'd be looking for, lovely. We sometimes get the ECG reports back and we're not too sure what we need to do with them. And one option is that we can use the advice and guidance service to get them.

some opinions. But we just wondered if you'd mind talking us through a few of the different findings we can sometimes pick up and the significance of them on a 24-hour ECG. If we maybe start with T-wave inversion. T-wave inversions are very nonspecific.

And if patients don't have any symptoms, I wouldn't really act upon just mere T wave inversions. Again, T wave inversions can occur in a... variety of situations including young patients again it could be related to repolarization changes as well in the ventricle and also T wave inversions can also occur in patients with left ventricular hypertrophy because of hypertension and strain so t wave inversions are pretty non-specific i must say

Atrial and ventricular ectopics, again, as I say, we all get ectopic beats and it all depends on the relative frequency of the ectopic beats, the burden of ectopic beats in relation to normal heartbeats and whether they are forceful enough to cause...

symptoms in patients. Yeah okay so that's more related to symptoms and correlating if it's the time the patients are feeling it. But then mind you if somebody's got significant ventriclectopic beats for example if 25 to 30 percent of the have been total heart rate and rhythm for 24 hours.

is made up of ectopics that has intermediate long-term sequelae by causing lateral ventricle dysfunction because of the burden of ectopics. And these patients develop what we call tachycardia-related macadamyapathy and they will need treatment. and by treating them with rate limiting drugs including beta blockers some of the cardiomyopathy changes can be reversed somewhat and it's important to hence diagnose and treat these patients appropriately

So that's for people with a large version of ectopic. Correct. For people with sinus tachycardia, is that ever particularly important? I don't think so. No, I don't think I've come across any patient with sinus tachycardia who's come to any significant harm. But again, it's important to try and figure out the cause of the sinus tachycardia, whether it's just anxiety, whether it's related to medications, related to alcohol intake, things like that.

addressing the underlying cause for the sinus tachycardia. A lot of times we get for pregnant women with sinus tachycardia and with pregnancy, your heart rate does go up and it's a normal physiological change. But again, it depends on how fast the heart is and whether they're going into the supraventricular.

tachycardia territory or if they're developing atrial flutter of fibrillation yeah which will need again treating um and i guess with the tachycardias we've got the bradycardias as well um you mentioned um before to us that it

depends on how the patient feels with the bradycardias because some people can tolerate it better than others. Yes. Is that the most thing that we need to look for with the bradycardias? Bradycardia is important because again if there is significant bradycardia including higher AV block.

or sinus pauses, then there is an indication to pace these patients. Some patients tend to have ventricular tachycardia triggered by bradycardia. Because of the slow heart rate, they tend to develop torsades or even VT and hence it's important to

look at the bladdercardia and they might need pacing to suppress or treat the bladdercardia and prevent them from going into ventricular tachyarrhythmias. And that's where bladdercardia is important. Yeah, so for QT changes, is that something that you find particularly important on ECU? QT changes are, again, quite non-specific.

They would probably be relevant only if patients have symptoms associated with them, including, say, chest pains when they're exerting themselves, walking, climbing stairs, and you find associated QT changes. And again, QT... Interval changes are important in patients who are on antipsychotic medications and drugs that can prolong QT intervals. That again makes them susceptible.

to end tickletic arrhythmias and potentially even life-threatening ones at times. Yeah, that's right. And the other thing that I sometimes find that is written in the report is per R-wave progression. I'm just wondering about the significance of that. So per R-wave progression is mostly related... to previous myocardial damage especially the anterior wall of the myocardium when somebody had a previous mi and they developed q waves and the transition of the

our way from v1 through v6 again it's a very non-specific finding uh in an ecg alone and it has got to be looked at in context of the patient if they have symptoms of heart failure if they've had previous myocardial infarction and that's a sign of myocardial damage somewhat. And if they've never had a reported myocardial infarction?

Would we be worried about it, thinking, has this happened in the past? Not if the patient is not symptomatic. I mean, if you have good reason to believe that this patient is developing symptoms of heart failure or LV dysfunction, then yes, it will need investigating. But again, if...

It's a middle-aged gentleman, for example, with a raised body mass index, with hypertension, diabetes, and other sort of cardiovascular risk factors. Again, it's important to look at the poor R-wave progression and consider... whether this patient has had an event without any chest pain symptoms before. And I could be useful there perhaps to look for any left ventricular dysfunction or wall motion abnormalities on the myocardium.

Yeah, that makes sense. And in terms of generally going back to the palpitations, is there anyone that we should be urgently referring to outpatient clinic, depending on what we've said or what they've said, sorry, or examination findings or ECG findings? If patients are getting...

Significant palpitations that are affecting the daily activities and with associated symptoms or features such as presyncope or syncope, breathlessness, then yes, they will need to be referred and seen in secondary or tertiary care. and the ones who have had features where they have definitely lost consciousness.

will need to be admitted to the hospital if they're hemodynamically unstable, where they drop their blood pressure or if they've got ongoing angina type of chest pain. So those patients will need to be admitted to hospital. And again, if you have reason to believe that the palpitations are related... to simple things like a really bad chest infection where they will need investigating or

Any form of sepsis will need to be admitted to hospital. Patients who have had issues with endocrine problems such as thyroid toxicosis or thyroid storm, they will need to be investigated and admitted. to hospital. So not everybody will have a primary cardiac cause. So we'll have to look for other causes, non-cardiac causes that could also precipitate and cause palpitations. Spraphone anemia because of a GI bleed or unknown bleeding, they can present as palpitations.

it's important to rule these other features out. Yeah, that's really important.

So I was just going to ask about the use of beta blockers in these patients. Is there anyone that we could start on beta blockers, say the small number of ectopics not need to refer? We do come across a lot of...

primary care colleagues who commence patients on beta blockers such as propranolol in patients. And it's not harmful to trial a small dose of propranolol or even bisoprolol in these patients. But many a time... what we come across is these patients do not seem to tolerate peter blocker and if they do tolerate they still have their palpitations which again suggests that they could probably stop the peter blocker and then be trained to live with their palpitations if they're not serious enough.

or affecting the daily activities. But there's definitely no reason why you shouldn't try a beta blocker if there is significant vectopic burden and or patients have significant symptoms that is debilitating them. Okay, lovely. Thank you. And so should we talk about AF? We should, yeah. With palpitations. So if we've picked up someone in clinic in GP with an irregular heartbeat, what sort of things would be worrying to us on that same day?

Obviously, you'll check the blood pressure, make sure they're not... unstable hypertensive number one number two you want to make sure the heart rate is not too fast so a 12 EDC is always useful to come to confirm a diagnosis of atrial fibrillation because merely checking a pulse is not totally reliable. It could be an irregular pulse because of ectopics. It could be an irregular pulse because of atrial fibrillation. So it's important to do a 12-EDCG.

Now, worrying symptoms, yes, if they have ongoing symptoms of chest pain, breathlessness, if they show signs of heart failure, it's important. And obviously, if they've had symptoms such as stroke or systemic embolic event. It will be useful like a transient ischemic attack or any lower limb or upper limb ischemia. It's important. Atrial fibrillation, as you know, is the commonest rhythm abnormality in our clinical practice and more common in patients in their sixth.

decade of life onwards essentially and it's important to diagnose atrial fibrillation promptly and treat it with either a rate control or a rhythm control strategy as the case may be and also it's important to remember that

Patients will need further workup to assess the risk for clots and to treat them appropriately for that. Okay. Can you talk us through the general management approach in terms of from general practice starting them on some of these medications and considering them? their crossing risk so in in stable asymptomatic patients and if they usually

older patients in their 60s and 70s and 80s. If the heart rate is somewhat fast, when it is somewhat fast, 80, 90, 100 plus, you might want to start them on a beta blocker as a first line for rate control. If they cannot have a beta blocker, then the next step or next line of drugs would be a calcium channel blocker such as deltaism. But again, it's important to make sure that the left ventricular function is normal because if they have LV dysfunction...

it's not as advisable to consider a diltasm or a bedepamil as they can be negatively inotropic. Ah, yes, that's right. Number one. Number two, a baseline echo would be useful to assess left ventricular function, to assess the atrial sizes, as well as look for any valvular heart disease. Now in terms of whether these patients should have rate control or rhythm control strategy, again it depends on symptoms mainly. If you have a young...

guy or a lady with atrial fibrillation where they have a structurally normal heart otherwise, then we tend to think about rhythm control strategy for these patients as a first line. So you would still start them on things like beta blocks to control the heart rate. You would want to anticoagulate them.

and then refer them for cardioversion in six weeks' time. Right. But older patients where you're going to accept AF as the baseline rhythm, then you can leave them on rate control medications and anticaragulant as per the CHADS2VAS score and the HAASPLED score. So just as an aside, we just wanted to elaborate on the scoring systems here because it's a really important point. The risks and benefits of people with atrial fibrillation.

And considering anticoagulation can be weighed up using the CHADVASc scoring system and the HasBled scoring. So nice clinical knowledge summaries currently have recommended offering anticoagulation treatment for all people with a CHADVASc score of over 2. but also considering anticoagulating men with a CHADVAS score of 1 after taking into account the person's risk of bleeding using the Hasbled scoring tool.

And also remembering to think about the contraindications for both warfarin and NOAC. There's really good information on ICKS about the contraindications and the monitoring that are required for all of those, as well as the risks and downsides. sides and side effects and so if you have a read of that and the bnf you'll be fully informed to have discussions with patients about anticoagulation lovely and now back to the podcast

And I think there is a bit of a split in terms of managing AF in general practice. Some people are very happy to manage it themselves and some people refer everybody through. Do you have any advice for us about that? So atrial fibrillation is a medical problem. That's what we all keep saying.

and it can be managed by general practitioners, by physicians and the only patients that really need to be referred across to secondary tertiary care is where patients are completely unstable and cannot tolerate atrial fibrillation and might perhaps benefit from a rhythm control strategy as well as maybe an ablation procedure to restore sinus rhythm in these patients.

So rate control, anticoagulation, echocardiography are the three sort of basic things that can be done after you have confirmed AF on an ECG. Lovely. And can you talk us through a little bit about some of the considerations?

when we're starting somebody on a NOAC or warfarin? Yeah. So first of all, in terms of anticoagulating patients, a lot of patients are deprived of oral anticoagulation due to a perceived risk of harm due to fall. and bleeding rather than the actual risk and if you if you do ask patients again it's a very individual thing and some patients might prefer to have a bleed rather than

have a debilitating stroke for the rest of their life. And it's important to have the discussion with the patients about oral anticoagulation. The non-warfarin oral anticoagulants or the direct acting oral anticoagulants are the... new kids on the block which have been shown to be non-inferior to warfarin and benefit patients and

they do take away the need for regular INR monitoring, which warfarin has had for years. So provided patients have non-valvular atrial fibrillation, i.e. they don't have significant mitral valve disease or a prostate. acidic valve, then they can be considered for a NOAC. Okay, lovely. And would that be your first line now? Correct, yes. Lovely. And is there any difference between the NOACs or any evidence to show that one is better than the other?

50 milligrams BD is the only drug that has been shown to be superior to warfarin, but otherwise they're all pretty much the same in my opinion. And again, they do have a lot of studies comparing these with warfarin in patients with renal failure, with diabetes. But I mean, they're all equally good, I think. From what I remember, the risk is, is it gastric bleeding with the direct? Yes, gastric bleeds more than intracranial bleeds, which was with morpherin.

Yes, thank you. And you've mentioned about doing an echo in people and you would suggest doing one in everyone that we pick up with AF. Yes, I mean, but mind you, if you have a bed-bound 95-year-old patient with atrial fibrillation, you might just want to leave him alone because in that situation, an echo might not change your overall management. You're just going to aim for rate control. And if it's safe to give...

anticoagulation you would anticoagulate the patient so yeah okay fantastic and um in myself whenever i've done it i've not really delayed starting the anticoagulant whilst waiting for the echo um would that be appropriate it makes sense in fact Just last week, we had in our audit meeting a presentation on atrial fibrillation clinic that's done in Plattebridge by a couple of my colleagues. And a very, very, very small number of patients were actually commenced on oral anticoagulation.

at the time of referral to the anticoagulation clinic and there was a good seven week delay before they could go on to oral anticoagulation from the day of first diagnosis at the primary care level. So I would encourage patients to be anticoagulated. but there's no contraindication for anticoagulation. And making sure the patients are aware of commencing anticoagulation and a sensible discussion has been done.

It's documented in your primary care notes as well. Yeah. And I guess if we've listened to the heart, we've not heard a murmur, we can be fairly happy that there's no valvular disease. Sure. And mind you, if you do find valvular heart disease later... on an echo we can only switch them to waffling yeah okay yeah that's good to know probably the safer option of the two yeah making sure they don't have a stroke in the meantime yeah

So thank you very much for talking to us today, Dr. Karthik. We really appreciate it. Is there anything else you'd like to add or want listeners to take away from this session? It's been a pleasure talking to you and I hope... my talks have been useful to colleagues in primary care and I would encourage them to discuss cardiovascular conditions with us on the advice and guidance and we're more than happy to offer any support.

That's fantastic. And like we said before, we've always had really good response from the advice and guidance cardiology questions. So yeah, we encourage everybody out there to use it if you've got a question. Thank you. All right, brilliant. Thank you. Thank you.

So thank you so much to Dr Karthik for that summary of palpitations. Yeah, it was really excellent going through all of that again, Sarah. I particularly enjoyed going through each of the individual ECG findings and being told exactly what's relevant and what I need to act on.

useful yeah that was really good and it was nice as well to to hear that in general practice we can be managing quite a lot of af patients and that sort of bolstered my confidence a bit yeah yeah and the really important thing that i got out of that as well was just thinking about starting anticoagulants quite quickly for patients who have no contraindications with a new diagnosis of af and

as long as they don't have a murmur we don't have to wait for the echo to make sure it's definitely not valvular af before starting anticoagulants yeah i agree that was really useful to hear So if anyone wants to get in contact with us, give us a bit of feedback, then you can contact us by email at primarycarepodcasts at gmail.com. You can also find us on Twitter. You can tweet at us or DM us at pckbpodcast.

And we've also got a survey that's got some more specific questions if you want to give us that feedback. And the link will be in the description of the episode for everybody to access. Thank you for listening. Until next time. On Primary Care Knowledge Boost. Hey guys, just a friendly reminder that these podcasts are for healthcare professional education and shouldn't be used for medical advice by the general public.

They were recorded in Wigan in 2019. Guidelines can vary by location as well as over time so always check for up-to-date local and national guidelines before making treatment decisions. The content is based on our interviewee's opinion and interpretation of current best practices. practice it's your responsibility to use your clinical judgment before applying or relying on information solely from this podcast check out the show notes for full details and any links we've mentioned in the episode