Arrhythmia & Palpitations

Working out what is happening

The history does most of the work: whether the sensation starts and stops abruptly or builds gradually, whether the rhythm is regular or irregular, what brings it on, how long it lasts, and whether it is accompanied by breathlessness, chest pain, dizziness or blackout.

Objective confirmation follows — an ECG during symptoms if possible, otherwise Holter or extended monitoring, with an echocardiogram to establish whether the underlying heart is structurally normal. Thyroid function, haemoglobin and electrolytes are checked, as each can produce palpitations without any primary cardiac problem.

Atrial fibrillation

The commonest sustained arrhythmia, and the one with the most serious consequence: irregular flow in the upper chambers allows clot to form, which can travel to the brain. Management has two separate strands — controlling the rhythm or rate to relieve symptoms, and assessing stroke risk to decide on anticoagulation.

Those two decisions are independent. A patient whose symptoms settle completely may still need lifelong anticoagulation, because the stroke risk is driven by the presence of the arrhythmia rather than by how it feels.

When a device is needed

A pacemaker is indicated where the heart rate is dangerously slow or conduction is failing, causing blackouts or severe fatigue. An implantable defibrillator is considered where there is a meaningful risk of a life-threatening ventricular rhythm, most often in the context of significantly reduced pumping function.

When to seek urgent care

Palpitations with chest pain, severe breathlessness, fainting or near-fainting need immediate assessment. So does any blackout without warning, particularly during exertion, and any family history of sudden unexplained death at a young age.