Reassure or refer? Investigating palpitations in general practice

Dr Alisha Dorrigan

writer

Dr Alisha Dorrigan

GP; Writer, Medical editor, Sydney

Dr Alisha Dorrigan

 

Wearable devices aren’t yet standardised enough to be incorporated into general practice assessments, expert says

Palpitations are one of the most common symptoms reported in general practice, and the second most common reason for referral to a cardiologist, but how do you know when it’s enough to simply reassure a patient, and when something more sinister is at play?

The clinical significance of palpitations varies greatly, and while many cases are benign, some patients will have serious underlying pathology that requires early cardiology referral to prevent adverse outcomes.

Dr David O’Donnell, Melbourne-based cardiologist and electrophysiologist, stresses the importance of ensuring a structured approach to these presentations, which includes thorough initial assessment and selecting appropriate investigations.

“That starts with an ECG. Knowing that ECG is abnormal, that’s really useful, and they need to go on to a specialist. If the ECG is normal, which is usually the case, that doesn’t stop you going further. It’s just a nice starting point,” he says.

The decision of whether to arrange a Holter monitor for further assessment depends on their history. “If someone’s having episodes every day, a Holter monitor is great. If someone’s only having an episode once every six months, there’s no point sticking the monitor on,” Dr O’Donnell says.

Investigation should not only include a work-up to assess for arrhythmia as the cause of palpitations—it’s also essential to consider referring for an echocardiogram to look at structural abnormalities.

“I don’t think that ECHOs are prioritised in this space probably as much as they should be,” Dr O’Donnell says, adding that baseline testing should include “some assessment of rhythm and some assessment of structure.”

Initial investigations can guide GPs in deciding who needs referral and who can be reassured, but patients with a normal panel of results and ongoing symptoms of concern will often still warrant referral. For those with minimal symptoms, no red flags or risk factors for cardiac disease, and normal investigations or benign findings such as ectopic beats, reassurance and a watchful waiting approach may be adopted.

“Regardless of preliminary findings, all patients with significant symptoms should be referred”, says Dr O’Donnell.

“If they’re actually blacking out, then that’s a significant symptom. If they’ve got known cardiac disease, or they’ve had a past history of cardiac disease, or if they’ve got a family history of cardiac disease” are all reasons to refer. Special circumstances may also warrant referral; these include pregnancy, elite athletes and certain occupations, such as commercial drivers and pilots.

Who to refer:
– Patients with recurrent symptoms​
– Patients with concerning symptoms​(e.g. breathlessness, chest pain, pre-syncope or syncope)
– Patients with abnormalities on baseline cardiac investigations​
– Patients with known cardiac abnormalities​
– Patients with a family history of sudden cardiac death​
– Patients engaged in high level sporting activities​
– Patients in “at risk” occupations​
– Patients who are or who want to become pregnant

The role of wearable recording devices in assessing palpitations is evolving, Dr O’Donnell says, but the technology may not be ready to be utilised in the primary care setting alone. “We do have a role for these watches and patches and apps, but that role is yet to be clearly defined.”

Variability between devices and significant limitations with the technology makes it challenging to interpret the results. At this point, that requires special expertise and a working knowledge of available products on the market. As such, the major role for these devices is “a cardiology tool for cardiologists.”

“Until we’ve got some standardisation with TGA approved devices, there’s going to be a whole lot on the market that may have limited value.” However, Dr O’Donnell believes wearable devices are likely to have an expanding role in the assessment of arrythmias as the technology improves “I think the future is absolutely around wearables.”

Dr O’Donnell will be speaking on this topic at Healthed’s free webcast on 21 March. Register here if you’d like to hear more.

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Dr Alisha Dorrigan

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Dr Alisha Dorrigan

GP; Writer, Medical editor, Sydney

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