Palpitations: History Taking and Differential Diagnoses

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History of Presenting Complaint

Overview

With each symptom, always (if relevant) ask about:

  • When did it start?
  • Did it come on suddenly or gradually?
  • Is it continuous or intermittent?
  • Has this ever happened before?

Palpitations

  • Character:
    • What do they feel like? (e.g. pounding/fluttering etc.)
  • Timeline:
    • How long have they been ongoing?
    • How often do episodes happen? (If relevant)
  • Exacerbating/relieving factors:
    • Does anything trigger them? (e.g. coffee/alcohol)
    • Does anything help with relieving them?

Review of systems

Past Medical History

Questions include:

  • Do they have any other medical conditions?
  • Do they have any risk factors for cardiac disease?
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
  • Do they take any over-the-counter medications, herbal remedies, or supplements?

Family History

  • Is there any family history of anything similar?
  • Any family history of heart problems or sudden death?

Allergy History

  • Are they allergic to anything?
  • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • If so, how much and how long?
  • Do they drink alcohol?
    • If so, how much and how long?
  • Do they use any illicit drugs?
    • If so, how much and how long?
  • Do they drink caffeine?
  • What is their occupation?
  • Who’s at home?
  • What support do they have?
  • How has this impacted their activities of daily living?
  • Has there been any recent foreign travel?

Investigations

When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations:

Differential Diagnoses

Atrial fibrillation

  • A history may reveal:
    • A history of cardiovascular disease (e.g. heart failure, ischaemic heart disease)
    • A history of thyrotoxicosis
  • A physical exam may reveal:
    • An irregularly irregular heartbeat
  • Investigations may reveal:
    • ECG:
      • Irregularly irregular rhythm without discrete P waves
      • Ambulatory ECG monitoring may be needed if the ECG does not identify the arrhythmia

Paroxysmal supraventricular tachycardia

  • A history may reveal:
    • Palpitations that suddenly start and go
    • Palpitations may be relieved with Valsalva manoeuvres (e.g. blowing against resistance or straining)
  • A physical exam may reveal:
    • A rapid and fluttering pulse
  • Investigations may reveal:
    • ECG:
      • Narrow QRS tachycardia
      • Ambulatory ECG monitoring may be needed if the ECG does not identify the arrhythmia

Ventricular tachycardia

  • A history may reveal:
    • Chest pain, shortness of breath, sweating, anxiety, pre-syncope, cold peripheries
    • A history of cardiac disease (e.g. ischaemic heart disease or heart failure)
  • A physical exam may reveal:
    • Tachycardia and hypotension
  • Investigations may reveal:
    • ECG:
      • Broad-complex tachycardia
      • Ambulatory ECG monitoring may be needed if the ECG does not identify the arrhythmia
    • The patient may be peri-arrest

Anxiety/panic disorder

  • A history may reveal:
    • Tingling, paraesthesias, a feeling like they’re ‘going to die’, stress
  • A physical exam may reveal:
    • n/a
    • May show tachycardia
  • Investigations may reveal:
    • ECG:
      • Sinus tachycardia

Hypoglycaemia

  • A history may reveal:
    • Insulin use, alcohol consumption, long periods without eating
    • Anxiety, nausea, hunger, jittering, tremors, dizziness, vision changes, weakness, seizures
  • Investigations may reveal:
    • Blood glucose:
      • Low

Hyperthyroidism

  • A history may reveal:
    • Weight loss, heat intolerance, sweating, anxiety, diarrhoea, oligomenorrhoea, eye problems
  • A physical exam may reveal:
    • Tachycardia, fine tremor, goitre, irregularly irregular pulse, hyperreflexia, pretibial myxoedema, exophthalmos 
  • Investigations may reveal:
    • ECG:
      • May show sinus tachycardia or atrial fibrillation
    • TFTs:
      • Low TSH and elevated T4 and T3

Fever

  • A history may reveal:
    • Sweating, cold intolerance, shivers, features of an underlying infection
  • A physical exam may reveal:
    • Fever
  • Investigations may reveal:
    • Depends on underlying cause

Excess alcohol

  • A history may reveal:
    • An episode of binge drinking
    • ‘Holiday heart syndrome’ – irregular heartbeat associated with high levels of alcohol consumption 
  • A physical exam may reveal:
    • Irregularly irregular pulse
    • Features of alcohol intoxication
  • Investigations may reveal:
    • ECG:
      • May show atrial fibrillation

Excess caffeine

  • A history may reveal:
  • Palpitations occur in correlation to caffeine consumption
  • Large amounts of caffeine ingested

Hypertrophic obstructive cardiomyopathy (HOCM)

  • A history may reveal:
    • A family history of sudden cardiac death
    • Shortness of breath on exertion, syncope or near-syncope on exertion
  • A physical exam may reveal:
    • Ejection systolic crescendo-decrescendo murmur in the right upper sternal border – louder with Valsalva manoeuvre and quieter with squatting
    • S4 heart sound may be heard
  • Investigations may reveal:
    • ECG:
      • May show deep Q waves and left ventricular hypertrophy
    • Echocardiography – MR SAM ASH:
      • MR – mitral regurgitation
      • SAM – systolic anterior movement of the anterior mitral valve leaflet
      • ASH – asymmetrical hypertrophy

Anaemia

  • A history may reveal:
  • A physical exam may reveal:
    • Conjunctival pallor, glossitis, hair loss, atrophic glossitis, koilonychia
  • Investigations may reveal:
    • Full blood count:
      • Low haemoglobin
      • Haematinics including B12, folate, and iron studies can help identify the underlying cause

Phaeochromocytoma

  • A history may reveal:
    • Flushing, headaches, anxiety, panic-attack-like symptoms with palpitations
  • A physical exam may reveal:
    • Hypertension and tachycardia
  • Investigations may reveal:
    • ECG:
      • May show sinus tachycardia
    • 24-hour urinary metanephrines:
      • Diagnostic test

Hyperkalaemia

  • A history may reveal:
  • Investigations may reveal:
    • ECG:
      • May show peaked or tall-tented T waves
      • May show loss of P waves and broad QRS complexes

Wolff-Parkinson-White syndrome (WPW)

  • A history may reveal:
    • Palpitations that can be terminated with Valsalva manoeuvres
    • A family history of sudden cardiac death
  • A physical exam may reveal:
    • Tachycardia
  • Investigations may reveal:
    • ECG:
      • May show a short PR interval and a delta wave (slurred upstroke of QRS complex)
    • Ambulatory ECG monitoring may be needed if the ECG does not identify the arrhythmia

Premature ventricular beats

  • A history may reveal:
    • Palpitations described as a missed beat followed by a heavier pounding beat, may be associated with caffeine
  • Investigations may reveal:
    • ECG:
      • May be normal, may show wide QRS complexes
    • Echocardiography:
      • Normal

Drug-induced palpitations

  • A history may reveal:
    • Stimulants, drugs that lengthen the QT interval (sotalol, tricyclic antidepressants, citalopram, macrolide antibiotics – particularly erythromycin), drugs affecting electrolytes (e.g. thiazide-like and loop diuretics)
  • Investigations may reveal:
    • ECG:
      • May show changes associated with the suspected drug
    • U&Es:
      • May be deranged, such as if diuretics have been used

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