How can heart palpitations be managed?

Palpitations can be harmless, but sometimes there is an underlying heart rhythm problem. Dr Allan Harkness, a leading cardiologist, discusses what a diagnosis would involve and what treatments are available, if required.

What tests can help to diagnose palpitations?

If you are experiencing palpitations, the first step is to have a thorough discussion about your symptoms with your doctor. Cardiologists are particularly good at teasing out all of the relevant features of palpitations as they see patients with this all the time. From time well spent listening to a patient, it may be quite clear to the cardiologist what the cause of the palpitations is without doing any tests. Features that your doctor will want to know are:

• Is it a change in rhythm, speed or forcefulness that you are feeling?
• How often does it occur?
• How long does it last for?
• Is it continuous or intermittent when it comes on?
• Is there any pattern, especially anything that brings it on?
• Does it happen during exercise?
• Are medications, alcohol or caffeine a factor?
• Do you notice it more when you are resting, especially in bed?
• Do you feel dizzy, or experience chest pain or breathless with it?
• When it stops, does is resolve gradually or suddenly?
• Does anyone in your family have heart problems or died at an early age?

All of these symptoms need to be put in context with any other health problems you have – if you are otherwise fit and healthy, palpitations are much less likely to be serious than if you have just recently had a heart attack.

Alongside this assessment, some simple blood tests may be required to ensure you are not anaemic and your thyroid is working normally. After listening to your symptoms, further tests to identify or confirm what the cause is may be required. The key test is to try to capture what your heart rhythm is doing when you have symptoms.

How can your heart rhythm be recorded?

• Many people now carry mobile devices that take their pulse – a Fitbit, Apple watch or even an iPhone can capture your pulse. Usually, this will only pick up a change in speed but a dramatic change in speed can be all that is needed to spot the problem. Unfortunately, these devices are not “medical grade” and give only a rough approximation of your actual heartbeat.
• You can buy relatively cheap add-ons to a mobile phone that will record a simple ECG (electrocardiogram) from either the fingers of both hands or from a strap around your chest. These can be of “medical grade” quality.
• Your doctor can arrange for you to have a cardiac monitor which will record very high-quality ECG tracings. Some monitors are only worn for a day and some can be on for up to a week. They usually have a few sticky electrodes placed on your chest and wires running to a small box that either goes around your neck or fits to your belt.
• A new device, the Zio patch, can stick to your chest for a whole two weeks. During this time, you can still wash or shower without it falling off. The patch is then peeled off and sent back to the company in the post for analysis. The final report is sent to your cardiologist.

All of these devices have some way of you activating them with a button to indicate that you have had symptoms. The specialist analysing the ECG trace will look at the ECG around the time you pressed the button to see if there was a change in heart rhythm or speed. Computer analysis of the tracings may also spot rhythm changes that you did not feel but could be relevant. You will also be asked to keep a diary whilst wearing the device and this diary can also help the specialist interpret the ECG.

If none of these devices pick up the problem, particularly if the palpitations are very infrequent, it may be worth you having an implantable monitor. This is a small device that sits under the skin in the front of your chest. It can monitor your heart for several years. Since these implantable devices are expensive and the procedure is invasive (you will have a very small scar on your chest afterwards), they are usually reserved for when your cardiologist is worried that a dangerous rhythm is causing the palpitations – for example, if they are associated with fainting.

What treatments are available?

For most people who have palpitations, there is no serious cause and no treatment is required either. Many people find their palpitations disappear once they are relieved that they are not serious. Many forms of palpitations can be ignored once you know they are not a sign of heart disease – for example, ectopic heart beats. Even palpitations such as SVT and atrial fibrillation may not require any treatment, especially if they are well tolerated.

Medication:

• If treatment is required, your cardiologist will usually start off with simple medication and only switch to more potent drugs if needed. The simplest medications are usually beta-blockers to slow the heart.
• If you have atrial fibrillation or flutter, you may have an increased risk of stroke. This risk depends on your age, gender, and whether you have diabetes, heart failure or a past stroke. Unless you have no risk factors, you may be recommended to start anticoagulants – traditionally we used warfarin but there are now several drugs available that do the same job without the hassle of regular blood tests.

Other treatment options:

• If you have recently developed atrial fibrillation or flutter, you might benefit from a controlled electric shock to the heart – a DC cardioversion. This shock can reset the heart back into a normal rhythm.
• If your heart is going too slow and causing symptoms, you may benefit from a pacemaker.
• If fast heart palpitations are not responding to medication, you might need a more invasive approach. SVT, AF and VT are all conditions where ablation can sometimes be the appropriate choice and occasionally even before trying drugs. Ablation involves passing fine catheters up the vein in your groin to your heart. These catheters can record the electrics from inside and determine where the problem is. Other catheters can burn a tiny part of the heart from inside and this can prevent the rhythm problem from starting. Ablation is a specialist and invasive treatment.

Your cardiologist can explain in detail what your treatment options are and what the risks and benefits of each option are.