#320 Palpitations with Dr. Joshua Cooper

February 7, 2022 | By Paul Williams

Video

Holt onto your cards!

When should you fold or Holt onto your cards for palpitations?  Learn about properly characterizing a patient’s palpitations, red flag symptoms, when to grab an echocardiogram and/or heart monitoring, and when certain “benign” ECG findings can be concerning.  We’re joined by the director of cardiac electrophysiology at Temple University Hospital, Dr. Joshua Cooper (@narrowQRS) for this episode chock full of cardiac pearls to make your heart skip a beat. 

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Credits

• Producer, Show Notes, Infographic, and Cover Art: Edison Jyang
• Producer: Paul Williams MD, FACP
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP
• Reviewer: Molly Heublein MD
• Executive Producer: Beth Garbitelli
• Showrunner: Matthew Watto MD, FACP
• Editor: Clair Morgan of nodderly.com
• Guest: Joshua Cooper MD

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Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner, Picks of the Week*
• Case from Kashlak
• Defining what the patient means by palpitations
• Common causes and misdiagnoses
• Red flag symptoms
• Exposures and medications to consider
• Sinus tachycardia
• Workup for palpitations
• Monitors
• Script for a negative workup
• Premature ventricular contractions
• Outro

Palpitations Pearls

1. Consider asking the patient to tap out their feeling of palpitations on the back of their hand (e.g. is it strong, slow and steady, or fast and intermittent).
2. In a healthy young patient with no heart disease, common causes of palpitations include: supraventricular tachycardia, premature ventricular beats, and inappropriate/appropriate sinus tachycardia.
3. Red flag symptoms include chest pain, lightheadedness, and loss of consciousness.
4. Some arrhythmias can be misdiagnosed as sinus tachycardia on ECG. The most common being atrial flutter with 2:1 conduction and another one being ectopic atrial tachycardia.
5. The frequency and severity of symptoms determine which heart monitor to use. 
6. Frequent symptoms that can be caught/analyzed early with a monitor may not need immediate echocardiograms, whereas infrequent but concerning symptoms may require echocardiograms earlier.
7. For AVNRT/AVRT, Dr. Cooper prefers the calcium channel blockers diltiazem and verapamil over beta blockers due to less unfavorable side-effects.
8. Catheter ablation can be diagnostic and curative 95% of the time.
9. PVCs that comprise ≥ 10% of a patient’s beats or in patients with past ischemic/structural heart disease should be further investigated/managed.

Palpitations Show Notes

Understand what the patient means by “palpitations”

Consider asking the patient to tap out the feeling on the back of their hand (e.g. is it strong, slow and steady, or fast and intermittent).

If a patient states their symptoms last for 20 minutes, clarify whether it is sustained for the entire time or on–and-off intermittently for that time.

Pay attention to the onset of symptoms. Classically, arrhythmias like SVT will have an abrupt onset and offset, whereas a sensation of palpitations associated with anxiety may build and relieve more gradually (Al-Zaiti 2016).

Common Causes

In a healthy young patient with no heart disease, common causes of palpitations include: supraventricular tachycardia, premature ventricular beats, and inappropriate/appropriate sinus tachycardia (Zimetbaum 1998).  

Dr. Cooper reports that some patients can mistake stomach rumbling, intercostal muscle twitching, reflux, and esophageal spasm as palpitations.

Is it “just” anxiety? Remember that an ECG is just a snapshot, and will not pick up an arrhythmia that occurred just before or after the test. Patients can also be quick to rationalize themselves the symptoms as stemming from anxiety, with doctors eager to agree. 

Red Flag Symptoms

Chest pain, lightheadedness, severe bradycardia and loss of consciousness, are all red flag symptoms (Abbott 2005)

• Chest pain could be an indicator of underlying congenital or acquired heart disease.
• Lightheadedness and a loss of consciousness could indicate a severe enough tachycardia to decrease brain blood flow (e.g. ventricular tachycardia/fibrillation, or atrial fibrillation with Wolff-Parkinson-White syndrome).
• Severe bradycardia could be an indicator of heart block.

Exposures/Medication

Hypo- or hyperthyroid patients can present with palpitations/arrhythmias.  In a hypothyroid patient, watch out for overtaking thyroid medication.

Alcohol is arrhythmogenic, as seen  in ‘holiday heart’ syndrome (Voskoboinik 2016, Tonelo 2013). Arrhythmia from alcohol can manifest the next day (e.g. from subsequent hypokalemia).

Caffeine is generally considered to not be arrhythmogenic (Voskoboinik 2018), however for a small number of people it can cause palpitations (as in this case study demonstrating the phenomenon). Dr. Cooper states that for patients who have a predisposition to arrhythmias, any stimulant (caffeine included) could provoke an arrhythmia.

Is Sinus Tachycardia Normal?

Dr. Cooper’s next question would be whether symptoms occur with or without sinus tachycardia.  If a patient presents with sinus tachycardia in the clinic but does not complain of concurrent symptoms, one should not just assume their palpitations are due to sinus tachycardia.

The degree of sinus tachycardia correlates with Dr. Cooper’s degree of concern.  Sinus tachycardia of just over 100 beats/min is less concerning and could just result from anxiety  in the office, while >150 beat/min could indicate an underlying issue.

Some arrhythmias can be misdiagnosed as sinus tachycardia on ECG. Commonly misdiagnosed arrhythmias include  atrial flutter (Shiyovich 2010)  with 2:1 conduction and ectopic atrial tachycardia.

An Electrophysiologist’s Thoughts on Wearable Devices

Dr. Cooper sees wearables as a helpful tool. He does point out to patients that these devices are not completely accurate, so most importantly emphasizes to his patients to not worry, but to bring the recordings in to a doctor. 

Workup

Blood Tests

Dr. Cooper bases his decision on whether to draw blood based on patient symptoms (e.g. less likely to order blood work for SVT symptoms).  Otherwise, he does a standard workup for anemia, thyroid, and electrolyte abnormalities.

Keep in mind: Hospitalized patients may have transient changes (e.g. dehydration, electrolyte disturbances) that may cause them to have abnormal heart readings.

Physical Exam

The physical exam does not play a large role in Dr. Cooper’s evaluation of palpitations, especially since the patient needs active symptoms to increase the chance of any findings.  He does note that if a patient with atrioventricular nodal reentrant tachycardia has active symptoms in the office, you can see cannon A waves on the patient’s jugular veins (Goyal 2021).

To echo, or not to echo?

Dr. Cooper takes into account the frequency of symptoms when he decides whether to order an echocardiogram. 

• If the patient has frequent symptoms, they can likely be recorded by an ECG first, which he then interprets and takes into account whether an echocardiogram is warranted (e.g. SVT does not need an echo, whereas PVCs with multiple morphologies warrant an echo). 
• If a patient has infrequent but severe symptoms, then Dr. Cooper will consider an echo as the likelihood of an ECG catching the symptoms concurrently is less likely.

Monitors

There are 3 main options for monitors to choose from:

• Holter Monitor (24-48 hours)
• 5 Day – Several Week Continuous or Event Monitor
• Implantable Monitor (3-4 years)

Dr. Cooper bases his decision on the frequency and severity of symptoms. Symptoms that occur every other day can likely be caught by a Holter monitor.  For most cases, 2 week monitoring is a good balance between length of monitoring and likelihood of catching symptoms.  Implantable monitors are important for severe symptoms (e.g. syncope) that occur infrequently.

Supraventricular Tachycardia (SVT)

SVT is most commonly caused by atrioventricular nodal reentrant tachycardia (AVNRT) or atrioventricular reentrant tachycardia (AVRT).

Dr. Cooper again takes into account the frequency, duration, and severity of symptoms when deciding on management of SVT.

1. Medications. Either daily or as needed when they occur (symptom duration <20 min would be ineffective for as needed medication due to onset of action).  For younger patients with AVNRT/AVRT, Dr. Cooper prefers the calcium channel blockers diltiazem and verapamil over beta blockers due to less unfavorable side-effects.  If Dr. Cooper suspects atrial tachycardia, then he considers flecainide, while making sure to rule out structural heart disease before prescribing.
2. Catheter ablation. This can be diagnostic and may be  curative 95% of the time (Adrade 2019, Peters 2000).
3. Doing nothing. Dr. Cooper counsels that SVT is benign, however does show them certain vagal maneuvers to help terminate it (e.g. bearing down, or ice water to the face).

Premature Ventricular Contractions (PVC)

Dr. Cooper takes into account the frequency and presence of past ischemic/structural heart disease for the management of PVCs. 

For infrequent PVCs in a young patient with minimal symptoms, normal echo, and normal ejection fraction, Dr. Cooper will reassure the patient on the benign nature of his PVCs and even explain the physiology of PVCs to help the patient understand themselves (Dr. Cooper has a Youtube video explaining PVCs in layman terms).

For PVCs that comprise of ≥ 10% of a patient’s beats (ie. 10,000/day) or in patients with past ischemic/structural heart disease, these require further management. Cardiomyopathy can develop when PVCs occur ≥ 10% of a patient’s beats (Baman 2010, Gerstenfeld 2019, Yalin 2017). Management includes catheter ablation or anti-arrhythmic medication.

Dr. Cooper notes that although beta blockers are first-line, they are not that effective for PVCs.

Note: Frequent PVCs can lead to cardiomyopathy, and cardiomyopathy can lead to PVCs.

Script for a negative workup

Dr. Cooper has 2 scripts for a negative workup that depends on the severity of symptoms. During these conversations, he makes sure to validate patient symptoms even if no further workup is indicated.

For patients with concerning symptoms such as syncope, Dr. Cooper speaks with the patient that although the initial workup is inconclusive, he would like to continue further investigation in case the final diagnosis is actually treatable and may cause the patient harm.

For patients with less concerning symptoms, Dr. Cooper will go down a differential diagnosis list of concerning conditions with the patient, explaining why he believes those conditions are not occurring. He reassures them that initial testing reveals no life-threatening or life-altering conditions are occurring and that testing may stop here, while also mentioning the option for further testing if the patient desires and what those next steps would be.

Dr. Cooper’s Take Home Points

1. Understand clearly what the patient means by palpitations.
2. Understand the different options for monitors.
3. Understand that there are treatments for most patient symptoms.
4. Understand red flag symptoms (e.g. syncope, presyncope, dyspnea).
5. Correlate symptoms with other medical conditions. 
6. Electrophysiologists are eager to help, even in an informal consult.

Links*

1. Everybody’s Got Something (book)
2. In Case You Didn’t Feel Like Showing Up (Live) (Album)
3. Nirvana MTV Unplugged (Album)
4. Castlevania (Netflix show)
5. Dr. Joshua Cooper – Arrhythmia Education (Youtube channel) 

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goal

Listeners will develop an approach to palpitations, differentiating between benign and alarming symptoms, deciding appropriate workup/monitoring, and when to refer to a specialist.

Learning objectives

After listening to this episode listeners will…  

1. Develop a general approach for a patient presenting with palpitations.
2. Explore the range of etiologies leading to palpitations.
3. Recognize which patients should receive an echocardiogram and/or heart monitoring.
4. Recognize when a patient should be referred for electrophysiologic testing.

Disclosures

Dr. Cooper is a consultant and speaker at educational sessions for Johnson & Johnson, Medtronic, Boston Scientific, and Abbott Medical. The Curbsiders report no relevant financial disclosures. 

Citation

Jyang E, Cooper J, Williams PN, Watto MF. “#320 Palpitations”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list February 7, 2022.