INSTRUCTION This patient has palpitations: would you like to ask her a few questions? SALIENT FEATURES History · Are the palpitations regular or irregular'? (Rapid regular rhythms suggest SVT or VT whereas rapid, irregular rhythms suggest atrial fibrillation, atrial flutter or tachycardia with varying block.) · ls the onset abrupt (paroxysmal tachyarrhythmias)? · How frequent are the palpitations'? · What is the duration of each episode'? · Is each episode followed by polyuria (seen in supraventricular tachycardia)? · Is there any relation to exercise (e.g. polymorphic VT in long QT syndrome)? · What happens on standing (postural hypotension, atrioventricular nodal tachycardia)? · Are there any precipitating factors such as colIee, tea, alcohol or medications such as thyroid extract, ephedrine, aminophylline, monoamine oxidase inhibitors? · Are there any associated symptoms such as chest pain or shortness of breath? · Is there associated syncope'? (Dizziness or syncope accompanying palpitations should prompt a search for ventricular tachycardia.) · Are the palpitations associated with anxiety or panic attacks'? (Anxiety or panic can result in palpitations.) Note. Palpitations are a common complaint in up to 16% of outpatients. They are non-specific and in only 15% of patients do they correlate with cardiac arrhythmia. Examination · Pulse for arrhythmia. · JVP is distended in heart failure and 'frog' sign (where prominent jugular venous pulsations match the rate of tachycardia) in atrioventricular nodal re-entrant tachycardia (l. xmcet 1993; 341: 1254-8). · Auscultate the heart for murmurs (mitral valve prolapse, valvular heart disease, harsh systolic murmur of hypertrophic cardiomyopathy), split second heart sound (atrial fibrillation). · Look for signs of atrial fibrillation. · Although palpitations may not be present at rest, when the ventricular response is slow, a brisk walk down the corridor may result in palpitations. Tell the examiner that you would like to examine the ECG for: · Presence of Q waves typical of old myocardial infarction, prompting a search for non-sustained ventricular tachycardia. · LVH with left atrial enlarg~.ment (as suggested by notched P wave in lead 11 or terminal P wave force in lead VI more negative than 0.04 s) as this is a likely substrate for atrial fibrillation. · Short PR interval and delta waves, which suggests ventricular pre-excitation and substrate for SVT (Wolff-Parkinson-White syndrome). · Marked left ventricular hypertrophy with deep septal Q waves in I, L and V4 through V6, which suggests hypertrophic cardiomyopathy. · Prolonged QT interval and abnormal T wave morphology, suggesting the presence of long QT syndrome. · Bradycardias and complete heart block since they may be associated with ventri-cular premature depolarizations, long QT syndrome and torsade de pointes. · Abnormal morphology of a ventricular ectopic, suggesting that one of the two types of idiopathic ventricular tachycardia is present. DIAGNOSIS This patient has palpitations (lesion) accompanied by polyuria, indicating a supra-ventricular tachycardia (aetiology). QUESTIONS What are the causes? · Extrasystole. · Tachycardia or bradycardia. · Drugs (see above). · Other: thyrotoxicosis, hypoglycaemia, unaccustomed exertion, phaeochromo-cytoma, fever. · Anxiety state (also known as da Costa's syndrome or cardiac neurosis). How would you investigate a patient suspected of having a disorder of cardiac rhythm ? · 12-lead ECG (look tk)r evidence of a rhythm disturbance and pre-excitation syndrome). · Continuous ambulatory (Holter) echocardiography (many patients with pal-pitations may have stable sinus rhythm). · Exercise ECG. J.M. da Costa (1833-1900) was Professor of Medicine at Jefferson Medical College, Philadelphia