Palpitations

Introduction

Palpitations are a common presenting complaint in Canadian primary care and emergency departments. As a future Canadian physician preparing for the MCCQE1, understanding the diagnosis and management of palpitations is crucial. This guide will help you navigate this topic with a focus on Canadian guidelines and practices.

Definition and Epidemiology

Palpitations are defined as an awareness of the heartbeat, often described by patients as a racing, pounding, or fluttering sensation in the chest or throat.

Canadian Epidemiology

• Palpitations account for approximately 16% of general practice consultations in Canada
• More common in women (ratio 3:2)
• Peak incidence: 40-50 years old

Etiology

Understanding the causes of palpitations is essential for MCCQE1 preparation. Here's a comprehensive list organized by system:

Clinical Assessment

For the MCCQE1, focus on the following steps in clinical assessment:

Canadian Guidelines for Palpitations Management

The Canadian Cardiovascular Society (CCS) provides guidelines for managing patients with palpitations. Key points include:

1. Risk stratification based on history and initial ECG
2. Low-risk patients can often be managed in primary care
3. High-risk features warrant urgent cardiology referral

Management

Management of palpitations in the Canadian healthcare context involves:

1. Treating underlying causes
2. Lifestyle modifications
3. Pharmacological interventions
4. Referral to cardiology when indicated

Pharmacological Management

Key Points to Remember for MCCQE1

• 🇨🇦 Understand the role of primary care in initial assessment and triage
• 🏥 Know the high-risk features that warrant urgent cardiology referral
• 📊 Familiarize yourself with Canadian epidemiology data
• 🩺 Master the approach to history taking and physical examination
• 🧪 Remember key investigations: ECG, Holter monitor, echocardiogram
• 💊 Know the main pharmacological interventions and their indications

MCCQE1 Mnemonics

Remember the causes of palpitations with this Canadian-themed mnemonic:

Canada's Heart Always Races Mightily

• Cardiac: Coronary artery disease, Cardiomyopathy
• Hormonal: Hyperthyroidism, Hypoglycemia
• Anxiety and panic disorders
• Respiratory: COPD, Pulmonary embolism
• Medications: Beta-agonists, Caffeine

Sample Question

A 45-year-old woman presents to her family physician in Toronto with a 3-month history of intermittent palpitations. She describes a "fluttering" sensation in her chest that lasts for a few minutes and occurs 2-3 times per week. She denies chest pain, syncope, or dyspnea. Her medical history is unremarkable, and she takes no medications. Her physical examination is normal, and her ECG shows normal sinus rhythm. Which one of the following is the most appropriate next step in management?

• A. Refer for immediate cardiology consultation
• B. Start metoprolol 25 mg twice daily
• C. Order a 24-hour Holter monitor
• D. Perform an exercise stress test
• E. Recommend avoiding caffeine and alcohol

Explanation

The correct answer is:

• C. Order a 24-hour Holter monitor

Explanation: In this case, the patient presents with intermittent palpitations without high-risk features (no syncope, chest pain, or abnormal ECG). According to Canadian guidelines, for low-risk patients with recurrent, short-lived palpitations, a 24-hour Holter monitor is an appropriate next step to capture any arrhythmias. This aligns with the Canadian approach of managing low-risk patients in primary care settings while ensuring thorough investigation.

Options A and D are not appropriate as the patient doesn't have high-risk features warranting immediate cardiology referral or stress testing. Option B (starting medication) is premature without a clear diagnosis. While option E (lifestyle modifications) may be helpful, it's not the most appropriate next step in determining the cause of palpitations.

Canadian Guidelines

The Canadian Cardiovascular Society (CCS) provides guidelines for the management of atrial fibrillation, which is a common cause of palpitations. Key points include:

1. Risk stratification using the CHA2DS2-VASc score
2. Anticoagulation recommendations based on risk factors
3. Rate control vs. rhythm control strategies
4. Emphasis on shared decision-making with patients

For the most up-to-date guidelines, always refer to the Canadian Cardiovascular Society website (opens in a new tab).

References

1. Raviele, A., et al. (2011). Management of patients with palpitations: a position paper from the European Heart Rhythm Association. Europace, 13(7), 920-934.

2. Thavendiranathan, P., et al. (2009). Does this patient with palpitations have a cardiac arrhythmia? JAMA, 302(19), 2135-2143.

3. Andrade, J. G., et al. (2020). 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Canadian Journal of Cardiology, 36(12), 1847-1948.

4. Heart and Stroke Foundation of Canada. (2021). Atrial Fibrillation. Retrieved from https://www.heartandstroke.ca/heart-disease/conditions/atrial-fibrillation (opens in a new tab)

5. Canadian Cardiovascular Society. (2021). Guidelines. Retrieved from https://ccs.ca/guidelines-and-position-statement-library/ (opens in a new tab)