Palpitations

1. Overview

Palpitations are an abnormal awareness of the heartbeat. Patients may describe the sensation as racing, pounding, fluttering, skipped beats or an irregular heartbeat. The OSCE priority is to identify whether the palpitations are due to a dangerous arrhythmia or underlying cardiac disease, and whether the patient has red flag symptoms such as syncope, chest pain or breathlessness.

Common causes include atrial fibrillation, supraventricular tachycardia, ectopic beats, anxiety, thyrotoxicosis, anaemia, stimulant use and medication effects. Serious causes include ventricular tachycardia, inherited arrhythmia syndromes, structural heart disease and arrhythmias associated with acute coronary syndrome.

Important serious causes to consider

• Atrial fibrillation or atrial flutter.
• Supraventricular tachycardia.
• Ventricular tachycardia.
• Arrhythmia secondary to acute coronary syndrome.
• Inherited arrhythmia syndromes such as long QT syndrome or Brugada syndrome.
• Structural heart disease, including cardiomyopathy and valvular disease.
• Thyrotoxicosis.
• Electrolyte disturbance.
• Drug-induced arrhythmia.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about the palpitations.
• Gain consent.
• Check whether the patient is currently having palpitations.
• If the patient is acutely unwell, state that you would assess using ABCDE and call for senior help.

Presenting complaint

• Ask the patient to describe what they mean by palpitations.
• Clarify whether the heartbeat feels fast, slow, irregular, pounding, fluttering or like skipped beats.
• Ask when the palpitations first started.
• Ask whether the onset was sudden or gradual.
• Ask whether the palpitations stop suddenly or gradually.
• Ask how long each episode lasts.
• Ask how frequently episodes occur.
• Ask whether the patient has symptoms at present.

Character of palpitations

• Regular rapid palpitations may suggest supraventricular tachycardia.
• Irregularly irregular palpitations may suggest atrial fibrillation.
• Occasional skipped beats may suggest ectopic beats.
• Palpitations with very rapid onset and offset may suggest paroxysmal SVT.
• Palpitations with collapse or syncope may suggest serious arrhythmia.
• Palpitations during exertion are more concerning than palpitations at rest.

Triggers and relieving factors

• Exercise or exertion.
• Emotional stress or panic.
• Caffeine or energy drinks.
• Alcohol.
• Smoking or nicotine.
• Recreational drugs such as cocaine, amphetamines or cannabis.
• Recent illness, fever or dehydration.
• Postural change.
• Pregnancy.
• New medications.
• Ask whether vagal manoeuvres, rest or medication relieve the symptoms.

Associated cardiac symptoms

• Chest pain or pressure.
• Shortness of breath.
• Syncope or near-syncope.
• Dizziness or light-headedness.
• Exercise intolerance.
• Orthopnoea.
• Paroxysmal nocturnal dyspnoea.
• Peripheral oedema.
• Fatigue.

Associated systemic symptoms

• Weight loss.
• Heat intolerance.
• Sweating.
• Tremor.
• Diarrhoea.
• Anxiety symptoms.
• Fever.
• Symptoms of anaemia such as fatigue, dizziness or pallor.
• Heavy menstrual bleeding.
• Gastrointestinal bleeding symptoms such as melaena or PR bleeding.

Past medical history

• Previous arrhythmia.
• Atrial fibrillation or atrial flutter.
• Supraventricular tachycardia.
• Previous myocardial infarction.
• Ischaemic heart disease.
• Heart failure.
• Valvular heart disease.
• Cardiomyopathy.
• Congenital heart disease.
• Thyroid disease.
• Anaemia.
• Diabetes mellitus.
• Chronic kidney disease.
• Previous stroke or TIA.

Drug history and allergies

• Current regular medications.
• Beta-blockers, calcium channel blockers, digoxin or anti-arrhythmic drugs.
• Anticoagulants such as warfarin, apixaban or rivaroxaban.
• Thyroxine replacement.
• Salbutamol or other beta-agonists.
• Decongestants or stimulant medications.
• Antidepressants or antipsychotics that may prolong QT interval.
• Diuretics that may cause electrolyte abnormalities.
• Recent medication changes.
• Drug allergies and reaction.

Family history

• Sudden cardiac death, especially at a young age.
• Inherited arrhythmia syndromes.
• Long QT syndrome.
• Brugada syndrome.
• Hypertrophic cardiomyopathy.
• Dilated cardiomyopathy.
• Premature ischaemic heart disease.
• Family history of atrial fibrillation.

Social history

• Smoking history.
• Alcohol intake, including binge drinking.
• Caffeine intake.
• Energy drink use.
• Recreational drug use, especially cocaine and amphetamines.
• Occupation, especially safety-critical jobs such as driving, flying or operating machinery.
• Exercise level and athletic activity.
• Stress, sleep deprivation and recent life events.
• Living situation and support.

Ideas, concerns and expectations

• Ask what the patient thinks is causing the palpitations.
• Ask what they are most worried about.
• Ask whether they are concerned about a heart attack, arrhythmia or sudden death.
• Ask what they were hoping would happen today.
• Acknowledge anxiety and explain that palpitations are common but should be assessed carefully.

Red flags

• Syncope or collapse.
• Palpitations during exertion.
• Chest pain.
• Severe breathlessness.
• Known structural heart disease.
• Family history of sudden cardiac death.
• Very rapid sustained palpitations.
• Palpitations with hypotension or shock.
• Neurological symptoms suggesting stroke or TIA.
• New palpitations in an older patient.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would examine them, check observations and arrange an ECG and relevant investigations.

3. Physical Examination

The examination should assess current stability, identify an arrhythmia if present, and look for signs of structural heart disease, heart failure, thyrotoxicosis, anaemia and systemic illness.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask if the patient currently has palpitations.
• Position the patient at 45 degrees.
• Ensure adequate exposure of the chest while maintaining dignity.
• Ask for a chaperone if appropriate.

Initial assessment: is the patient unstable?

• Look from the end of the bed: is the patient comfortable, pale, sweaty, breathless, cyanosed or confused?
• Assess whether the patient is speaking normally.
• Look for oxygen therapy, cardiac monitor, IV lines, GTN spray or resuscitation equipment.
• If the patient is acutely unwell, state that you would perform an ABCDE assessment and call for senior help.

ABCDE assessment if acutely unwell

• Airway: check if the patient can speak and whether the airway is patent.
• Breathing: assess respiratory rate, oxygen saturation, work of breathing and auscultate the chest.
• Circulation: assess pulse, blood pressure, capillary refill, skin temperature, ECG monitoring and obtain IV access.
• Disability: assess consciousness level and capillary blood glucose.
• Exposure: check temperature, inspect for signs of thyrotoxicosis, anaemia, infection and drug use while maintaining dignity.

Vital signs

• Heart rate.
• Pulse rhythm.
• Blood pressure.
• Respiratory rate.
• Oxygen saturation.
• Temperature.
• Level of consciousness.
• Pain score if chest pain is present.

Hands

• Look for peripheral cyanosis.
• Check capillary refill time.
• Look for clubbing, which may suggest cyanotic heart disease, infective endocarditis or lung disease.
• Look for splinter haemorrhages suggesting infective endocarditis.
• Look for nicotine staining.
• Look for palmar pallor suggesting anaemia.
• Assess for fine tremor, which may suggest thyrotoxicosis or beta-agonist use.
• Feel the hands for warmth and sweating, which may suggest thyrotoxicosis.

Pulse

• Assess radial pulse rate.
• Assess rhythm: regular, regularly irregular or irregularly irregular.
• Assess pulse volume.
• Check for pulse deficit by comparing apical heart rate and radial pulse if atrial fibrillation is suspected.
• An irregularly irregular pulse suggests atrial fibrillation.
• A very regular rapid pulse may suggest SVT.
• Occasional extra beats may suggest ectopic beats.

Blood pressure

• Measure blood pressure.
• Hypotension with palpitations suggests haemodynamic instability.
• Hypertension is a risk factor for atrial fibrillation and structural heart disease.
• Postural blood pressure may be useful if dizziness or syncope is present.

Face and eyes

• Look for conjunctival pallor suggesting anaemia.
• Look for central cyanosis.
• Look for xanthelasma or corneal arcus suggesting hyperlipidaemia.
• Look for lid lag, lid retraction or exophthalmos suggesting Graves disease.
• Look for anxiety, sweating or distress.

Neck

• Assess jugular venous pressure at 45 degrees.
• Raised JVP may suggest heart failure, fluid overload or pulmonary hypertension.
• Inspect the neck for thyroid swelling.
• Palpate the thyroid if clinically appropriate.
• Listen for a thyroid bruit if Graves disease is suspected.
• Assess cervical lymphadenopathy if systemic disease is suspected.

Precordial inspection

• Inspect the chest for scars such as sternotomy, thoracotomy or pacemaker scars.
• Look for pacemaker or ICD.
• Look for chest wall deformity.
• Look for visible pulsations.
• Look for signs of respiratory distress.

Palpation of the chest

• Palpate the apex beat and describe its location.
• A displaced apex beat may suggest cardiomegaly.
• Palpate for a parasternal heave suggesting right ventricular hypertrophy.
• Palpate for thrills over the valve areas.

Auscultation of the heart

• Auscultate the aortic area.
• Auscultate the pulmonary area.
• Auscultate the tricuspid area.
• Auscultate the mitral area.
• Identify first and second heart sounds.
• Listen for added heart sounds such as S3 or S4.
• Listen for murmurs suggesting valvular disease.
• Listen for irregular rhythm.
• Auscultate with the bell at the apex if mitral stenosis is suspected.
• Auscultate with the patient leaning forward if aortic regurgitation is suspected.

Signs of heart failure

• Raised JVP.
• Displaced apex beat.
• Third heart sound.
• Bibasal crackles.
• Peripheral pitting oedema.
• Hepatomegaly or ascites in advanced right-sided heart failure.

Respiratory examination

• Inspect respiratory rate and work of breathing.
• Auscultate the lung bases for crackles suggesting heart failure.
• Listen for wheeze if asthma, COPD or beta-agonist use is relevant.
• Assess for signs of pulmonary oedema or respiratory disease.

Peripheral and systemic examination

• Check for peripheral oedema.
• Assess for signs of DVT if PE is suspected.
• Look for signs of anaemia such as pallor and tachycardia.
• Look for signs of thyrotoxicosis: tremor, warm hands, sweating, thyroid swelling, lid signs and brisk reflexes.
• Consider neurological examination if there are symptoms of TIA or stroke.

Specific findings to mention in palpitations OSCE

• Atrial fibrillation may cause an irregularly irregular pulse.
• SVT may cause a regular narrow-complex tachycardia and sudden onset palpitations.
• Ectopic beats may feel like skipped beats or pauses.
• Heart failure signs suggest structural heart disease.
• Thyrotoxicosis may cause tachycardia, tremor, warm hands and thyroid signs.
• Anaemia may cause pallor, tachycardia and flow murmur.
• A normal examination does not exclude intermittent arrhythmia.

To complete the examination

To complete my examination, I would review observations, perform a 12-lead ECG, check blood tests including full blood count, electrolytes and thyroid function tests, and arrange ambulatory ECG monitoring if symptoms are intermittent. I would escalate urgently if the patient is unstable, has syncope, chest pain, severe breathlessness or a concerning ECG.

4. Differential Diagnosis

Cardiac arrhythmias

• Atrial fibrillation.
• Atrial flutter.
• Supraventricular tachycardia.
• Ventricular tachycardia.
• Ectopic beats.
• Bradyarrhythmias with compensatory awareness of heartbeat.
• Inherited arrhythmia syndromes such as long QT syndrome or Brugada syndrome.

Structural cardiac disease

• Ischaemic heart disease.
• Heart failure.
• Valvular heart disease.
• Cardiomyopathy.
• Congenital heart disease.
• Myocarditis.

Endocrine, metabolic and haematological causes

• Thyrotoxicosis.
• Anaemia.
• Hypoglycaemia.
• Electrolyte disturbance, especially potassium, magnesium or calcium abnormalities.
• Fever or sepsis.
• Pregnancy.

Drug, stimulant and lifestyle causes

• Caffeine.
• Alcohol.
• Nicotine.
• Energy drinks.
• Cocaine or amphetamines.
• Salbutamol or other beta-agonists.
• Decongestants.
• Excess thyroxine replacement.
• QT-prolonging medications.

Psychological causes

• Anxiety.
• Panic attacks.
• Stress.
• Sleep deprivation.

5. Investigations

Bedside tests

• 12-lead ECG.
• Repeat ECG if symptoms recur.
• Continuous cardiac monitoring if currently symptomatic or unstable.
• Full observations.
• Capillary blood glucose.
• Postural blood pressure if dizziness or syncope is present.

Blood tests

• Full blood count to assess anaemia or infection.
• Urea and electrolytes.
• Magnesium and calcium if arrhythmia or electrolyte disturbance is suspected.
• Thyroid function tests.
• CRP if infection or inflammation is suspected.
• Troponin if chest pain or ACS is suspected.
• Pregnancy test in women of reproductive age when appropriate.

Cardiac investigations

• Ambulatory ECG monitoring if symptoms are intermittent.
• 24-hour Holter monitor if symptoms occur daily.
• Longer event monitor if symptoms are less frequent.
• Echocardiogram if structural heart disease, murmur, heart failure or abnormal ECG is present.
• Exercise testing if exertional symptoms are present and appropriate.
• Cardiology referral if red flags, abnormal ECG or suspected significant arrhythmia.

Important investigation points

• A normal ECG does not exclude intermittent arrhythmia.
• Try to capture an ECG during symptoms.
• Check for atrial fibrillation, flutter, SVT, ventricular ectopy, pre-excitation, prolonged QT and conduction disease.
• Electrolyte and thyroid abnormalities are reversible causes.
• Echocardiography is important if structural disease is suspected.

6. Management

Management depends on whether the patient is currently unstable, the rhythm diagnosis, underlying cause and risk of complications. In OSCEs, always start with safety and escalation before definitive treatment.

Immediate approach

1. Assess ABCDE if acutely unwell.
2. Call for senior help if unstable, hypotensive, shocked, confused, breathless or having chest pain.
3. Attach cardiac monitoring.
4. Obtain IV access.
5. Perform a 12-lead ECG.
6. Check blood glucose and electrolytes.
7. Treat reversible causes.
8. Escalate urgently if ventricular tachycardia, broad-complex tachycardia or haemodynamic instability is suspected.

If atrial fibrillation is suspected

• Assess haemodynamic stability.
• If unstable, urgent senior help and emergency cardioversion may be required according to local protocol.
• If stable, consider rate control, rhythm control and anticoagulation assessment according to guideline and clinical context.
• Assess stroke risk and bleeding risk.
• Look for triggers such as infection, thyrotoxicosis, alcohol, PE or heart failure.
• Arrange follow-up and consider cardiology input.

If SVT is suspected

• Assess haemodynamic stability.
• If stable, vagal manoeuvres may be attempted according to local protocol.
• Adenosine may be used in appropriate monitored settings according to local protocol.
• If unstable, urgent senior help and synchronized cardioversion may be required.
• Refer for cardiology assessment if recurrent episodes occur.

If ventricular tachycardia is suspected

• Treat as a medical emergency.
• Assess pulse and haemodynamic stability.
• Call for senior, cardiology or resuscitation team help immediately.
• Follow local advanced life support tachyarrhythmia protocol.
• Correct reversible causes such as electrolyte disturbance, ischaemia and drug toxicity.

If ectopic beats are likely

• Reassure if benign features and no structural heart disease are present.
• Advise reduction of caffeine, alcohol, nicotine and stimulant use.
• Check ECG and consider blood tests.
• Consider ambulatory monitoring if frequent or symptomatic.
• Refer if associated with syncope, structural heart disease or abnormal ECG.

Long-term management

• Treat the underlying cause.
• Optimize cardiovascular risk factors.
• Manage thyroid disease, anaemia or electrolyte disturbance if present.
• Review medications that may contribute to palpitations.
• Avoid triggers such as excess caffeine, alcohol and recreational drugs.
• Provide safety-net advice for syncope, chest pain, severe breathlessness or prolonged palpitations.
• Arrange follow-up with primary care or cardiology depending on risk and diagnosis.

7. Examiner Questions

1. What are the common causes of palpitations?
2. What red flags would you ask about?
3. What features suggest SVT?
4. What features suggest atrial fibrillation?
5. Why is syncope with palpitations concerning?
6. What investigations would you request?
7. Why can a normal ECG be falsely reassuring?
8. When would you arrange ambulatory ECG monitoring?
9. What blood tests are useful in palpitations?
10. What are reversible causes of arrhythmia?
11. How would you manage unstable tachyarrhythmia?
12. What lifestyle advice would you give?
13. When should the patient be referred to cardiology?
14. What is the significance of family history of sudden cardiac death?

Suggested short answers

8. OSCE Pearls

• Ask the patient what they mean by palpitations; patients describe them differently.
• Clarify whether the rhythm feels regular or irregular.
• Sudden onset and sudden offset suggests SVT.
• Irregularly irregular palpitations suggest atrial fibrillation.
• Syncope with palpitations is a major red flag.
• Always ask about exertional symptoms.
• Always ask about family history of sudden cardiac death.
• Ask about caffeine, alcohol, energy drinks and recreational drugs.
• Ask about thyrotoxicosis symptoms.
• A normal ECG does not exclude intermittent arrhythmia.
• Try to capture an ECG during symptoms.
• Mention ambulatory ECG monitoring for intermittent symptoms.
• Escalate urgently if the patient is unstable or has chest pain, syncope or severe breathlessness.

9. Example Presentation to Examiner

10. References

• NICE Clinical Knowledge Summary: Atrial fibrillation.
• ESC Guidelines for the diagnosis and management of atrial fibrillation.
• Resuscitation Council UK: Adult tachycardia algorithm.
• Local hospital emergency medicine and cardiology protocols.
• Standard undergraduate clinical examination and OSCE teaching resources.