Does this patient with palpitations have a cardiac arrhythmia?

Abstract

Many patients have palpitations and seek advice from general practitioners. Differentiating benign causes from those resulting from clinically significant cardiac arrhythmia can be challenging and the clinical examination may aid in this process.
To systematically review the accuracy of historical features, physical examination, and cardiac testing for the diagnosis of cardiac arrhythmia in patients with palpitations. Data Source, Study Selection, and
MEDLINE (1950 to August 25, 2009) and EMBASE (1947 to August 2009) searches of English-language articles that compared clinical features and diagnostic tests in patients with palpitations with a reference standard for cardiac arrhythmia. Of the 277 studies identified by the search strategy, 7 studies were used for accuracy analysis and 16 studies for diagnostic yield analysis. Two authors independently reviewed articles for study data and quality and a third author resolved disagreements.
Most data were obtained from single studies with small sample sizes. A known history of cardiac disease (likelihood ratio [LR], 2.03; 95% confidence interval [CI], 1.33-3.11), having palpitations affected by sleeping (LR, 2.29; 95% CI, 1.33-3.94), or while the patient is at work (LR, 2.17; 95% CI, 1.19-3.96) slightly increase the likelihood of a cardiac arrhythmia. A known history of panic disorder (LR, 0.26; 95% CI, 0.07-1.01) or having palpitations lasting less than 5 minutes (LR, 0.38; 95% CI, 0.22-0.63) makes the diagnosis of cardiac arrhythmia slightly less likely. The presence of a regular rapid-pounding sensation in the neck (LR, 177; 95% CI, 25-1251) or visible neck pulsations (LR, 2.68; 95% CI, 1.25-5.78) in association with palpitations increases the likelihood of a specific type of arrhythmia (atrioventricular nodal reentry tachycardia). The absence of a regular rapid-pounding sensation in the neck makes detecting the same arrhythmia less likely (LR, 0.07; 95% CI, 0.03-0.19). No other features significantly alter the probability of clinically significant arrhythmia. Diagnostic tests for prolonged periods of electrocardiographic monitoring vary in their yield depending on the modality used, duration of monitoring, and occurrence of typical symptoms during monitoring. Loop monitors have the highest diagnostic yield (34%-84%) for identifying an arrhythmia.
While the presence of a regular rapid-pounding sensation in the neck or visible neck pulsations associated with palpitations makes the diagnosis of atrioventricular nodal reentry tachycardia likely, the reviewed studies suggest that the clinical examination is not sufficiently accurate to exclude clinically significant arrhythmias in most patients. Thus, prolonged electrocardiographic monitoring with demonstration of symptom-rhythm correlation is required to make the diagnosis of a cardiac arrhythmia for most patients with recurrent palpitations.

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. 2009;302(19):2135-2143 (doi:10.1001/jama.2009.1673) JAMA
Paaladinesh Thavendiranathan; Akshay Bagai; Clarence Khoo; et al.


Arrhythmia?
Does This Patient With Palpitations Have a Cardiac

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CLINICIAN’S CORNER
THE RATIONAL
CLINICAL EXAMINATION
Does This Patient With Palpitations
Have a Cardiac Arrhythmia?
Paaladinesh Thavendiranathan, MD
Akshay Bagai, MD
Clarence Khoo, MD
Paul Dorian, MD
Niteesh K. Choudhry, MD, PhD
CLINICAL SCENARIO
A 58-year-old woman presents to the
emergency department with intermit-
tent episodes of palpitations. She
describes “heart fluttering” that usu-
ally lasts less than 5 minutes, which is
associated with a sense of “impending
doom,” sweating, and paresthesia in
both hands. She is unable to tell
whether the rhythm is regular or
irregular and denies a regular rapid-
pounding sensation in the neck.
There is no associated presyncope or
syncope. She has a history of panic
disorder but is otherwise healthy and
takes no medications. Her pulse rate
and rhythm are palpably normal and
the rest of her physical examination
along with a 12-lead electrocardio-
gram is normal.
WHY IS THE CLINICAL
EXAMINATION FOR
PALPITATIONS IMPORTANT?
Palpitations are a common, unpleas-
ant, and often alarming awareness of
heartbeats,1with a prevalence as high
as 16% in medical outpatients.2They
often pose a clinical challenge3
because of the wide differential diag-
nosis(BOX).Palpitationsmayoccurdue
to a change or abnormality in heart
CME available online at
www.jamaarchivescme.com
and questions on p 2160.
Author Affiliations: Division of Cardiology, Depart-
ment of Medicine (Dr Thavendiranathan) and Divi-
sion of Cardiology, St Michael’s Hospital (Drs Bagai
andDorian),UniversityofToronto,Toronto,Ontario,
Canada;DivisionofCardiology,DepartmentofMedi-
cine,UniversityofBritishColumbia,Vancouver,Canada
(DrKhoo);andDivisionofPharmacoepidemiologyand
Pharmacoeconomics, Department of Medicine,
Brigham and Women’s Hospital and Harvard Medi-
cal School, Boston, Massachusetts (Dr Choudhry).
Corresponding Author: Niteesh K. Choudhry,
MD, PhD, Brigham and Women’s Hospital, Har-
vard Medical School, 1620 Tremont St, Ste
3030, Boston, MA 02120 (nchoudhry@partners
.org).
The Rational Clinical Examination Section Editors:
David L. Simel, MD, MHS, Durham Veterans Affairs
Medical Center and Duke University Medical Center,
Durham, NC; Drummond Rennie, MD, Deputy
Editor.
Context Many patients have palpitations and seek advice from general practitioners.
Differentiating benign causes from those resulting from clinically significant cardiac ar-
rhythmia can be challenging and the clinical examination may aid in this process.
Objective To systematically review the accuracy of historical features, physical ex-
amination, and cardiac testing for the diagnosis of cardiac arrhythmia in patients with
palpitations.
Data Source, Study Selection, and Data Extraction MEDLINE (1950 to Au-
gust 25, 2009) and EMBASE (1947 to August 2009) searches of English-language ar-
ticles that compared clinical features and diagnostic tests in patients with palpitations
with a reference standard for cardiac arrhythmia. Of the 277 studies identified by the
search strategy, 7 studies were used for accuracy analysis and 16 studies for diagnos-
ticyieldanalysis.Twoauthorsindependentlyreviewedarticlesforstudydataandqual-
ity and a third author resolved disagreements.
DataSynthesis Mostdatawereobtainedfromsinglestudieswithsmallsamplesizes.
A known history of cardiac disease (likelihood ratio [LR], 2.03; 95% confidence inter-
val [CI], 1.33-3.11), having palpitations affected by sleeping (LR, 2.29; 95% CI, 1.33-
3.94), or while the patient is at work (LR, 2.17; 95% CI, 1.19-3.96) slightly increase
the likelihood of a cardiac arrhythmia. A known history of panic disorder (LR, 0.26;
95% CI, 0.07-1.01) or having palpitations lasting less than 5 minutes (LR, 0.38; 95%
CI, 0.22-0.63) makes the diagnosis of cardiac arrhythmia slightly less likely. The pres-
ence of a regular rapid-pounding sensation in the neck (LR, 177; 95% CI, 25-1251)
or visible neck pulsations (LR, 2.68; 95% CI, 1.25-5.78) in association with palpita-
tions increases the likelihood of a specific type of arrhythmia (atrioventricular nodal
reentry tachycardia). The absence of a regular rapid-pounding sensation in the neck
makes detecting the same arrhythmia less likely (LR, 0.07; 95% CI, 0.03-0.19). No
other features significantly alter the probability of clinically significant arrhythmia. Di-
agnostic tests for prolonged periods of electrocardiographic monitoring vary in their
yield depending on the modality used, duration of monitoring, and occurrence of typi-
calsymptomsduringmonitoring.Loopmonitorshavethehighestdiagnosticyield(34%-
84%) for identifying an arrhythmia.
Conclusions While the presence of a regular rapid-pounding sensation in the neck
or visible neck pulsations associated with palpitations makes the diagnosis of atrio-
ventricular nodal reentry tachycardia likely, the reviewed studies suggest that the clini-
cal examination is not sufficiently accurate to exclude clinically significant arrhythmias
in most patients. Thus, prolonged electrocardiographic monitoring with demonstra-
tion of symptom-rhythm correlation is required to make the diagnosis of a cardiac ar-
rhythmia for most patients with recurrent palpitations.
JAMA. 2009;302(19):2135-2143
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rhythm, such as an arrhythmia (ie, an
abnormal, disordered, or disorga-
nized heartbeat), due to an appropri-
ate increase in normal sinus rate,
orwithanormalsinusrateandrhythm
due to heightened sensitivity and
perception of one’s heartbeats
(eFigure 1 is available at http://www
.jama.com).
In one study, primary cardiac dis-
ease (43%) and anxiety or panic dis-
order (31%) were the most common
causes in patients presenting with
palpitations to the emergency depart-
ment, admitted to the hospital, or
attending a medical clinic.4Among
patients with cardiac disease, palpita-
tions were attributable to arrhythmia
in 91% of cases. Thus, the pretest
probability of cardiac arrhythmia in a
similar patient population would be
39%. In 2 other studies, 19% of
patients presenting with palpitations
were found to have a clinically sig-
nificant arrhythmia.5,6
Because a minority of patients have
palpitations while being examined by
theirphysician,thechallengeistocap-
ture a recording of the cardiac rhythm
during symptoms. While event moni-
torshavebeendesignedtofacilitatethis
process,thediagnosticyieldvarieswith
the frequency of symptoms and dura-
tionofthemonitoredperiod.Arrhyth-
miasalsomayoccurinindividualswho
havenosymptomsatall.7Therefore,the
presenceofanarrhythmiaondiagnos-
tictestingdoesnotconfirmthatitisthe
cause of a patient’s symptoms.7To be
certain, their symptoms must be cor-
related with an electrocardiographi-
cally documented rhythm distur-
bance.Similarly,ifthepatientrepeatedly
has a normal cardiac rate and rhythm
duringtypicalsymptoms,onecanreas-
sure the patient that the cause is likely
nonarrhythmic.
While palpitations are usually be-
nign, they may be a manifestation of
life-threatening conditions. More im-
portantly,recurrentpalpitationscanbe
associatedwithsignificantdisability,in-
cluding impaired work performance
and the inability to perform house-
holdduties.4,8However,usingdiagnos-
tic tests such as event monitors and
echocardiogramsforeverypersonwith
palpitationscanbecostlyandoflowdi-
agnostic yield. Therefore, we re-
viewed the utility of clinical history,
physicalexamination,andrestingrou-
tine electrocardiography as screening
tests for identifying patients with pal-
pitationswhosesymptomsarelikelyor
unlikelytobeduetoacardiacarrhyth-
mia.
HOW TO EVALUATE A PATIENT
WITH PALPITATIONS
Patient History
Most demographic and historical fea-
turesdonotsignificantlyinfluencethe
likelihood of clinically significant ar-
rhythmias.5,6Patient age may be im-
portantbecausesupraventriculartachy-
cardias, particularly ones that use a
bypass tract (atrioventricular reentry
tachycardia)(eFigure1D),maybefirst
experiencedearlierinlife.9,10Inyoung
athletes with palpitations, it is impor-
tanttoconsiderclinicallysignificantar-
rhythmiasassociatedwithsuddencar-
diac death. Atrial fibrillation, flutter,
atrial tachycardia, and ventricular
tachycardia (eFigure 1A, B, I) tend to
occur later in life and are often associ-
atedwithstructuralheartdisease.Some
arrhythmias such as atrioventricular
nodereentrytachycardia(eFigure1C)
may be more common in women than
men.9-11
Ahistoryofpanicdisordershouldbe
explored.12The details of a family his-
tory of palpitations should be re-
corded, especially if family members
have established diagnoses such as ar-
rhythmogenic right ventricular cardi-
omyopathy13oratrialfibrillation.14Any
historyofpreviouscardiacdiseasemay
predispose patients to more clinically
significant arrhythmias4,6and suggest
the need for a more aggressive search
for a cardiac cause.
Patients should be asked to tap out
the rhythm of their palpitations, or to
choose from cadences tapped by the
physician,toidentifytheregularityand
speedofthepalpitations.Singleskipped
beats or a sensation of the heart stop-
ping and then starting with a pound-
ing,flipping,orjumpingsensation,es-
peciallywhilesittingquietlyorlyingin
bed and lasting only for brief periods,
have traditionally been attributed to
prematureatrialorventricularextrasys-
toles.15,16An irregular heartbeat, both
inrhythmandstrength,thatbeginsand
terminates abruptly suggests atrial
fibrillation.
The association of polyuria and pal-
pitations may indicate supraventricu-
lartachycardiabecauseincreasedatrial
pressures stimulate production of na-
triuretic peptides.17A regular rapid-
poundingsensationintheneckmaysig-
nify atrioventricular node reentry
tachycardiawhenthecontractionofthe
atria against closed atrioventricular
valves produces increased right atrial
pressures and reflux of blood into the
superior vena cava.18Associated shirt
flapping, defined as visible movement
of patient’s clothes during the epi-
sode,alsohasbeendescribedwithboth
atrioventricularnodereentrytachycar-
Box. Differential Diagnosis
of Palpitations
Arrhythmia
Definedasatrialfibrillationorflut-
ter, atrioventricular node reentry
tachycardiaoratrioventricularre-
entrytachycardia,atrialtachycar-
dia, ventricular tachycardia, pre-
matureventricularcontractionsor
premature atrial contractions, or
multifocal atrial tachycardia
The causes are primary electrical
abnormality or electrical abnor-
malitysecondarytostructuralcar-
diac disease or comorbid medical
conditions.
Sinus tachycardia
Thecausesincludehyperthyroid-
ism,anxietyorpanicdisorder,fe-
ver,hypovolemia,stimulants(caf-
feine,alcohol),medications,blood
loss, pheochromocytoma, hypo-
glycemia, and idiopathic.
Normal sinus rhythm
The cause is heightened cardiac
perception for an unclear reason.
PALPITATIONS AND CARDIAC ARRHYTHMIA
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diaandatrioventricularreentrytachy-
cardia.19Presyncope or syncope may
representmoreclinicallysignificantar-
rhythmias such as ventricular tachy-
cardia (eFigure 1I).16However, syn-
copecanoccasionallyresultfromacute
vasodilatation and/or rapid heart rate
with low cardiac output that occurs at
the beginning of a supraventricular
tachycardia20,21or due to conversion
pauses occurring at the end, espe-
cially in patients with underlying si-
nus node disease. Conditions such as
hyperthyroidism could be associated
with sinus tachycardia or atrial fibril-
lation (eFigure 1G, I). Similarly, pal-
pitations associated with a psychiatric
diagnosissuchaspanicdisordercould
suggest sinus tachycardia. However, it
isessentialtoruleoutclinicallysignifi-
cantarrhythmiasbeforeattributingpal-
pitations to the patient’s psychiatric
condition.4,8,22
Onset during catecholamine ex-
cess,suchasduringexercise,maysug-
gest ventricular tachycardia or sinus
tachycardia (more commonly).23Pal-
pitationsstartingduringsleeporstates
of increased vagal tone (eg, at termi-
nation of exercise) can be associated
with vagal-mediated atrial fibrillation
or, less likely, certain subtypes of
long-QTsyndromes.24Othertriggersfor
tachycardias include alcohol or caf-
feine consumption.25,26
While patients with QT prolonga-
tion and associated arrhythmias usu-
ally present with syncope, a medica-
tion review is warranted. Drugs that
prolongQTandpredisposepatientsto
torsadesdepointesandotherventricu-
lar arrhythmias include antiarrhyth-
mics, antimicrobials, antihistamines,
psychotropic drugs, and other miscel-
laneous drugs such as motility drugs,
diureticsviaelectrolytedepletion,and
protease inhibitors for human immu-
nodeficiency virus.27-30
Physical Examination
Most patients with episodic palpita-
tions are examined when asymptom-
atic.Typically,thepurposeofthephysi-
cal examination in this setting is to
identify structural heart abnormalities
that may give rise to an arrhythmia.
Whenapatientisexaminedwhilehav-
ing palpitations or the examiner de-
tectsanasymptomaticarrhythmia,cer-
tainphysicalexaminationfeaturesmay
be useful. Atrial fibrillation is sug-
gestedbyapulsethatisnotregularand
has no repeating pattern (ie, irregu-
larlyirregular),thepresenceofapulse
deficit(ie,obtainingalowerpulserate
atthewristthanattheapex),ortheaus-
cultation of variable first heart sound
intensity.Thesefindingsareduetobeat-
to-beatvariationinstrokevolumethat
occurs during atrial fibrillation. The
presence of cannon A waves on the
jugularvenouspressuresuggestsanar-
rhythmiaassociatedwithatrioventric-
ular dissociation such as ventricular
tachycardia.31A cannon A wave is a
prominent wave in the jugular venous
pressure that occurs due to the con-
traction of the right atrium against a
closed tricuspid valve.
Diagnostic Tests
Standard 12-lead electrocardiography
is the initial test in patients with pal-
pitationsandmayidentifythearrhyth-
mia or provide insight into underly-
ingstructuralandelectricalabnormality
that may be a precipitant for arrhyth-
mias. Patients with electrical or struc-
turalabnormalitieson12-leadelectro-
cardiography may warrant a more
aggressivesearchforacardiaccauseof
palpitations.
Theprototypicalclinicaleventmoni-
tor is the Holter monitor that continu-
ously and simultaneously records 2 or
3electrocardiographicleads.Attheend
of the monitoring period (typically 24
or 48 hours), the data are analyzed for
arrhythmias (eFigure 1) and are cor-
relatedwithsymptomsrecordedbythe
patient. The Holter monitor detects
asymptomatic arrhythmias and may
capturearrhythmiasinpatientswhoare
unable to trigger the device (eg, dur-
ingsyncope).Frequently,patientsmay
not experience their usual symptoms
during monitoring and the test is
nondiagnostic.
Intermittent event recorders can be
worncontinuously(looprecorders)or
appliedatthetimeofsymptoms(event
recorders).32Traditionally, intermit-
tent event recorders store electrocar-
diographicmonitoringforseveralmin-
utes once activated by the patient and
hencecannotcaptureasymptomaticar-
rhythmiasorthoseassociatedwithloss
ofconsciousness.32Newerlooprecord-
ers provide continuous, real-time out-
patient electrocardiographic monitor-
ing and can automatically detect
asymptomatic arrhythmias in addi-
tion to being activated by the pa-
tient.33,34Intermittent event recorders
allowforprolongedmonitoring(weeks
tomonths)inpatientswhohaveinfre-
quent symptoms. These devices may
haveahigherspecificitybecausethepa-
tient activates the recording during
symptoms. Specifically, loop moni-
tors save information for a predeter-
mined period prior to the patient trig-
ger, and hence, can help identify the
initiation sequence for arrhythmias.
These stored events can be transmit-
ted through a telephone for physician
review.
Anelectrophysiologicstudyisanin-
vasive test of the electrical conduction
systemoftheheart.Althoughoftenper-
formed for diagnostic and therapeutic
purposes in patients with a known ar-
rhythmia or who have presented
with syncope or resuscitated sudden
cardiac death, it is occasionally per-
formed as a diagnostic test in patients
withpalpitationsinwhomthereishigh
suspicion for cardiac origin.35
Exercisetreadmilltestingwithastan-
dard Bruce protocol may be useful in
patientswhosepalpitationstypicallyoc-
curduringexerciseorareprovokedby
cardiac ischemia.15,36
When palpitations occur infre-
quently or are associated with serious
events such as syncope that cannot be
identified using intermittent event
recorders, implantable loop recorders
(implanted under the skin in the left
parasternal region) can record the
patient’s electrocardiogram continu-
ously for prolonged periods (several
months to years).37,38Patients keep a
diary of their symptoms for symptom-
rhythm correlation. The device can
PALPITATIONS AND CARDIAC ARRHYTHMIA
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also be triggered with an external
activator.
Echocardiography may identify
structural heart diseases that may be a
precipitant for arrhythmias.15,39While
the presence of structural heart dis-
easeincreasesthelikelihoodofaclini-
cally significant arrhythmia and sug-
gests the need for a more aggressive
search for an arrhythmic substrate, it
doesnotprovethatthepatient’spalpi-
tations are secondary to an arrhyth-
mia.
METHODS
Search Strategy
and Data Collection
Structured MEDLINE (1950 to Au-
gust 25, 2009) and EMBASE (1947 to
August 2009) literature searches were
performed to identify English-
language articles relevant to the preci-
sion or accuracy of the clinical exami-
nation for patients with palpitations.
Searchtermsincludedpalpitations,heart
racing, heart pounding, physical exami-
nation, medical history taking, profes-
sionalcompetence,“sensitivityandspeci-
ficity,”reproducibilityofresults,observer
variation,“diagnostictests,routine,”de-
cision support techniques, Bayes theo-
rem, and mass screening. Two authors
independentlyreviewedtheabstractsof
thesearchandretrievedpotentiallyrel-
evant articles and a third author re-
solved disagreements. Additional ar-
ticles were identified by reviewing the
reference lists of retrieved articles and
expert suggestions.15,16,40
Articles reporting original empiri-
cal studies evaluating historical fea-
tures, physical examination, or diag-
nostictestsagainstareferencestandard
for the diagnosis of palpitations sec-
ondary to an arrhythmia were in-
cluded. Acceptable reference stan-
dardsincludedclinicaleventmonitors,
intermittent event recorders, implant-
able loop recorders, in-hospital telem-
etry, 12-lead electrocardiographic
monitoringduringsymptoms,orelec-
trophysiologicalstudy.Excludedstud-
ies (1) focused primarily on nonar-
rhythmic diagnoses in patients with
palpitations;(2)enrolledpatientswith
several presenting complaints but did
not provide separate data for the sub-
group with palpitations; (3) focused
only on comparison between specific
arrhythmiasorusedthepresenceofar-
rhythmiasasopposedtopalpitationsas
inclusion criteria; or (4) did not re-
quiresymptomrhythmcorrelationfor
the diagnosis of arrhythmia. From the
results of the same literature search,
studies were identified providing data
on the diagnostic yield of the various
tests(eg,electrocardiographyandloop
monitoring).
The data extracted were the num-
ber of patients enrolled, symptoms,
signs or tests assessed, the number of
patients with and without arrhythmia
foreachclinicalparameter,andthefre-
quency of typical symptoms and clini-
callysignificantarrhythmias(whenpre-
sent). From this, the likelihood ratios
(LRs) were calculated for the indi-
vidual findings described, along with
the 95% confidence intervals (CIs).
Where possible, the LRs were sepa-
rately calculated for detecting any ar-
rhythmiasandclinicallysignificantar-
rhythmias.Anarrhythmiawasdefined
as any rhythm with a heart rate of 60/
min or less, or 100/min or greater,
and/or that was not normal sinus
rhythm.Clinicallysignificantarrhyth-
miaswerethosethatlikelyrequirespe-
cific management including ventricu-
lar tachycardia, atrioventricular node
reentrytachycardia,atrioventricularre-
entry tachycardia, atrial fibrillation,
atrial flutter, atrial tachycardia, junc-
tionaltachycardia,orventricularecto-
pic beats occurring in salvos.
The yield of the various diagnostic
tests was calculated and defined as the
number of patients who had any ar-
rhythmia or clinically significant ar-
rhythmia during monitoring. When-
ever available, separate data were
provided for the subgroup of patients
who had their typical symptoms dur-
ing the monitoring period.
Articles were graded for method-
ological quality using standard meth-
ods with a threshold of more than 100
patientsdistinguishinglevel1fromlevel
2 studies.41
RESULTS
Only 7 studies met inclusion criteria
for the assessment of diagnostic
accuracy (TABLE 1; eFigure 2 is a
flow diagram illustrating the identifi-
cation of articles and is available at
http://www.jama.com).4-6,11,12,18,42Pal-
pitations were the predominant pre-
senting complaint in these studies
(99.4% of the included patients). The
majorityofthedatawasextractedfrom
the 2 level 1 studies.5,6Only 1 study
assessed a limited number of physical
examinationsignsinpatientswithpal-
pitations.6No study evaluated a com-
bination of historical and physical ex-
amination features or the precision of
anyhistoricalorphysicalexamination
feature.Thereferencestandardsinthe
included studies were electrophysi-
ologicalstudy,1824-hourHoltermoni-
tor,12,42intermittent event record-
ers,5,6and in 2 studies a combination
ofmethods.4,11Amongstudiesthatused
looprecorders(bothfordiagnosticac-
curacy and yield data), only 1 study34
hadtheautomatictriggerfeaturetorec-
ord asymptomatic arrhythmias.
Only 2 of the 7 diagnostic accuracy
studies distinguished clinically insig-
nificant and significant arrhyth-
mias,5,6althoughonly1allowedforthe
calculation of LRs for both types of
rhythm disturbances.5Other studies
lookedonlyatclinicallysignificantar-
rhythmias11,18,42or did not differenti-
ate between the 2.4,12
Sevenstudiesexaminedtheutilityof
the features on history for diagnosing
an arrhythmia as the cause of palpita-
tions (TABLE 2). Most of the data are
obtainedfromstudieswithsmallsample
sizes. Although several features in-
crease the likelihood that a patient’s
palpitations were secondary to an ar-
rhythmia, most have 95% CIs cross-
ing unity and thus may not be clini-
cally useful.
TheonlyfindingswithanLRof2.00
orgreaterforanyarrhythmiawereahis-
tory of cardiac disease (LR, 2.03; 95%
CI, 1.33-3.11) and palpitations af-
fected by sleeping (LR, 2.29; 95% CI,
1.33-3.94; which are presumably pal-
pitationsthataresevereenoughtowake
PALPITATIONS AND CARDIAC ARRHYTHMIA
2138
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