A physician in the UK specializing in geriatric medicine discusses a commonly vexing ailment in the elderly… unexplained and recurrent heart palpitations.
Palpitations are a common presentation in the elderly.
For many the answer is clean cut with a new diagnosis of atrial flutter or fibrillation. Often it is just a sinus arrhythmia that needs reassurance. But there are those times when the same patient keeps coming in to the emergency department and you just can’t find the answer.
The baseline ECG is normal. The heart rate and blood pressure are fine. Septic screen does not identify any source of infection that might cause a bounding pulse causing more “awareness” of the heart beat.
In our hospital we have immediate access to 24 hour and five day tapes. Though yes they might pick up something useful; if the baseline ECG is normal a short tape probably won’t. A longer tape obviously has better yield but a few beats of SVT too often leads to the initiation of a beta blocker which cause more problems in the elderly than they fix.
There was once such patient in our hospital. She had normal results for all of the above and it went as far as one clinician requesting urinary metanephrines even though we had seen no evidence of a tachy arrhythmia. The final diagnosis in this case was anxiety but this much investigation had gone too far in cementing the notion there could be a medical cause. That just made the anxiety worse.
Eventually the patient gets handed back to their GP with generic advice to refer the patient to cardiology if symptoms continue. Having had all the investigation they need I feel in most cases burdening already busy cardiology clinics with these patients tends to be fruitless.
So what is the next step? Start a beta blocker? Reassure? Repeat tapes?
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