Clinical Impact of Cardiac Fibromas
Megan K. CovingtonPhillip M. YoungMelanie C. BoisJoseph J. MaleszewskiVidhu AnandJoseph A. DearaniKyle W. Klarich
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In the diagnostic work-up of patients with palpitations the first-line investigations involve history, physical examination and 12-lead ECG. In a good proportion of patients, these investigations allow the prognostic stratification of patients and a definite or suspected diagnosis of the cause of symptoms. However, when results of the initial evaluation are negative (which occurs more frequently in paroxysmal, short-lasting palpitations) and the patient is suffering from heart disease, or if palpitations are frequent or poorly tolerated with a high probability of an arrhythmic origin, ambulatory electrocardiographic monitoring and/or electrophysiological study should be undertaken.
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‘Palpitations’ include a broad range of symptoms relating to the perception of abnormal activity of the heart. They may reflect an underlying arrhythmia or a hyperawareness of normal cardiac activity caused by stress or anxiety. The challenge to a clinician assessing patients with palpitations is to assess the likely cause of symptoms, to stratify the individual patient risk and to choose the correct management strategy delivered with appropriate urgency. The young military population, subject to increased exposure to environmental stress, is at an increased risk of palpitations. Due to the distracting nature of this symptom and the frequently sudden and unheralded onset, a common consequence is medical downgrading. This article will provide a guide to assessing the heterogeneous group presenting with palpitations and how to both establish the cause and identify the correct treatment for each patient in a timely manner.
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In patients with palpitations it is essential to ascertain whether there is a structural heart disease and/or heart disease at risk of arrhythmias, and to obtain an electrocardiographic recording during the episodes of palpitation. Thus, in all subjects with palpitations, the initial evaluation will involve a thorough clinical history, a careful objective examination, and 12-lead ECG at the baseline and, if possible, during an episode of palpitations [1].
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Abstract Background The 2020 European Society of Cardiology atrial fibrillation guidelines recommend opportunistic screening for atrial fibrillation by pulse taking or ECG rhythm strip in those aged over 65 years. Hypothesis We aimed to compare the diagnostic accuracy of pulse palpation to ECG rhythm strip when screening for atrial fibrillation. A secondary aim was to investigate whether participants with palpitations were more likely to be diagnosed with new atrial fibrillation. Methods The study population were 75/76 year old individuals that participated in the STROKESTOP II study, a Swedish screening study for atrial fibrillation. Pulse palpation of the radial pulse for 30 sec was performed by healthcare professionals and recorded as regular or irregular. Thereafter a 30‐sec single‐lead ECG was registered. Patients were asked also if they had a history of palpitations. Results Of the 6159 participants included in the study, 461 (7.5%) had irregular pulse. Twenty‐two (4.8%) of those with irregular pulse were diagnosed with atrial fibrillation on single‐lead ECG rhythm strip. Among those with regular pulse, 6 (0.1%) cases of new atrial fibrillation were found. The sensitivity of the pulse palpation test was 78.6% and positive predictive value 4.8%. The proportion of newly diagnosed atrial fibrillation was not different between those with and without history of palpitations. Conclusion Pulse palpation was inferior to single‐lead ECG when screening for atrial fibrillation. We therefore advocate the use of single‐lead ECG rather than pulse palpation when screening for atrial fibrillation. Palpitations did not predict atrial fibrillation.
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Most patients with idiopathic ventricular premature depolarizations (VPDs) complain of symptoms related to this arrhythmia, but some patients are asymptomatic even with a high VPD burden. Our understanding of the relationship between symptoms and cardiomyopathy related to this arrhythmia remains limited. We evaluated 801 subjects (381 men; mean age, 55 ± 17 years) who visited our outpatient clinic. All subjects were diagnosed with frequent VPDs (1% or >1000 beats/day). The patients were divided into two groups according to the presence or absence of typical VPD symptoms (palpitations or skipped beats during VPDs): symptomatic patients (n = 455) and asymptomatic patients (n = 346). Clinical and electrocardiogram parameters were compared between these two groups. In the symptomatic group, palpitations were the most frequent symptom (91%). Daily VPD burden (P = 0.90) and electrocardiogram parameters (P>0.05) did not differ significantly between groups. The incidence of frequent VPDs with left ventricular dysfunction was significantly higher in the asymptomatic group (symptomatic patients, 3.0%; asymptomatic patients, 10.5%; P < 0.001). The absence of typical VPD-related symptoms may be a risk factor for cardiomyopathy and be associated with an adverse outcome.
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