Dr Charbel Abi Khalil, assistant professor of medicine and genetic medicine at WCM-Q, and consultant cardiologist at the Heart Hospital under the Hamad Medical Corporation (HMC), wrote a paper entitled ‘Investigating palpitations, the role of Holter monitoring and loop recorders.‘ The work has now been published by the British Medical Journal.
Heart palpitations make an individual feel that their heart is racing, missing a beat, or has an irregular rhythm, and although they usually have a benign cause, like stress, they can be indicative of a more serious, underlying heart condition.
Holter monitoring involves having a battery-operated monitor attached to a patient’s clothing which monitors electrocardiogram (ECG) readings through electrodes attached to the skin. The Holter monitor can be worn for as little as 24 hours or up to two weeks to gain a fuller picture. Loop recorders operate in a similar manner, but are implanted beneath the skin, detecting the heart’s electrical activity over time in order to diagnose an irregular pulse.
Dr Abi Khalil has written about the best approach for doctors faced with a patient who suffers from palpitations, detailing the steps they should take in order to make the most accurate diagnosis and prognosis.
He stated that physicians must consider the history and lifestyle of individual patients. For example, symptoms that also include dizziness and blacking out might suggest a serious form of arrhythmia, caused by disorganised electrical activity in the ventricles. Palpitations that are preceded by exercise or the consumption of caffeine may suggest a less worrying condition. A cardiovascular examination may also reveal heart disease so the palpitations could be a sign of congestive heart failure or valvular heart disease.
As well as issues with the heart, palpitations can also be caused by metabolic disorders like hyperthyroidism, induced by certain medications, or even be symptoms of a psychiatric problem like panic attacks or depression.
The first medical investigation that should be performed is to get a full blood count, thyroid and kidney function test, and measurements of blood sugars and electrolytes, as Dr Abi Khalil said these give an indication of common metabolic disorders that could be causing the irregular heartbeats.
The next step would be to use a Holter monitor. This can be used as a diagnostic and prognostic tool but also as a method of monitoring patient with a diagnosed condition to ascertain how they are responding to treatment. If a Holter monitor is used but no arrhythmia is found, Dr Abi Khalil said it is then advisable to use a loop monitoring system, which can be worn for a much longer period of time.
However, physicians should be aware that under certain circumstances, a patient complaining of palpitations should be referred immediately to a cardiology clinic rather than undergoing monitoring. These circumstances include a history of cardiac disease or premature death in the patient’s family; palpitations associated with chest pain; or an abnormal electrocardiogram reading.
Patients should be immediately referred to the emergency department if they report persistent chest pain or display symptoms of heart failure.
The paper was supported by Qatar National Research Fund (QNRF).
Dr Abi Khalil said that as a cardiologist myself, it is always useful to have your knowledge refreshed about the latest best practices.
Thanks to the support of Qatar National Research Fund – I hope that this paper provides a template for the wider medical community, ensuring the people of Qatar receive the very best of care. I would also like to acknowledge the work of my colleague Dr Jassim Al Suwaidi, associate professor of clinical medicine and senior consultant in cardiology at the HMC Heart Hospital. His support and examples of Holter monitoring were invaluable to the writing of this paper.’
Visit the WCM-Q website for more information about Dr Abi Khalil’s paper.