Assessment of palpitations

The problem:

Atrial Fibrillation (AF) is associated with a fivefold increase in stroke risk (Adderley, Ryan, Nirantharakumar and Marshall, 2018). AF can be asymptomatic and transient but may commonly present with palpitations. Cardiac causes contribute 43% of all patients with palpitations (Weber & Kapoor, 1996), the most common being AF. This determines the substantial need for early diagnosis and providing early prophylaxis against thromboembolic events.

My approach:

The assessment of palpitations requires a structured approach with attention to history, examination and investigations. This retrospective case review involved evaluation of the assessment of palpitations against NICE guidance in 48 patients at Pendleside Medical Practice, Clitheroe. In addition, use of a patient-controlled ECG device over regular 12 lead ECG and Holter monitors was evaluated.

The learning:

The results showed variable documentation of history and examination findings. Good documentation of examination skills (85%) and performance of same day investigations (65% had same day blood tests, 63% given ECG and Holter monitors). AF was detected promptly in 4/48 (8.3%) of the sample and all were immediately referred. Patient controlled ECG was used in only 7/48 (14.58%), hence its efficacy cannot be elicited. It was found that red flag symptoms were seldom documented: Dyspnoea 9/48 (18.75%), Chest pain 3/48 (6.25%), Syncope 2/48 (4.16%). Furthermore, only 21/48 (43%) were given a formal diagnosis.  Pulse rate (41/48) and rhythm (39/48) were not always documented. Therefore, improving documentation strategies and promptly recognising and referring patients with red flag symptoms can improve quality of care.

Why it matters:

Studies have shown that 20-30% of patients with ischemic stroke have undiagnosed AF in the background. (Kirchhof et al., 2016) It is also important to rule out red flags and associated non-cardiac causes. Therefore, due to the complex nature of assessing palpitations, a quality improvement project is indicated to improve and simplify the existing pathway to ensure high diagnostic accuracy.

Presenting speaker: Deepa Sharma (UCLan Year 5 MBBS)

            Email: DSharma@uclan.ac.uk

Supervisor: Dr Lucy Astle

General Practitioner, Pendleside Medical Practice

Cardiovascular Lead, Ribblesdale Primary Care Network

            Email: lucy.astle@nhs.net