Have you ever experienced palpitations with exercise?
The symptom of palpitations in an athlete or perspective athlete can range from benign with no relationship to arrhythmias to malignant with a risk of a fatal arrhythmic event. This awareness of heartbeats could be due to a normal physiological process, an underlying CV pathology, a systemic cause, or a psychological issue. The heartbeat that is felt may be regular or erratic, fast or slow, strong or weak or may feel like a missed or extra beat that can occur during exercise, emotional situations, and stress and sometimes without any provoking factors (5,16). The figure shows common cardiac and noncardiac causes of palpitations (13,20).
The variability of clinical outcomes of palpitations, ranging from a single benign event to the first sign of a potentially life-threatening problem, makes the evaluation of palpitations a challenging process (17). In two clinical studies, a clinically significant arrhythmia was diagnosed in one-fifth of patients presenting with palpitations (8,24) while a lower prevalence of pathology is found in healthy young athletes (13). The prevalence of palpitations in athletes varies widely depending on age and type of sports. The fourth edition PPE monograph inquires exclusively about palpitations during exercise, and query regarding exertional palpitations is now included in the 2014 AHA elements for preparticipation evaluation (15).
When the answer is positive for exertional palpitations, a careful history examination should be conducted to determine whether further evaluation is needed and which diagnostic testing should be ordered. The critical questions are listed in Table 1.
1) Analysis of the complaint
This should start by an open-ended question without prompting but noted in the record. Asking the athlete to tap the rhythm of their palpitations or to choose from rhythms tapped by the physician can be helpful (Table 2) (25). Palpitations associated with syncope or presyncope may signify a clinical significant arrhythmia such as supraventricular or ventricular tachycardia (VT) in athletes (14,29). Palpitations while sitting quietly or lying in bed that last for brief periods and felt as a single skipped beat or a sensation of stopping of the heartbeats and then restarting suggest premature atrial or ventricular extrasystoles (1,29).
Palpitations are not likely to be due to a significant cardiac arrhythmia when the onset and termination are gradual (20). For example, a sudden onset and abrupt termination of an irregularly irregular heartbeat reinforced by atrial fibrillation (AF) type tapping out along with weakness and fatigue suggest AF. However, sudden onset of fast regular palpitations that continue after stopping exercise broken by positional change or vagal maneuver that can be associated with polyuria, pounding sensation in the neck, shirt flapping, and/or visible cannon A waves in the neck “frog sign” suggests a supraventricular reentry tachyarrhythmia particularly atrioventricular reentrant tachycardia (AVRT) and atrioventricular nodal reentrant tachycardia (AVNRT) (2,7,11,20).
Patients with regular palpitations were found to be twice more likely to have a “significant” cardiac arrhythmia as a cause for their palpitations (24). When palpitations are felt as strong or powerful contractions, but regular and persistent, the physician should think of a systemic cause, such as a high stroke volume or a structural heart disease, such as aortic regurgitation (20). Frequent extra beats, some with super hard beats, some running in a row or associated with weakness or collapse, could be premature ventricular contractions (PVC) or VT.
Even though palpitations can trigger a panic attack, usually the onset of a panic attack precedes the palpitations and is associated with numbness around the mouth and hand spasms. Often, individuals with panic attacks have learned to stop them by breathing into a paper bag or can be told to try this maneuver and will find it effective in stopping their palpitations.
2) Obtaining a family history
This is considered the most important component in the history taking of athletes complaining of palpitations. The physician should inquire not only for a history of sudden death but also for other deaths that may have been a manifestation of arrhythmia, such as the sudden infant death syndrome, drowning, near drowning, and unexplained car accident, as these might have been due to syncope (3,22). This question should consider only first-degree family members (<40 years old) (19,28).
A family history of syncope and sudden cardiac death (SCD), palpitations, supine syncope, and syncope associated with exercise and emotional stress should alert physicians to the high risk for Wolff-Parkinson-White (WPW) syndrome and Long QT syndrome (LQTS) in this individual. Accordingly, the physician should obtain an ECG paying attention to the WPW pattern or the QT interval respectively (6).
3) Identification of noncardiac causes
The next step would be the identification of any existent noncardiac causes and acting accordingly. Emotions can initiate many significant arrhythmias (10), while panic attacks are usually accompanied by tachycardia (4). However, a combination of cardiac and psychiatric causes can coexist (9), so it remains very important to rule out any underlying cardiac etiology of palpitations (9,26,27). Anxiety-related palpitations are usually preceded by unspecific symptoms, such as tingling in the hands and face, a lump in the throat, mental confusion, agitation, atypical chest pains, and sighing dyspnea (20).
Direct questioning about alcohol consumption and caffeine intake (including sodas and energy drinks) (21) should be included, as they can be the sole cause of palpitations or may exacerbate any underlying cardiac pathology. Increased caffeine intake is usually associated with headache, tremor, and insomnia in addition to palpitations (23).
Exposure to medications, supplements, illicit drugs, or performance-enhancing agents (PEA) should be questioned. The World Anti-Doping Agency Web site (http://www.list.wada-ama.org/prohibited-all-times/prohibited-substances/) has a complete sports-specific listing of approved and nonapproved drugs. Also, there is a list of medications affecting QT duration at http://www.sads.org.uk/drugs_to_avoid.htm. In females, benign premature atrial contractions (PAC) have been linked to the use of oral contraceptive pills or the fluctuating levels of estrogen during the menstrual cycle (13). Other drugs like beta-agonists, thyroid hormones, and weight reduction drugs can cause palpitations. A statistical difference was found between using marijuana and/or cocaine and the occurrence of palpitations than nonusers (18).
Physical examination does not add much if the athlete is in normal rhythm, but auscultation of the heart is important to detect any murmurs of structural heart diseases. You may be fortunate enough to detect some irregularity suggestive of AF or just simple PVC or PAC that could immediately be confirmed with a simple single lead ECG recorder, even one working through your smartphone (AliveCor™). The physician should look for any signs of anemia, thyroid diseases, hyperdynamic state, anxiety, or fever.
The first step could be a standard ECG with a rhythm strip, but the real challenge is to capture a recording of the cardiac rhythm while experiencing palpitations.
If the palpitations remain unexplained, a prolonged ECG monitoring is needed to find any underlying arrhythmias. The usual clinical options are available including Holter monitoring and event recorders, but these require carrying a device and using cables to connect to electrodes. These devices can interfere with an athlete’s usual exercise program, so we now prefer to use adhesive patches that have the electrodes and ECG electronics combined and do not require cables (Zio Patch™). We have even used these for swimmers by covering them with water-proof bandages.
An exercise test can be helpful to evaluate whether the arrhythmia is brought out by exercise or occur in the recovery period. Catecholaminergic polymorphic VT can be brought out by exercise and QT prolongation associated with LQTS.
After the cause of the palpitations is determined to be pathophysiological but not a conduction problem, an echocardiogram can be helpful to see whether a cardiomyopathy or other structural problem is the cause.
Once the palpitations are diagnosed as an arrhythmia, referral to a cardiologist or electrophysiologist is appropriate. Otherwise, reassurance and/or evaluation of psychological issues are the next steps.
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