ECG signal

Dr Diana R Holdright
MD, FRCP, FESC, FACC, MBBS, DA, BSc

Consultant Cardiologist

Dr Diana Holdright
 
 

Drug Therapy - Palpitations

The term “palpitations” implies an awareness of the heart beat, which may or may not be a sign of a cardiac abnormality, and as such defining the precise cause of the palpitations is essential to direct treatment appropriately. Frequently a patient is aware of skipped or missed beats which, in the absence of underlying structural heart disease, do not require treatment and often settle spontaneously; cutting down on caffeine and trying to minimise personal stress may help.

There are a number of different heart rhythms which may signify an underlying heart problem such as impairment of the pumping action of the heart or an inadequate blood supply; problems such as these should be treated in their own right, which may also alleviate the palpitations. In some cases, however, the palpitations may be due to an irregular heart rhythm (known as arrhythmia), which is actually the primary problem; for example, it may be caused by an extra (accessory) electrical pathway within the heart which causes the heart to beat extremely rapidly – in these cases rather than giving drugs to suppress abnormal heart rhythms, a curative procedure called ablation will very likely be the best course of action; a number of other heart rhythms are increasingly amenable to ablation, such as atrial flutter and atrial fibrillation in appropriately selected patients.

There are several classes of drug available to treat arrhythmias, with different and often complex mechanisms of action, and each with its own side-effect profile. Unfortunately all anti-arrhythmic drugs have the potential to be pro-arrhythmic and thereby worsen the situation, and consequently they are only prescribed after careful evaluation. In addition to anti-arrhythmic drug therapy, patients with arrhythmias, especially atrial fibrillation, might be advised to take either aspirin or warfarin to reduce the risk of clot formation within the heart and the potential for stroke; this is because blood does not travel so speedily through the heart, and clots may form in the atria and, if propelled from the heart, may block smaller arteries causing stroke and other conditions.  

Whether aspirin or the more effective drug, warfarin, is prescribed will depend on an individual patient’s risk of stroke, which is determined using the CHA2DS2VaSc scoring system, whereby presence of a recognised risk factor is acknowledged with points as indicated below:

Congestive heart failure
1
Hypertension
1
Age 75+
2
Age 65-74 
1
Diabetes
1
Prior stroke/TIA/thromboembolic event
2
Vascular disease 
1
Gender (female)
1

A total score of 2 or more indicates that formal anticoagulation, i.e. warfarin therapy, would be of greater benefit than aspirin. There is currently considerable research being undertaken into new drugs to replace warfarin, such as dabigatran, rivaroxaban and apixaban, which do not require such rigorous monitoring with blood tests.

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Related pages:

News - March 2013 - Three new alternatives to warfarin for atrial fibrillation - which to choose?

News - October 2012 - Yet another alternative to warfarin on its way in patients with atrial fibrillation

News - November 2011 - Dabigatran treatment in atrial fibrillation


Drug Therapy - Palpitations