More investigation needed to gauge concern for palpitations

DEAR DR. ROACH >> How serious are palpitations? I’m a diabetic woman, age 77. I get these sensations various times throughout the day. Will I have a heart attack or stroke? — B.G.

DEAR READER >> Palpitations are when the heart beats in a particularly forceful, irregular or rapid fashion. They are extremely common and have multiple causes.

One common reason is a cardiac arrhythmia, an abnormal heartbeat. Most of us have times throughout the day where we get an early beat, followed by a pause, with a sensation of a “skipped beat.” The early beat can come from the top chambers (premature atrial contraction, or PAC) or bottom chambers of the heart (premature ventricular contraction, or PVC). A “run” of these may cause an unusually fast heart rate (called a “tachyarrhythmia”), usually lasting only a few beats.

On average, people have about 500 PACS or PVCS a day, so occasional sensations like this may be normal. However, there are more concerning arrythmias like atrial flutter or fibrillation. People with palpitations will often get recommended for a heart monitor to look at the heart rhythm for a prolonged time.

People with diabetes and palpitations should be considered for low blood sugar. One of the ways that the body responds to low blood sugar is to increase stress hormones like adrenaline, which can cause a fast, forceful heartbeat and palpitations.

High thyroid-hormone levels can cause very similar symptoms. Some commonly used substances, like the caffeine in coffee, can often cause a fast and strong heart rate. Very anxious people make their own adrenaline with the same result.

The evaluation for a person with palpitations starts with a careful history and physical exam; may involve some blood testing and a regular, inoffice electrocardiogram; and often includes a heart monitor that lasts anywhere between a day and a few weeks. Most of the time, primary care doctors, like me, can make a diagnosis after this kind of evaluation, but once in a while, a referral to an expert is appropriate for further testing.

DEAR DR. ROACH >> I have three small spots of basal cell carcinoma on my nose, clavicle and forehead. My dermatologist said that each need to be removed on three separate occasions. Is this medically necessary, or is this for the convenience of the doctor? I know they have to keep checking to see if they removed it all, but I was told that I should plan on spending half a day in the office for each. The procedure is Mohs surgery.

— J.B.

DEAR READER >> Mohs surgery has several advantages. It reduces recurrence rates of high-risk skin cancers like yours, minimizes the amount of damage to normal tissue (very important, especially on the face), and allows for immediate reconstruction.

Unfortunately, it is not only time-consuming and expensive, but requires a highly qualified clinician, an experienced team of nurses, histopathology technicians and a fully certified Mohs laboratory. It is entirely possible that each procedure could take up to four hours. Doing three on the same day simply may not be possible, given the amount of histologic preparation and analysis as well as the demands of the practice.

Contact Dr. Roach at Toyourgoodhealth@med. cornell.edu.