Advising A Patient Against Unnecessary Investigations

Case Scenario: You are a junior doctor in a cardiology outpatient clinic when a 28 years old female comes for investigation of palpitations. She had previously not been worried about these symptoms,
but recent knowledge of the deaths of two relatives following sudden collapses has made her very concerned. At her first appointment it became clear from her history that the palpitations were consistent with ventricular ectopic beats.
Examination was normal, as was a routine 12-lead ECG.
Echocardiography showed her heart to be normal and a 24-hour  ECG demonstrated ectopic beats when she was symptomatic.
She is keen to have further investigations, but these would not be appropriate.
Your task is to reassure the patient that her condition is benign and explain that further investigations are not necessary.

Key issues to explore: 

• What is the patient’s main concern? 
• Why does she want further investigation? 
• Does her desire stem from the actual symptoms or the perceived risk from the condition in view of her family history?

Key points to establish:

• Reassure the patient that the diagnosis of ectopics is certain, as her symptoms have been clearly correlated with ectopics on the 24-hour ECG. 
• Additional reassurance is often provided when patients understand that most people have ectopic beats at some stage every day, the majority of whom are unaware of them. Some people have a lot more ectopics than others, but this does not signify anything if the heart is normal. In this case we know from investigations that her heart is normal and further tests will add nothing to this.
• It is important that the patient understands her symptoms are not being dismissed. 
• An explanation that ectopic beats can be very debilitating in some people can reassure. Further, knowing the symptom is benign often leads to a significant improvement in the degree of intensity and awareness the patient feels.

Appropriate responses to likely questions

Patient: what can I do to make them go away?

Doctor: in many cases they will just settle down without needing to do anything. Some people find that they are worse after alcohol or after drinks containing caffeine. It might be worthwhile trying to reduce your intake of these to see whether the symptoms improve. Other people find relaxation tricks such as taking a few deep breaths or lying down can be helpful.

Patient: are there any tablets that you can give me to help with them?

Doctor: there are drugs that can help suppress the symptoms, but these ectopic beats are, essentially, a normal heart rhythm. We would not generally advise patients to take any medication unless absolutely necessary, because you can end up with more symptoms from the side effects of the medication than the actual palpitations themselves. If you are desperate to take something for these then beta-blockers may help. I can explain how they work and what side effects they might cause.

Patient: am I likely to die suddenly like my relatives?

Doctor: it is difficult to answer this question without further knowledge of exactly what was responsible for the deaths of your two relatives. However, we have very carefully assessed your heart

and can find no problems that would give us cause for concern at all. I can certainly reassure you

that the palpitations will not cause you to die.

Patient: I am really worried about these symptoms. Would it be possible to have a second opinion?

Doctor: of course you can. Either your GP or I can organise this for you, but I would emphasise that all of the investigations have been reassuring and we know that these ectopic beats, whilst

unpleasant, are not in any way life-threatening, but if you’d like to have a second opinion, then I can help arrange this.