- Palpitations
- Subjective awareness of the heart beat
- Sensation of missed beats or racing, fluttering, pounding in the chest
- See Palpitation Causes
- Palpitation characteristics
- Onset (sudden or gradual)
- Duration (instant, paroxysmal or sustained, esp. >5 minutes)
- Quality (rapid, regular or irregular)
- Frequency (daily, weekly, monthly)
- Associated Symptoms
- Chest Pain or Shortness of Breath
- Presyncope or Syncope
- Nausea
- Provocative factors
- See Red Flags below
- Exertional Palpitations or Exertional Syncope
- Emotional stress
- Positional
- Medications, over-the-ounter agents and recreational drugs
-
Family History of Sudden Cardiac Death
- Premature Coronary Artery Disease
- Sudden Arrhythmia Death Syndrome (Brugada Syndrome)
- Past Medical History
- Unexplained event history (Syncope, fall from height, MVA)
- Thyroid disease
- Cardiovascular disease history
- Coronary Artery Disease
- Mitral Valve Prolapse
- Cardiomyopathy or Myocarditis
- Aortic Stenosis
- Hypertrophic Cardiomyopathy
- Wolff-Parkinson-White Syndrome
- Long QT Syndrome
- Pulmonary Disease
- Chronic obstruction lung disease (with associated hypercarbia, Hypoxia)
- Pulmonary Hypertension
- Psychiatric Illness
- Generalized Anxiety Disorder or Panic Attacks
- Drug Abuse
- Pounding, racing, fluttering or flopping Sensation in the chest
-
Sensation of skipping or missing a beat
-
Sensation that heart is stopping, jumping or racing
- Full Vital Signs
- See Toxin Induced Vital Sign Changes
- Consider stimulants if Hypertension, Tachycardia, diaphoresis, behavior changes, Mydriasis,
- Orthostatic Blood Pressure and pulse
-
Thyroid exam
- Careful cardiopulmonary exam
- Examine heart while standing and squatting to accentuate murmurs
- Evaluate for signs of Cardiomyopathy
- Evaluate for mid-systolic click
- Irregular pulse or heart rhythm (e.g. Atrial Fibrillation, PVCs)
- Telemetry (emergency department)
- Ectopy (e.g. PVCs) can often be matched to Palpitation Sensation at the bedside
- Red Flags
-
Symptoms suggestive of serious cause
-
Syncope or Near Syncope
- Palpitations on exertion or at work
- Palpitations interfering with sleep
- Associated cardiopulmonary symptoms (Dyspnea, Orthopnea, Leg Edema)
-
Prolonged QT interval or other EKG abnormality (see below)
- Known heart disease
- Visible neck pulsations (LR: 2.7)
- Palpitations affect sleep (LR 2.3)
- Palpitations at work (LR 2.2)
- Known heart disease history (LR 2.0)
- Palpitations due to Arrhythmia in up to 91% of cases
- Thavendiranathan (2009) JAMA 302(19):2135-43 +PMID: 19920238 [PubMed]
- Male gender (LR 1.7)
- Palpitations last >5 minutes (LR 1.5)
- Risk factors
-
Psychiatric cause of Palpitations
- Precaution: Panic may be comorbid with organic cause (up to 13% of cases)
- Emotional stress associated adrenergic hyperactivation may also predispose to Arrhythmia
-
Family History of Panic Disorder
- Palpitations <5 minutes
- Younger age (typically <40 years old)
- Comorbid Disability
-
Somatization or Hypochondriasis history
- See Palpitation Causes
- Causes by category
- Cardiac (43%, closer to 30% in other studies)
- Structural heart disease (e.g. Mitral Valve Prolapse)
- Arrhythmia (e.g. Atrial Fibrillation 10%, SVT 9.5%, PVCs 8%)
- Psychiatric (31%)
- Anxiety Disorder
- Panic Disorder
- Miscellaneous (10%)
- Illicit Drugs
- Medications
- Anemia
- Thyrotoxicosis
- idiopathic (16%)
- References
- Weber (1996) Am J Med 100(2): 138-48 [PubMed]
-
Chest XRay
- Consider in suspected cardiac disease
-
Echocardiogram
- Suspected structural heart disease
- Nondiagnostic evaluation
- Palpitations with cardiopulmonary symptoms
-
Cardiomyopathy findings (e.g. Leg Edema, Dyspnea, rales, increased Jugular Venous Pressure)
-
Family History of Sudden Cardiac Death or Hypertrophic Cardiomyopathy
- See EKG Changes in Syncope due to Arrhythmia
-
General
- Overall diagnostic yield for single EKG is low (3 to 26%)
- However yield for Arrhythmia approaches 50% when EKG is performed with ongoing Palpitations
- Prior Myocardial Infarction
-
Left Ventricular Hypertrophy
-
Right Ventricular Hypertrophy
-
Atrial Fibrillation
- Atrial enlargement
- AV nodal block
-
Prolonged QT Interval (QTc >460 in women, QTc >440 in men)
- Delta Waves
- Wolff-Parkinson-White Syndrome
-
Short PR Interval
- AV Nodal reentry rhythm
-
Brugada sign (End of QRS marked by significant upward deflection, ST Elevation V1-3)
- Brugada Syndrome
- Diagnostics
-
Additional Testing when Indicated
-
Exercise Stress Test
-
Exercise induced Palpitations or associated cardiopulmonary symptoms
- Known heart disease or significant risk factors
- Abnormal EKG suggestive of Ischemic Heart Disease
- Electrophysiologic Study
- Highly diagnostic and therapeutic for tachyarrhythmias
- Indications
- Non-diagnostic Ambulatory EKG Monitoring
- Recurrent Syncope (esp. with preceding Palpitations)
- Life threatening Arrhythmia or tachyarrhythmia suspected
- Wolff-Parkinson-White (or other Arrhythmia syndrome)
- Evaluate for cardiac specific causes and for emergent conditions
- Consider cardiology or electrophysiology Consultation
- Exclude cardiac causes first as they have the potential to be life threatening
- Hemodynamic instability (e.g. Hypotension, significant Tachycardia)
- Altered Level of Consciousness
- Acute Coronary Syndrome
- Exercise Induced Syncope
- EKG Changes in Syncope due to Arrhythmia
- Manage specific causes (identified in 40% of patients)
- Extrasystoles
- Refer if 25% of beats are PVCs (risk of Cardiomyopathy) or associated with structural heart disease
- Intermittent PVCs and PACs are common, benign, and typically respond to general measures below
- Supraventricular Tachycardia
- Paroxysmal Supraventricular Tachycardia (PSVT)
- Wolff-Parkinson-White (WPW)
- Atrial Fibrillation or Atrial Flutter
- Ventricular Tachycardia
- Long QT Interval
-
General measures for symptomatic relief of benign causes (see positive prognostic factors below)
- Exercise program (if evaluation negative)
- Yoga for 45 to 60 min, three times weekly
- Sharma (2021) Int J Yoga 14(1): 26-35 [PubMed]
- Eliminate Caffeine, Alcohol, Tobacco and Illicit Drugs
- Avoid Stimulant Medications and adrenergic agents
- Maximize hydration
- Stress reduction
- Consider AV Nodal Blockers for symptomatic ectopy
- See precautions related to very frequent Extrasystoles as above
- Beta Blockers (e.g. Propranolol, Metoprolol) for PVCs or PACs
- Non-Dihydropyridine Calcium Channel Blocker (e.g. Diltiazem, Verapamil) for PVCs
- Consider other agents for symptomatic Palpitations without associated Arrhythmia or significant ectopy
- Alpha-2 Agonists (e.g. Clonidine)
- Benign course in most patients, but recurrence is common (75% of patients)
- Red flag findings above identify the minority of patients with more serious causes
- Findings associated with excellent prognosis
- No structural or arrhythmogenic heart disease
- No Family History of Sudden Cardiac Death
- Isolated Palpitations not provoked by Exercise
- No EKG abnormalities
- No associated cardiopulmonary symptoms (e.g. Chest Pain, Presyncope or Syncope, Dyspnea)
- Associated with increased emotional stress or psychomotor activation
loading