Palpitation

See Also

Palpitation Causes

Definitions

Palpitations
1. Subjective awareness of the heart beat
2. Sensation of missed beats or racing, fluttering, pounding in the chest

Epidemiology

Incidence: 0.6% of emergency department visits
1. Probst (2014) Am J Cardiol 113(10): 1685-90 [PubMed]

History

See Palpitation Causes
Palpitation characteristics
1. Onset (sudden or gradual)
2. Duration (instant, paroxysmal or sustained, esp. >5 minutes)
3. Quality (rapid, regular or irregular)
4. Frequency (daily, weekly, monthly)
5. Associated Symptoms
  1. Chest Pain or Shortness of Breath
  2. Presyncope or Syncope
  3. Nausea
6. Provocative factors
  1. See Red Flags below
  2. Exertional Palpitations or Exertional Syncope
  3. Emotional stress
  4. Positional
Medications, over-the-ounter agents and recreational drugs
Family History of Sudden Cardiac Death
1. Premature Coronary Artery Disease
2. Sudden Arrhythmia Death Syndrome (Brugada Syndrome)
Past Medical History
1. Unexplained event history (Syncope, fall from height, MVA)
2. Thyroid disease
Cardiovascular disease history
Pulmonary Disease
1. Chronic obstruction lung disease (with associated hypercarbia, Hypoxia)
2. Pulmonary Hypertension
Psychiatric Illness
1. Generalized Anxiety Disorder or Panic Attacks
2. Drug Abuse

Symptoms

Pounding, racing, fluttering or flopping Sensation in the chest
Sensation of skipping or missing a beat
Sensation that heart is stopping, jumping or racing

Exam

Full Vital Signs
1. See Toxin Induced Vital Sign Changes
2. Consider stimulants if Hypertension, Tachycardia, diaphoresis, behavior changes, Mydriasis,
3. Orthostatic Blood Pressure and pulse
Thyroid exam
Careful cardiopulmonary exam
1. Examine heart while standing and squatting to accentuate murmurs
2. Evaluate for signs of Cardiomyopathy
3. Evaluate for mid-systolic click
4. Irregular pulse or heart rhythm (e.g. Atrial Fibrillation, PVCs)
Telemetry (emergency department)
1. 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

Risk Factors
Arrhythmia cause of Palpitations (with Likelihood Ratio)

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)
1. Palpitations due to Arrhythmia in up to 91% of cases
2. 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)
1. 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

Causes

See Palpitation Causes
Causes by category
1. Cardiac (43%, closer to 30% in other studies)
  1. Structural heart disease (e.g. Mitral Valve Prolapse)
  2. Arrhythmia (e.g. Atrial Fibrillation 10%, SVT 9.5%, PVCs 8%)
2. Psychiatric (31%)
  1. Anxiety Disorder
  2. Panic Disorder
3. Miscellaneous (10%)
  1. Illicit Drugs
  2. Medications
  3. Anemia
  4. Thyrotoxicosis
4. idiopathic (16%)
References
1. Weber (1996) Am J Med 100(2): 138-48 [PubMed]

Labs

Thyroid Stimulating Hormone (TSH)
Hemoglobin
Consider additional tests when indicated
Other testing to generally AVOID unless specific indications
1. Serum Troponin
2. Brain Natriuretic Peptide (BNP)

Imaging

Chest XRay
1. Consider in suspected cardiac disease
Echocardiogram
1. Suspected structural heart disease
2. Nondiagnostic evaluation
3. Palpitations with cardiopulmonary symptoms
4. Cardiomyopathy findings (e.g. Leg Edema, Dyspnea, rales, increased Jugular Venous Pressure)
5. Family History of Sudden Cardiac Death or Hypertrophic Cardiomyopathy

Dignostics
Electrocardiogram (EKG)

See EKG Changes in Syncope due to Arrhythmia
General
1. Overall diagnostic yield for single EKG is low (3 to 26%)
2. 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
1. Wolff-Parkinson-White Syndrome
Short PR Interval
1. AV Nodal reentry rhythm
Brugada sign (End of QRS marked by significant upward deflection, ST Elevation V1-3)
1. Brugada Syndrome

Diagnostics
Ambulatory EKG Monitoring

Indications
1. Nondiagnostic EKG and high suspicion for Arrhythmia
2. Structural heart disease
3. Family History of Sudden Cardiac Death
4. Inherited channelopathy (e.g. Long QTc Syndrome)
5. Syncope or Near Syncope
Devices (e.g. Zio Patch, CAM Patch, Event Monitor)
1. See Ambulatory EKG Monitoring
2. Highest yield duration of monitoring is 14 days (diagnostic in 70 to 85% of cases)
References
1. Francisco-Pascual (2021) World J Cardiol 13(11):608-27 +PMID: 34909127 [PubMed]
2. Steinberg (2017) Heart Rhythm 14(7):e55-e96 +PMID: 28495301 [PubMed]

Diagnostics
Additional Testing when Indicated

Exercise Stress Test
1. Exercise induced Palpitations or associated cardiopulmonary symptoms
2. Known heart disease or significant risk factors
3. Abnormal EKG suggestive of Ischemic Heart Disease
Electrophysiologic Study
1. Highly diagnostic and therapeutic for tachyarrhythmias
2. Indications
  1. Non-diagnostic Ambulatory EKG Monitoring
  2. Recurrent Syncope (esp. with preceding Palpitations)
  3. Life threatening Arrhythmia or tachyarrhythmia suspected
  4. Wolff-Parkinson-White (or other Arrhythmia syndrome)

Management

Evaluate for cardiac specific causes and for emergent conditions
1. Consider cardiology or electrophysiology Consultation
2. Exclude cardiac causes first as they have the potential to be life threatening
3. Hemodynamic instability (e.g. Hypotension, significant Tachycardia)
4. Altered Level of Consciousness
5. Acute Coronary Syndrome
6. Exercise Induced Syncope
7. EKG Changes in Syncope due to Arrhythmia
Manage specific causes (identified in 40% of patients)
1. Extrasystoles
  1. Refer if 25% of beats are PVCs (risk of Cardiomyopathy) or associated with structural heart disease
  2. Intermittent PVCs and PACs are common, benign, and typically respond to general measures below
2. Supraventricular Tachycardia
  1. Paroxysmal Supraventricular Tachycardia (PSVT)
  2. Wolff-Parkinson-White (WPW)
3. Atrial Fibrillation or Atrial Flutter
4. Ventricular Tachycardia
5. Long QT Interval
General measures for symptomatic relief of benign causes (see positive prognostic factors below)
1. Exercise program (if evaluation negative)
  1. Yoga for 45 to 60 min, three times weekly
    1. Sharma (2021) Int J Yoga 14(1): 26-35 [PubMed]
2. Eliminate Caffeine, Alcohol, Tobacco and Illicit Drugs
3. Avoid Stimulant Medications and adrenergic agents
4. Maximize hydration
5. Stress reduction
6. Consider AV Nodal Blockers for symptomatic ectopy
  1. See precautions related to very frequent Extrasystoles as above
  2. Beta Blockers (e.g. Propranolol, Metoprolol) for PVCs or PACs
  3. Non-Dihydropyridine Calcium Channel Blocker (e.g. Diltiazem, Verapamil) for PVCs
7. Consider other agents for symptomatic Palpitations without associated Arrhythmia or significant ectopy
  1. Alpha-2 Agonists (e.g. Clonidine)

Prognosis

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
1. No structural or arrhythmogenic heart disease
2. No Family History of Sudden Cardiac Death
3. Isolated Palpitations not provoked by Exercise
4. No EKG abnormalities
5. No associated cardiopulmonary symptoms (e.g. Chest Pain, Presyncope or Syncope, Dyspnea)
6. Associated with increased emotional stress or psychomotor activation

References

Braunwald (2001) Heart Disease, Saunders, p. 37-38
Degowin (1987) Diagnostic Exam, MacMillan, p. 334
Gale (2016) BMJ 352:H5649 [PubMed]
Goroll (2000) Primary Care, Lippincott, p. 141-6
Thavendiranathan (2009) JAMA 302(19): 2135-43 [PubMed]
Wexler (2017) Am Fam Physician 96(12): 784-9 [PubMed]
Wexler (2011) Am Fam Physician 84(1): 63-9 [PubMed]