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Palpitations

By

Andrea D. Thompson

, MD, PhD, Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan;


Michael J. Shea

, MD, Michigan Medicine at the University of Michigan

Last full review/revision Sep 2020| Content last modified Sep 2020
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Palpitations are the perception of cardiac activity. They are often described as a fluttering, racing, or skipping sensation. They are common; some patients find them unpleasant and alarming. Palpitations can occur in the absence of heart disease or can result from life-threatening heart disorders. The key to diagnosis and treatment is to “capture” the rhythm on ECG and make careful observations during the palpitations.

Pathophysiology of Palpitations

The mechanisms responsible for the sensation of palpitations are unknown. Ordinarily, sinus rhythm at a normal rate is not perceived, and palpitations thus usually reflect changes in cardiac rate or rhythm. In all cases, it is the abnormal movement of the heart within the chest that is felt. In cases of isolated extrasystoles, the patient may actually perceive the augmented postextrasystolic beat as the “skipped” beat rather than the premature beat itself, probably because the extrasystole blocks the next sinus beat and allows longer ventricular filling and thus a higher stroke volume.

The clinical perception of cardiac phenomena is highly variable. Some patients are aware of virtually every premature ventricular beat, but others are unaware of even complex atrial or ventricular tachyarrhythmias. Awareness is heightened in sedentary, anxious, or depressed patients and reduced in active, happy patients. In some cases, palpitations are perceived in the absence of any abnormal cardiac activity.

Etiology of Palpitations

Some patients simply have heightened awareness of normal cardiac activity, particularly when exercise, febrile illness, or anxiety increases heart rate. However, diligent evaluation for arrhythmia as the cause of palpitations is warranted. Arrhythmias range from benign to life threatening.

The most common arrhythmias include

Both of these arrhythmias usually are harmless.

Other common arrhythmias include

Bradyarrhythmias rarely cause a complaint of palpitations although some patients are aware of the slow rate.

Causes of arrhythmias

Some arrhythmias (eg, PACs, PVCs, PSVT) often occur spontaneously in patients without serious underlying disorders, but others are often caused by a serious cardiac disorder.

Serious cardiac causes include myocardial ischemia Overview of Acute Coronary Syndromes (ACS) Acute coronary syndromes result from acute obstruction of a coronary artery. Consequences depend on degree and location of obstruction and range from unstable angina to non–ST-segment elevation... read more or other myocardial disorders, congenital heart disease (eg, Brugada syndrome, arrhythmogenic right ventricular cardiomyopathy, congenital long QT syndrome Long QT Syndrome and Torsades de Pointes Ventricular Tachycardia Torsades de pointes is a specific form of polymorphic ventricular tachycardia in patients with a long QT interval. It is characterized by rapid, irregular QRS complexes, which appear to be twisting... read more ), valvular heart disease Overview of Cardiac Valvular Disorders Any heart valve can become stenotic or insufficient (also termed regurgitant or incompetent), causing hemodynamic changes long before symptoms. Most often, valvular stenosis or insufficiency... read more , and conduction system disturbances (eg, disturbances that cause bradycardia or heart block Atrioventricular Block Atrioventricular (AV) block is partial or complete interruption of impulse transmission from the atria to the ventricles. The most common cause is idiopathic fibrosis and sclerosis of the conduction... read more Atrioventricular Block ). Patients with orthostatic hypotension Orthostatic Hypotension Orthostatic (postural) hypotension is an excessive fall in blood pressure (BP) when an upright position is assumed. The consensus definition is a drop of > 20 mm Hg systolic, 10 mm Hg diastolic... read more commonly sense palpitations caused by sinus tachycardia upon standing.

Some drugs, including digitalis, caffeine, alcohol, nicotine, and sympathomimetics (eg, albuterol, amphetamines, cocaine, dobutamine, epinephrine, ephedrine, isoproterenol, norepinephrine, and theophylline), frequently cause or exacerbate palpitations.

Consequences

Evaluation of Palpitations

A complete history and physical examination are essential. Observations by other medical personnel or reliable observers should be sought.

History

History of present illness should cover the frequency and duration of palpitations and provoking or exacerbating factors (eg, emotional distress, activity, change in position, intake of caffeine or other drugs). Important associated symptoms include syncope, light-headedness, tunnel vision, dyspnea, and chest pain. Asking the patient to tap out the rate and cadence of palpitations is better than a verbal description and often allows a definitive diagnosis, as in the “missed beat” of atrial or ventricular extrasystoles or the rapid total irregularity of atrial fibrillation.

Past medical history should identify known potential causes, including documented arrhythmias and heart or thyroid disorders. Family history should note occurrences of syncope (sometimes mistakenly described as seizures) or sudden death at an early age.

The drug profile should be reviewed for offending prescription drugs (eg, antiarrhythmics, digoxin, beta-agonists, theophylline, and rate-limiting drugs); over-the-counter drugs (eg, cold and sinus drugs, dietary supplements containing stimulants), including alternative medicines; and illicit drugs (eg, cocaine, methamphetamines). Caffeine (eg, coffee, tea, numerous soft drinks and energy drinks), alcohol, and tobacco use should be determined.

Physical examination

The general examination should note whether an anxious demeanor or psychomotor agitation is present. Vital signs are reviewed for fever, hypertension, hypotension, tachycardia, bradycardia, tachypnea, and low oxygen saturation. Orthostatic changes in blood pressure (BP) and heart rate should be measured.

Examination of the head and neck should note any abnormality or dyssynchrony of the jugular pulse waves compared with the carotid pulse or auscultated heart rhythm and findings of hyperthyroidism, such as thyroid enlargement or tenderness and exophthalmos. The conjunctivae, palmar creases, and buccal mucosa should be inspected for pallor.

Cardiac auscultation should note the rate and regularity of the rhythm as well as any murmurs or extra heart sounds that might indicate underlying valvular or structural heart disease.

Neurologic examination should note whether resting tremors or brisk reflexes are present (suggesting excess sympathetic stimulation). An abnormal neurologic finding suggests that seizures rather than a cardiac disorder may be the cause if syncope is one of the symptoms.

Red flags

Certain findings suggest a more serious etiology:

Interpretation of findings

Palpation of the arterial pulse and cardiac auscultation may reveal a rhythm disturbance. However, the examination is not always diagnostic of a specific rhythm, except when it identifies the unique irregular irregularity of some cases of rapid atrial fibrillation, the regular irregularity of coupled atrial or ventricular extrasystoles, the regular tachycardia at 150 beats/minute of PSVT, and the regular bradycardia of < 35 beats/minute of complete atrioventricular block.

Careful examination of the jugular venous pulse waves simultaneously with cardiac auscultation and palpation of the carotid artery allows evaluation of atrial rhythm through jugular waves while the auscultated sounds or the pulse in the carotids are the product of ventricular contraction.

Thyroid enlargement or tenderness with exophthalmos suggests thyrotoxicosis. Marked hypertension and regular tachycardia suggest pheochromocytoma.

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Testing

Testing typically is done.

  • ECG, sometimes with ambulatory monitoring

  • Laboratory testing

  • Sometimes imaging studies, stress testing, or both

ECG is done, but unless the recording is done while symptoms are occurring, it may not provide a diagnosis. Many cardiac arrhythmias are intermittent and show no fixed ECG abnormalities; exceptions include

If no diagnosis is apparent and symptoms are frequent, Holter monitoring Holter monitor The standard electrocardiogram (ECG) provides 12 different vector views of the heart’s electrical activity as reflected by electrical potential differences between positive and negative electrodes... read more for 24 to 48 hours is useful; for intermittent symptoms, an event recorder worn for longer periods and activated by the patient when symptoms are felt is better. These tests are used mainly when a sustained arrhythmia is suspected, rather than when symptoms suggest only occasional skipped beats. Patients with very infrequent symptoms that clinicians suspect represent a serious arrhythmia may have a device implanted beneath the skin of the upper chest. This device, often called a loop recorder, continuously records the rhythm and can be interrogated by an external machine that allows the cardiac rhythm to be printed. Finally, a variety of commercially available products that patients may be using may provide additional useful information. These products include fitness trackers, which monitor heart rate, and mobile ECG monitors that are available for phones and watches.

Laboratory testing is needed in all patients. All patients should have a complete blood count and measurement of serum electrolytes, including magnesium and calcium. Further testing should be aimed at suspected causes. The cardiac marker troponin should be measured in patients with ongoing arrhythmias, chest discomfort, or other symptoms suggesting active or recent coronary ischemia, myocarditis, or pericarditis.

Thyroid function tests are indicated when atrial fibrillation is newly diagnosed or there are symptoms of hyperthyroidism. Patients with paroxysms of high BP should be evaluated for pheochromocytoma.

Treatment of Palpitations

For isolated PACs and PVCs in patients without structural heart disease, simple reassurance is appropriate. For otherwise healthy patients in whom these phenomena are disabling, a beta-blocker can be given provided efforts are made to avoid reinforcing the perception by anxious patients that they have a serious disorder.

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Geriatrics Essentials

Older patients are at particular risk of adverse effects of antiarrhythmics; reasons include lower glomerular filtration rate and concomitant use of other drugs. When drug treatment is needed, lower doses should be used to start. Subclinical conduction abnormalities may be present (recognized on ECG or other studies), which might worsen with use of antiarrhythmics; such patients may require a pacemaker to allow the use of antiarrhythmics.

Key Points

  • Palpitations are a frequent but relatively nonspecific symptom.

  • Palpitations are not a reliable indicator of a significant arrhythmia, but palpitations in a patient with structural heart disease or an abnormal ECG may be a sign of a serious problem and warrant investigation.

  • An ECG or other recording done during symptoms is essential; a normal ECG in a symptom-free interval does not rule out significant disease.

  • Most antiarrhythmics themselves can cause arrhythmias.

  • If in doubt about a rapid tachyarrhythmia in a patient in hemodynamic distress, cardiovert first and ask questions later.

Drugs Mentioned In This Article

Drug Name Select Trade
LEVOPHED
ISUPREL
ELIXOPHYLLIN
ADRENALIN
MULTAQ
RYTHMOL
No US brand name
CORDARONE
TIKOSYN
CALAN
XYLOCAINE
CARDIZEM, CARTIA XT, DILACOR XR
PROVENTIL-HFA, VENTOLIN-HFA
CORVERT
COMMIT, NICORETTE, NICOTROL
BETAPACE
LANOXIN
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