Palpitation

1. See Also
   1. Palpitation Causes
2. Definition
   1. Awareness of the heart beat
3. Symptoms
   1. Pounding or fluttering sensation in the chest
   2. Sensation of skipping or missing a beat
   3. Sensation that heart is stopping or jumping
4. Exam
   1. Full vital signs
   2. Thyroid exam
   3. 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
5. Red Flags: Symptoms suggestive of serious cause
   1. Syncope or near Syncope
   2. Palpitations on exertion
   3. Associated cardiopulmonary symptoms (Dyspnea, Orthopnea, Leg Edema)
   4. Prolonged QT interval or other EKG abnormality (see below)
   5. Known heart disease
6. Risk Factors: Arrhythmia cause of Palpitations (with Likelihood Ratio)
   1. Visible neck pulsations (LR: 2.7)
   2. Palpitations affect sleep (LR 2.3)
   3. Palpitations at work (LR 2.2)
   4. Known heart disease history (LR 2.0)
   5. Male gender (LR 1.7)
   6. Palpitations last >5 minutes (LR 1.5)
7. Risk factors: Psychiatric cause of Palpitations
   1. Precaution: Panic may be comorbid with organic cause (up to 13% of cases)
   2. Family History of Panic Disorder
   3. Palpitations <5 minutes
   4. Younger age (typically <40 years old)
   5. Comorbid Disability
   6. Somatization or Hypochondriasis history
8. Causes
   1. See Palpitation Causes
   2. Causes by category
      1. Cardiac (43%)
         1. Structural heart disease (e.g. Mitral Valve Prolapse)
         2. Arrhythmia
      2. Psychiatric (31%)
         1. Anxiety Disorder
      3. Miscellaneous (10%)
      4. idiopathic (16%)
      5. Weber (1996) Am J Med 100(2): 138-48
9. Labs
   1. Thyroid Stimulating Hormone (TSH)
   2. Hemoglobin
   3. Consider additional tests when indicated
      1. Serum Potassium
      2. Serum Calcium
      3. Serum Magnesium
      4. Serum Glucose
      5. Digoxin level
      6. Urine Drug Screen
      7. Urine Pregnancy Test
10. Dignostics: Electrocardiogram
    1. Prior Myocardial Infarction
    2. Left Ventricular Hypertrophy
    3. Right Ventricular Hypertrophy
    4. Atrial Fibrillation
    5. Atrial enlargement
    6. AV nodal block
    7. Prolonged QT Interval (QTc >460 in men, QTc >440 in men)
    8. Delta Waves
       1. Wolff-Parkinson-White Syndrome
    9. Short PR Interval
       1. AV Nodal reentry rhythm
11. Diagnostics: Other
    1. Ambulatory EKG monitoring
       1. Continuous EKG Monitor (Holter Monitor for 24-48 hours)
       2. Event Monitor (loop recorder for intermittent episodes over 1 month)
    2. Consider additional testing when indicated
       1. Exercise Stress Test
          1. Exercise induced Palpitations or associated cardiopulmonary symptoms
          2. Known heart disease or significant risk factors
          3. Abnormal Ekg
       2. Echocardiogram
          1. Suspected structural heart disease
          2. Nondiagnostic evaluation
          3. Palpitations with cardiopulmonary symptoms
       3. Electrophysiologic Study
          1. Syncope
          2. Life threatening arrhythmia suspected
          3. Wolff-Parkinson-White
12. Management
    1. Evaluate for cardiac causes specific causes
       1. Exclude cardiac causes first as they have the potential to be life threatening
       2. Consider cardiology consultation
    2. Manage specific causes
       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
    3. General measures for symptomatic relief of benign causes
       1. Exercise program (if evaluation negative)
       2. Eliminate Caffeine, Alcohol, and Tobacco
       3. Maximize hydration
       4. Stress reduction
       5. Consider Beta Blocker (e.g. Propranolol, Metoprolol)
13. References
    1. Braunwald (2001) Heart Disease, Saunders, p. 37-38
    2. Degowin (1987) Diagnostic Exam, MacMillan, p. 334
    3. Goroll (2000) Primary Care, Lippincott, p. 141-6
    4. Thavendiranathan (2009) JAMA 302(19): 2135-43
    5. Wexler (2011) Am Fam Physician 84(1): 63-9