Palpitation

Aka: Palpitation

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II. Definitions

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

III. Epidemiology

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

IV. History

  1. See Palpitation Causes
  2. 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
  3. Medications, over-the-ounter agents and recreational drugs
  4. Family History of Sudden Cardiac Death
    1. Premature Coronary Artery Disease
    2. Sudden Arrhythmia Death Syndrome (Brugada Syndrome)
  5. Past Medical History
    1. Unexplained event history (Syncope, fall from height, MVA)
    2. Thyroid disease
  6. Cardiovascular disease history
    1. Coronary Artery Disease
    2. Mitral Valve Prolapse
    3. Cardiomyopathy or Myocarditis
    4. Aortic Stenosis
    5. Hypertrophic Cardiomyopathy
    6. Wolff-Parkinson-White Syndrome
    7. Long QT Syndrome
  7. Pulmonary Disease
    1. Chronic obstruction lung disease (with associated hypercarbia, Hypoxia)
    2. Pulmonary Hypertension
  8. Psychiatric Illness
    1. Generalized Anxiety Disorder or Panic Attacks
    2. Drug Abuse

V. Symptoms

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

VI. Exam

  1. 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
  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 or heart rhythm (e.g. Atrial Fibrillation, PVCs)
  4. Telemetry (emergency department)
    1. Ectopy (e.g. PVCs) can often be matched to Palpitation Sensation at the bedside

VII. Red Flags: Symptoms suggestive of serious cause

  1. Syncope or Near Syncope
  2. Palpitations on exertion or at work
  3. Palpitations interfering with sleep
  4. Associated cardiopulmonary symptoms (Dyspnea, Orthopnea, Leg Edema)
  5. Prolonged QT interval or other EKG abnormality (see below)
  6. Known heart disease

VIII. 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)
    1. Palpitations due to Arrhythmia in up to 91% of cases
    2. Thavendiranathan (2009) JAMA 302(19):2135-43 +PMID: 19920238 [PubMed]
  5. Male gender (LR 1.7)
  6. Palpitations last >5 minutes (LR 1.5)

IX. Risk factors: Psychiatric cause of Palpitations

  1. Precaution: Panic may be comorbid with organic cause (up to 13% of cases)
    1. Emotional stress associated adrenergic hyperactivation may also predispose to Arrhythmia
  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

X. Causes

  1. See Palpitation Causes
  2. 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%)
  3. References
    1. Weber (1996) Am J Med 100(2): 138-48 [PubMed]

XI. 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
  4. Other testing to generally AVOID unless specific indications
    1. Serum Troponin
    2. Brain Natriuretic Peptide (BNP)

XII. Imaging

  1. Chest XRay
    1. Consider in suspected cardiac disease
  2. 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

XIII. Dignostics: Electrocardiogram (EKG)

  1. See EKG Changes in Syncope due to Arrhythmia
  2. 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
  3. Prior Myocardial Infarction
  4. Left Ventricular Hypertrophy
  5. Right Ventricular Hypertrophy
  6. Atrial Fibrillation
  7. Atrial enlargement
  8. AV nodal block
  9. Prolonged QT Interval (QTc >460 in women, QTc >440 in men)
  10. Delta Waves
    1. Wolff-Parkinson-White Syndrome
  11. Short PR Interval
    1. AV Nodal reentry rhythm
  12. Brugada sign (End of QRS marked by significant upward deflection, ST Elevation V1-3)
    1. Brugada Syndrome

XIV. Diagnostics: Ambulatory EKG Monitoring

  1. 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
  2. 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)
  3. 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]

XV. Diagnostics: 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 suggestive of Ischemic Heart Disease
  2. 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)

XVI. Management

  1. 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
  2. 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
  3. 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)

XVII. Prognosis

  1. Benign course in most patients, but recurrence is common (75% of patients)
  2. Red flag findings above identify the minority of patients with more serious causes
  3. 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

XVIII. References

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

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