II. Definition
- Awareness of the heart beat
III. History
- See Palpitation Causes
- Medications, over-the-ounter agents and recreational drugs
- Family History of Sudden Cardiac Death
- Cardiovascular disease history
- Psychiatric Illness
- Provocative factors
- See Red Flags below
- Exertional Palpitations or Exertional Syncope
IV. Symptoms
V. Exam
- Full Vital Signs
- See Toxin Induced Vital Sign Changes
- Consider stimulants if Hypertension, Tachycardia, diaphoresis, behavior changes, Mydriasis,
- 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)
VI. 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
VII. 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)
- Male gender (LR 1.7)
- Palpitations last >5 minutes (LR 1.5)
VIII. Risk factors: Psychiatric cause of Palpitations
- Precaution: Panic may be comorbid with organic cause (up to 13% of cases)
- Family History of Panic Disorder
- Palpitations <5 minutes
- Younger age (typically <40 years old)
- Comorbid Disability
- Somatization or Hypochondriasis history
IX. Causes
- See Palpitation Causes
- Causes by category
- Cardiac (43%, closer to 30% in other studies)
- Structural heart disease (e.g. Mitral Valve Prolapse)
- Arrhythmia
- Psychiatric (31%)
- Miscellaneous (10%)
- idiopathic (16%)
- Weber (1996) Am J Med 100(2): 138-48 [PubMed]
- Cardiac (43%, closer to 30% in other studies)
X. Labs
- Thyroid Stimulating Hormone (TSH)
- Hemoglobin
- Consider additional tests when indicated
XI. Dignostics: Electrocardiogram
- 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
-
Short PR Interval
- AV Nodal reentry rhythm
- Brugada sign (End of QRS marked by significant upward deflection, ST Elevation V1-3)
XII. Diagnostics: Other
- Ambulatory EKG monitoring
- Continuous EKG Monitor (Holter Monitor for 24-48 hours)
- Event Monitor (loop recorder for intermittent episodes over 1 month)
- Consider additional testing when indicated
- Exercise Stress Test
- Exercise induced Palpitations or associated cardiopulmonary symptoms
- Known heart disease or significant risk factors
- Abnormal EKG
- Echocardiogram
- Suspected structural heart disease
- Nondiagnostic evaluation
- Palpitations with cardiopulmonary symptoms
- Cardiomyopathy findings (e.g. Leg Edema, Dyspnea, rales, increased Jugular Venous Pressure)
- Electrophysiologic Study
- Syncope
- Life threatening Arrhythmia suspected
- Wolff-Parkinson-White
- Exercise Stress Test
XIII. Management
- Evaluate for cardiac causes specific causes
- Exclude cardiac causes first as they have the potential to be life threatening
- Consider cardiology Consultation
- Manage specific causes
- 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
- Atrial Fibrillation or Atrial Flutter
- Ventricular Tachycardia
- Long QT Interval
- Extrasystoles
-
General measures for symptomatic relief of benign causes
- Exercise program (if evaluation negative)
- Eliminate Caffeine, Alcohol, and Tobacco
- Maximize hydration
- Stress reduction
- Consider Beta Blocker (e.g. Propranolol, Metoprolol)
XIV. 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]
Images: Related links to external sites (from Bing)
Related Studies
Definition (NCI_CTCAE) | A disorder characterized by an unpleasant sensation of irregular and/or forceful beating of the heart. |
Definition (NCI_NCI-GLOSS) | A rapid or irregular heartbeat that a person can feel. |
Definition (NCI) | An unpleasant sensation of irregular and/or forceful beating of the heart. |
Concepts | Finding (T033) |
ICD9 | 785.1 |
ICD10 | R00.2 |
SnomedCT | 207004005, 207006007, 158334000, 139224009, 158336003, 139222008, 139227002, 161965005, 161970003, 161967002, 80313002 |
LNC | LA16997-1 |
English | PALPITATION, HEART THROBBING, Palpitation, Palpitation(s), Palpitations NOS, [D]Palpitations (context-dependent category), [D]Palpitations NOS (context-dependent category), [D]Palpitations, [D]Palpitations NOS, palpitations (symptom), palpitations, palpitations (diagnosis), heart irregularities, Heart throbbing, heart throb, heart throbbing, [D]Palpitations NOS (situation), [D]Palpitations (situation), Palpitations NOS (finding), PALPITATIONS, palpitation, Palpitations (finding), Palpitations |
Italian | Palpitazioni, Sensazione di cuore che pulsa, Palpitazione |
Dutch | hartklopping, hartbonzen, Palpitaties, hartkloppingen |
French | Palpitations cardiaques, Palpitation, PALPITATIONS, Palpitations |
German | Palpitation, pochendes Herz, HERZKLOPFEN, HERZSCHLAGEN VERSTAERKT, Palpitationen |
Portuguese | Palpitações cardíacas, Palpitação, PALPITACAO CARDIACA, PALPITACOES, Palpitações |
Spanish | Palpitación, Palpitaciones cardiacas, [D]palpitaciones (categoría dependiente del contexto), [D]palpitaciones, SAI (categoría dependiente del contexto), PALPITACIONES, Palpitations NOS, palpitaciones, SAI (hallazgo), [D]palpitaciones, SAI (situación), [D]palpitaciones (situación), [D]palpitaciones, SAI, palpitaciones, SAI, [D]palpitaciones, palpitaciones (hallazgo), palpitaciones, Palpitaciones |
Japanese | 動悸, ドウキ |
Czech | Palpitace, Bušení srdce |
Korean | 두근거림 |
Hungarian | Szívdobogásérzés, Palpitatio, Lüktető szív |