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Palpitation
Aka: Palpitation
- See Also
- Palpitation Causes
- Definition
- Awareness of the heart beat
- History
- See Palpitation Causes
- Medications, over-the-ounter agents and recreational drugs
- Family History of Sudden Cardiac Death
- Premature Coronary Artery Disease
- Sudden Arrhythmia Death Syndrome (Brugada Syndrome)
- Cardiovascular disease history
- Coronary Artery Disease
- Mitral Valve Prolapse
- Cardiomyopathy or Myocarditis
- Aortic Stenosis
- Hypertrophic Cardiomyopathy
- Wolff-Parkinson-White Syndrome
- Long QT Syndrome
- Psychiatric Illness
- Generalized Anxiety Disorder or Panic Attacks
- Drug Abuse
- Provocative factors
- See Red Flags below
- Exertional Palpitations or Exertional Syncope
- Symptoms
- Pounding, 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
- 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)
- 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)
- 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)
- 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
- Cardiac (43%, closer to 30% in other studies)
- Structural heart disease (e.g. Mitral Valve Prolapse)
- Arrhythmia
- Psychiatric (31%)
- Anxiety Disorder
- Miscellaneous (10%)
- idiopathic (16%)
- Weber (1996) Am J Med 100(2): 138-48 [PubMed]
- Labs
- Thyroid Stimulating Hormone (TSH)
- Hemoglobin
- Consider additional tests when indicated
- Serum Potassium
- Serum Calcium
- Serum Magnesium
- Serum Glucose
- Digoxin level
- Urine Drug Screen
- Urine Pregnancy Test
- 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
- Wolff-Parkinson-White Syndrome
- Short PR Interval
- AV Nodal reentry rhythm
- Brugada sign (End of QRS marked by significant upward deflection, ST Elevation V1-3)
- Brugada Syndrome
- 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
- 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
- Paroxysmal Supraventricular Tachycardia (PSVT)
- Wolff-Parkinson-White (WPW)
- Atrial Fibrillation or Atrial Flutter
- Ventricular Tachycardia
- Long QT Interval
- 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)
- 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]