Palpitation

Aka: Palpitation

1. See Also
   1. Palpitation Causes
2. Definition
   1. Awareness of the heart beat
3. History
   1. See Palpitation Causes
   2. Medications, over-the-ounter agents and recreational drugs
   3. Family History of Sudden Cardiac Death
      1. Premature Coronary Artery Disease
      2. Sudden Arrhythmia Death Syndrome (Brugada Syndrome)
   4. 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
   5. Psychiatric Illness
      1. Generalized Anxiety Disorder or Panic Attacks
      2. Drug Abuse
   6. Provocative factors
      1. See Red Flags below
      2. Exertional Palpitations or Exertional Syncope
4. Symptoms
   1. Pounding, fluttering or flopping Sensation in the chest
   2. Sensation of skipping or missing a beat
   3. Sensation that heart is stopping, jumping or racing
5. Exam
   1. Full Vital Signs
      1. See Toxin Induced Vital Sign Changes
      2. Consider stimulants if Hypertension, Tachycardia, diaphoresis, behavior changes, Mydriasis,
   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)
6. 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
7. 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)
8. 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
9. 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
      2. Psychiatric (31%)
         1. Anxiety Disorder
      3. Miscellaneous (10%)
      4. idiopathic (16%)
      5. Weber (1996) Am J Med 100(2): 138-48 [PubMed]
10. 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
11. 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 women, QTc >440 in men)
    8. Delta Waves
       1. Wolff-Parkinson-White Syndrome
    9. Short PR Interval
       1. AV Nodal reentry rhythm
    10. Brugada sign (End of QRS marked by significant upward deflection, ST Elevation V1-3)
        1. Brugada Syndrome
12. 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
          4. Cardiomyopathy findings (e.g. Leg Edema, Dyspnea, rales, increased Jugular Venous Pressure)
       3. Electrophysiologic Study
          1. Syncope
          2. Life threatening Arrhythmia suspected
          3. Wolff-Parkinson-White
13. 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)
14. 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]