palpitations

Introduction

Any uncomfortable awareness of heartbeats. It does not necessarily imply a rapid heartbeat. Palpitations may be described as pounding, flopping, skipping, jumping, fluttering or thumping.

Etiology

• conditions with sinus tachycardia
  • anxiety, panic disorder
  • exercise
  • fever
  • stress
  • menopause
• pharmacologic agents
  • decrease in vagal activity
    • anticholinergic agents
    • nicotine
  • increase in adrenergic activity
    • coffee (caffeine)
    • adrenergic agents
  • vasodilators causing reflex tachycardia
• high cardiac output states
  • anemia
  • thyrotoxicosis
  • pregnancy
• arrhythmias
  • premature atrial contractions (PACs)
  • premature ventricular contractions (PVC)
  • atrioventricular (AV) block
  • bradyarrhythmias
  • sick sinus syndrome
  • Wolff-Parkinson-White (WPW) syndrome
  • atrial fibrillation
  • atrial flutter
  • paroxysmal supraventricular tachycardia
  • ventricular tachycardia
• other serious conditions
  • myocardial infarction
  • myocardial ischemia
  • hypokalemia
  • hypomagnesemia
  • valvular heart disease
  • hypoxia
  • pheochromocytoma
  • hypoglycemia

History

• relationship to stress or exercise
• chest pain
  • pleuritic chest pain
• dyspnea
• dizziness
• nausea
• edema
• syncope
• weakness
• fatigue
• diaphoresis
• fever
• anxiety
• pharmaceutical agents, over the counter agents, illicit drugs
• history of heart problems

Clinical manifestations

• symptoms
  • feeling of heart stopping, fluttering or irregular heartbeat are most predictive symptoms of arrhythmia
• signs
  • generally normal physical exam
  • tachycardia
  • hypertension
  • abnormal heart sounds

Laboratory

• complete blood count with peripheral smear
• thyroid function tests
• serum K+
• serum Mg+2

Diagnostic procedures

• electrocardiogram (ECG) during an episode of palpitations is the most useful laboratory test
• event recorder is twice as likely as HOLTER to document an arrhythmia
• echocardiography
• exercise stress test (if exercise-related)

Radiology

• chest radiograph

Management

• therapy aimed at underlying etiology
  • palpitations unrelated to exercise, anxiety or drugs suggest an arrhythmia
• general measures
  • reassurance: most palpitations are benign
  • behavioral modification
    • smoking cessation
    • limiting caffeine & alcohol intake
    • discontinuation of causative drugs
    • stress reduction
• situations warranting cardiology referral
  • sustained supraventricular tachycardia
  • ventricular tachycardia
  • Wolf-Parkinson-White syndrome
  • syncope or dizziness associated with palpitations
  • unexplained arrhythmia associated with palpitations

More general terms

• sign/symptom

Additional terms

• event monitoring (event recording, loop recording, Zio patch)
• HOLTER