Palpitations

Background

• Sensation of rapid or irregular heart rate

Red flags

• Cardiac disease
• Known ECG abnormality
• Syncope/pre-syncope
• Exertional palpitations
• Hypotension or relative hypotension
• Heart failure symptoms

Clinical Features

• Sensation of rapid or irregular heart rate
• Syncope or pre-syncope
• Shortness of breath
• Anxiety

Differential Diagnosis

Palpitations

• Arrhythmias:
  • Narrow-complex tachycardias
  • Wide-complex tachycardias
  • AV blocks
    • Second Degree AV Block Type I (Wenckeback)
    • Second Degree AV Block Type II
    • Third Degree AV Block
  • Premature atrial contraction
  • Premature junctional contraction
  • Premature ventricular contraction
  • Sick sinus syndrome
• Non-arrhythmic cardiac causes:
  • Acute coronary syndrome
  • Cardiomyopathy
  • Congenital heart disease
  • Congestive heart failure (CHF)
  • Mitral valve prolapse
  • Pacemaker complication
  • Pericarditis
  • Myocarditis
  • Valvular disease
• Psychiatric causes:
  • Panic attack
  • Anxiety
  • Somatic Symptom Disorder
• Drugs and Medications:
  • Alcohol
  • Caffeine
  • Drugs of abuse (e.g. cocaine)
  • Medications (e.g. digoxin, theophylline)
  • Tobacco
• Misc
  • Anemia
  • Hyperthyroidism
  • Pulmonary embolism
  • Dehydration
  • Sepsis
  • Pheochromocytoma

Evaluation

Work-Up

• ECG
• CBC
• BMP
• TSH
• CXR
• Troponin in patients with suspicion for underlying heart disease or failure
• Consider extended electrolytes (Mg/Phos)
• Consider toxicologic work-up if concern for intoxications

Diagnosis

• Thyroid exam
• Careful cardiac exam for murmurs
• Cardiac monitoring
• Consider walk test if palpitations primarily present with exertion

Management

• Etiology specific

Disposition

• Etiology specific
• Consideration for Holter monitoring (or similar) with outpatient cardiologist if clinically stable for discharge home
• Recommend avoidance of stimulants and alcohol pending outpatient follow-up
• Criteria for admission from Management of patients with palpitations: a position paper from the European Heart Rhythm Association

Criteria for the hospitalization of patients with palpitations from Management of patients with palpitations: a position paper from the European Heart Rhythm Association, EP Europace, Volume 13, Issue 7, July 2011, Pages 920–934, https://doi.org/10.1093/europace/eur130

See Also

• Atrial Fibrillation

Antonio Raviele, Franco Giada, Lennart Bergfeldt, Jean Jacques Blanc, Carina Blomstrom-Lundqvist, Lluis Mont, John M. Morgan, M.J. Pekka Raatikainen, Gerhard Steinbeck, Sami Viskin, Document reviewers, Paulus Kirchhof, Frieder Braunschweig, Martin Borggrefe, Meleze Hocini, Paolo Della Bella, Dipen Chandrakant Shah, Management of patients with palpitations: a position paper from the European Heart Rhythm Association, EP Europace, Volume 13, Issue 7, July 2011, Pages 920–934, https://doi.org/10.1093/europace/eur130