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Key Features

Essentials of Diagnosis

  • Inquire about

    • Forceful, rapid, or irregular beating of the heart

    • Rate, duration, and degree of regularity of heart beat

    • Age at first episode

    • Factors that precipitate or terminate episodes

    • Light-headedness or syncope

    • Neck pounding

    • Chest pain; history of myocardial infarction or structural heart disease

General Considerations

  • Palpitations are defined as an unpleasant awareness of the forceful, rapid, or irregular beating of the heart

  • Usually benign; however, they are occasionally the symptom of a life-threatening arrhythmia

Clinical Findings

History

  • Guiding the patient through a careful description of their palpitations may indicate a mechanism and narrow the differential diagnosis

  • Pertinent questions include

    • Age at first episode

    • Precipitants

    • Rate, duration, and degree of regularity of the heart beat during the subjective palpitations

  • The examiner can ask the patient to "tap out" the rhythm with their fingers

Symptoms

  • Palpitations that start and stop abruptly suggest supraventricular or ventricular tachycardias

  • Patient-terminated palpitations using vagal maneuvers (such as the Valsalva maneuver) suggests supraventricular tachycardia

  • Three common descriptions of palpitations are

    • "Flip-flopping" (or "stop and start"), often caused by premature contraction of the atrium or ventricle

    • Rapid "fluttering in the chest"

      • Regular "fluttering" suggesting supraventricular or ventricular arrhythmias (including sinus tachycardia)

      • Irregular "fluttering" suggesting atrial fibrillation, atrial flutter, or tachycardia with variable block

    • "Pounding in the neck" or neck pulsations, often due to "cannon" A waves in the jugular venous pulsations that occur when the right atrium contracts against a closed tricuspid valve

  • When associated with chest pain, palpitations suggest ischemic heart disease

  • If chest pain is relieved by leaning forward, suspect pericardial disease

  • May signify life-threatening cardiac arrhythmia when associated with light-headedness, presyncope, or syncope

  • Palpitations that occur regularly with exertion suggests a rate-dependent bypass tract or hypertrophic cardiomyopathy

  • Noncardiac symptoms should also be elicited since palpitations may be caused by a normal heart responding to a metabolic or inflammatory condition

    • Weight loss may suggest hyperthyroidism

    • Palpitations can be precipitated by vomiting or diarrhea that leads to electrolyte disorders and hypovolemia

    • Hyperventilation, hand tingling, and nervousness are common when anxiety or panic disorder is the root cause

    • Palpitations associated with flushing and diaphoresis may be caused by a pheochromocytoma

  • Chagas disease may cause palpitations and acute myocarditis

  • A family history of palpitations or sudden death suggests an inherited etiology, such as long QT syndrome or Brugada syndrome

Physical Examination

  • The midsystolic click of mitral valve prolapse can suggest the diagnosis of a supraventricular arrhythmia

  • The harsh holosystolic murmur of hypertrophic cardiomyopathy suggests atrial fibrillation or ventricular tachycardia

  • Presence of dilated cardiomyopathy increases the likelihood of ventricular tachycardia and atrial fibrillation

  • In patients with chronic atrial fibrillation, in-office exercise (eg, a brisk walk in the hallway) may reveal an intermittent accelerated ventricular response as the cause of the palpitations

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