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ESSENTIAL INQUIRIES
Forceful, rapid, or irregular beating of the heart.
Rate, duration, and degree of regularity of heartbeat; 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.
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GENERAL CONSIDERATIONS
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Palpitations are defined as an unpleasant awareness of the forceful, rapid, or irregular beating of the heart. They are the primary symptom for approximately 16% of patients presenting to an outpatient clinic with a cardiac complaint. In an observational cohort study of palpitations at an outpatient cardiac unit, cardiac arrhythmias were the cause of palpitations in 81% of cases; 77% were caused by atrial arrhythmias, 15%, by junctional tachycardia, and 8%, by ventricular arrhythmias. Prehospital ECG and ECG at admission had the best positivity rates. Palpitations represent 5.8 of every 1000 emergency department visits, with an admission rate of 24.6%. While palpitations are usually benign, they are occasionally the symptom of a life-threatening arrhythmia. To avoid missing a dangerous cause of the patient’s symptom, clinicians sometimes pursue expensive and invasive testing when a conservative diagnostic evaluation is often sufficient. The converse is also true; in one study, 54% of patients with supraventricular tachycardia were initially wrongly diagnosed with panic, stress, or anxiety disorder. A disproportionate number of these misdiagnosed patients are women. Table 2–3 lists history, physical examination, and ECG findings suggesting a cardiovascular cause for the palpitations.
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Although described by patients in a myriad of ways, guiding the patient through a careful description of their palpitations may indicate a mechanism and narrow the differential diagnosis. Pertinent questions include the age at first episode; precipitants; and rate, duration, and degree of regularity of the heartbeat during the subjective palpitations. Palpitations lasting less than 5 minutes and a family history of panic disorder reduce the likelihood of an arrhythmic cause (LR = 0.38 and LR = 0.26, respectively). To better understand the symptom, the examiner can ask the patient to “tap out” the rhythm with his or her fingers. The circumstances associated with onset and termination can also be helpful in determining the cause. Palpitations that start and stop abruptly suggest supraventricular or ventricular tachycardias. Termination of palpitations using vagal maneuvers (eg, Valsalva maneuver) suggests supraventricular tachycardia.
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