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  • 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 MI or structural heart disease.


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.

Table 2–3.Palpitations: Patients at high risk for a cardiovascular cause.

When assessing a patient with palpitations in an urgent care setting, the clinician must ascertain whether the symptoms represent (1) a significant CVD, (2) a cardiac manifestation of a systemic disease such as thyrotoxicosis, (3) an arrhythmia that is minor and transient, or (4) a benign somatic symptom that is amplified by the patient’s underlying psychological state.


Patients with palpitations who seek medical attention in an emergency department instead of a medical clinic are more likely to have a cardiac cause (47% versus 21%), whereas psychogenic causes are more common among those who seek attention in office practices (45% versus 27%). In a study of patients who went to a university medical clinic with the chief complaint of palpitations, causes were cardiac in 43%, psychogenic in 31%, and miscellaneous in 10%.

Cardiac arrhythmias that can result in symptoms of palpitations include sinus bradycardia; atrial fibrillation or flutter; sinus, supraventricular, and ...

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