Palpitations

Key Features

Essentials of Diagnosis

• Inquire about

  • 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

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 patients 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 patients 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 atrial tachycardia with variable atrioventricular 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, episodic hypertension, headaches, anxiety and diaphoresis may be caused by a pheochromocytoma or paraganglioma

• 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

• A crescendo mid-diastolic murmur may be caused by an atrial myxoma

• Presence of dilated cardiomyopathy increases the likelihood ...