CHAPTER 23 Palpitations

Palpitations are defined as an unpleasant awareness of the forceful, rapid, or irregular beating of the heart. It is a common presenting symptom that is usually benign; however, occasionally palpitations can indicate a life-threatening arrhythmia.

Palpitations are described by patients as a “thumping,” “pounding,” or “fluttering” sensation in the chest. This sensation can be either intermittent or sustained, and either regular or irregular. Patients often note palpitations when quietly resting, a time when other stimuli are minimal.

Causes of palpitations can be cardiac arrhythmias, psychological factors, drugs and medications, nonarrhythmic cardiac problems, and systemic (extracardiac) conditions. Arrhythmias include premature atrial and ventricular contractions, supraventricular and ventricular arrhythmias, and atrial fibrillations. Psychological causes of palpitations include panic attack or disorder, anxiety states, and somatization. Drugs and medications including alcohol, tobacco, caffeine, aminophylline, atropine, thyroxine, cocaine, and amphetamines enhance the strength of myocardial contraction and can cause the sensation of palpitations. Nonarrhythmic cardiac problems, such as mitral valve prolapse, pericarditis, congestive heart failure, valvular disease, congenital heart disease, and cardiac myopathy, can produce palpations. Systemic conditions, such as hyperthyroidism, vasovagal syncope, and hypoglycemia, can cause palpitations. Hyperdynamic cardiovascular states caused by catecholaminergic stimulation from exercise, stress, or pheochromocytoma can cause palpitations. In many cases, the cause of the palpitations is unknown.

In children, fever, anxiety, exercise, and anemia are common causes of palpitations.

Although palpitations are usually of benign etiology, the principal goal in assessing patients with palpitations is to determine if the symptom is caused by a life-threatening arrhythmia.

Diagnostic reasoning: focused history

Could this patient have a life-threatening arrhythmia?

Key questions

Do you have a history of coronary artery disease (CAD)?

Are you lightheaded or have you had episodes of passing out?

Are you having chest pain?

Have you had difficulty breathing?

Do you have a family history of sudden cardiac death?

Have you had heart surgery?

Coronary artery disease

Patients with risk factors for or preexisting coronary artery disease (CAD) are at greater risk for ventricular arrhythmias as a cause for palpitations. Risk factors include smoking, hypertension, diabetes, a history of myocardial infarction (MI), and a family history of heart attack or stroke before age 60.

Lightheadedness/syncope

The association of palpitations with other symptoms suggesting hemodynamic compromise, including presyncope, syncope, or lightheadedness, may signify a life-threatening cardiac arrhythmia.

Chest pain, dyspnea

Palpitations caused by sustained tachyarrhythmias in patients with CAD can be accompanied by angina pectoris or dyspnea. Palpitations associated with chest pain suggest ischemic heart disease or, if the chest pain is relieved by leaning forward, pericardial disease. Exertional palpitations associated with chest pain, lightheadedness, or both in the athlete may indicate an underlying cardiovascular disorder.

Sudden cardiac death

A family history of sudden cardiac death (SCD) may indicate an inherited cardiac problem.

Cardiac surgery

Children and adults who have had cardiac surgery are at risk for arrhythmias and palpitations.

What else do I need to know about the palpitation?

Key questions

Can you describe the palpitation/sensation?

When do the palpitations occur?

How long do the palpitations last?

Do the palpitations start or stop abruptly?

Description of palpitations

Flip-flopping.

Single skipped beats or a sensation of the heart stopping and then starting with a pounding, flipping, or jumping sensation, especially while sitting quietly or lying in bed and lasting only for brief periods, are typically attributed to premature contraction of the atrium or ventricle. The sensation that the heart has stopped results from the pause following the premature contraction, and the pounding or flipping sensation results from the forceful contraction following the pause.

Rapid fluttering in the chest.

A feeling of rapid fluttering in the chest may result from atrial or ventricular arrhythmias, including sinus tachycardia.

Pounding in the neck.

A pounding feeling in the neck is caused by the dissociation of atrial and ventricular contractions so that the atria contract against closed tricuspid and mitral valves, producing cannon A waves. The sensation of rapid and regular pounding in the neck is typical of reentrant supraventricular arrhythmias, particularly atrioventricular nodal tachycardia.

Occurrence of palpitations

Palpitations that start during sleep or states of increased vagal tone (e.g., at termination of exercise) may be associated with vagal-mediated atrial fibrillation or certain subtypes of long QT syndromes. Palpitations that are worse at night may be caused by benign ectopy or atrial fibrillation.

Palpitations that start and stop abruptly suggest supraventricular or ventricular tachycardias. Palpitations that can be stopped using patient-initiated vagal maneuvers, such as the Valsalva maneuver, suggest supraventricular tachycardia.

Rapid palpitations during catecholamine excess, such as during exercise, suggest ventricular tachycardia, sinus tachycardia, or atrial fibrillation. Palpitations that occur regularly with exertion suggest hypertrophic cardiomyopathy or CAD.

Positional palpitations may reflect atrioventricular nodal tachycardia, pericarditis, or a structural process within the heart (e.g., atrial myxoma) or adjacent to the heart (e.g., mediastinal mass).

Could this be related to stress or a psychological condition?

Key questions

Have you experienced panic attacks (brief periods [seconds or minutes] of an overwhelming panic or terror accompanied by racing heartbeats, shortness of breath, or dizziness)?

Can you describe your stress level and how you cope with stress in your life?

Do you or does anyone in your family have a problem with panic attacks, anxiety, or depression?

What other symptoms are you having?

Panic disorder/stress/anxiety

Common psychological causes of palpitations include panic disorder and anxiety states. Patients with psychological causes for palpitations more commonly report a longer duration of the sensation (>15 min) and accompanying symptoms than do patients with other causes. Panic attacks, however, may also indicate pheochromocytoma.

Other symptoms

Palpitations associated with hyperventilation, hand tingling, nervousness, shortness of breath, or dizziness are common when anxiety or panic disorder is the underlying cause. Children with serious arrhythmias may not report palpitations. Young infants may exhibit poor feeding or be irritable when palpitations are present.

Are drugs/medications or other substances implicated?

Key questions

What prescription and over-the-counter (OTC) medications are you taking?

What recreational drugs do you use?

Are the palpitations associated with caffeine, tobacco, or alcohol use?

Medications

Palpitations can result from OTC and prescription medications. Medications that prolong the QT interval and predispose patients to arrhythmias include antidysrhythmics, antimicrobials, antihistamines, psychotropic drugs, and other miscellaneous drugs, such as motility drugs, electrolyte-depleting diuretics, and protease inhibitors for human immunodeficiency virus. In children, cold medicines may cause palpitations.

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