Overview
Palpitations are a subjective experience in which a person becomes aware of their own heartbeat and perceives it as too fast, too strong, uneven, or skipped. Palpitations are a symptom rather than a diagnosis, and cardiac causes are the most concerning aetiology. Because the same sensation can arise from very different conditions, clinicians focus on identifying the underlying cause. Palpitations are a common symptom in patients presenting to family physicians.
Description
People use many words to describe the sensation. They are often described by the patient as a rapid fluttering, skipping or pounding sensation in the chest or neck. The feeling may also be located in the throat, and the symptom may be in the chest, back, abdomen, throat, or neck. Some episodes are brief, while others last longer. Importantly, the heartbeat itself is not always abnormal: some patients simply have heightened awareness of normal cardiac activity, particularly when exercise, febrile illness, or anxiety increases heart rate.
Causes
Cardiac causes
Cardiac causes are commonly divided into structural heart disease and arrhythmias. Cardiac causes are classified as structural or arrhythmic, with testing guided by clinical suspicion. Arrhythmias vary widely in seriousness. Arrhythmias range from benign to life threatening. Among the most frequent are premature beats: premature atrial contractions (PACs) and premature ventricular contractions (PVCs). Sustained rhythm disturbances such as atrial fibrillation and ventricular tachycardia can also present with palpitations, as the American Heart Association notes in a consumer article: arrhythmias, electrical malfunctions such as atrial fibrillation or ventricular tachycardia. Palpitations may also reflect underlying cardiovascular disease.
Non-cardiac causes
Many palpitations have no primary heart disease. The patient may have obvious associated illness with fever, dehydration, hypoglycemia, anemia, or evidence of thyrotoxicosis. Substances can provoke them. Use of drugs such as cocaine, and alcohol, caffeine, and tobacco can precipitate palpitations. Certain medicines are also implicated; triggers for palpitations may include medications, including nasal decongestants and treatments for asthma and ADHD.
Psychological factors are frequent contributors. In one study of patients with supraventricular tachycardia, two thirds of the patients were diagnosed with panic, stress, or anxiety disorder, and this was especially common among young women. Sensations of this kind are discussed further in the context of anxiety disorders. Thyroid overactivity and low potassium or anemia are also recognized reversible contributors, and laboratory tests for these are routinely considered.
Evaluation
History and examination
A careful history is the first step. The clinician will want to know how long symptoms have been going on, how frequently they occur, what times of day they are most prominent and whether there are triggers. Certain features raise suspicion for a cardiac cause. Persons with a history of cardiovascular disease, palpitations at work, or palpitations that affect sleep have an increased risk of a cardiac cause. In contrast, episodes lasting less than about five minutes make an arrhythmic origin less likely, according to a review of likelihood ratios. Palpitation duration less than 5 minutes decreases this probability. Physical examination and diagnostic testing then follow. A thorough history and physical examination, followed by targeted diagnostic testing, can distinguish cardiac conditions from other causes of palpitations.
Electrocardiography and ambulatory monitoring
The standard first test is a resting electrocardiogram (ECG). This quick and painless test measures the electrical activity of the heart. Because many arrhythmias are intermittent, a single ECG often fails to capture them. Frequently, patients with palpitations are asymptomatic during medical evaluation, underscoring the paroxysmal nature of some etiologies.
For this reason, ambulatory recording is used. A Holter monitor is a type of ambulatory electrocardiography device, a portable device for cardiac monitoring worn for at least a day. Event recorders are an alternative for less frequent symptoms. When palpitations occur unpredictably or do not occur daily, an initial two-week course of continuous closed-loop event recording is indicated. Guidance on the choice of device has changed over time: a 2005 review noted that trans-telephonic event monitors are more effective and cost-effective than Holter monitors for most patients.
Laboratory tests may also be ordered. Blood tests may be ordered to check for thyroid problems, anemia, electrolyte imbalances, or other conditions that could cause palpitations.
Warning signs
Most evaluations aim to separate benign palpitations from those requiring urgent care. Palpitations accompanied by chest pain, shortness of breath, dizziness, or fainting could indicate serious heart rhythm problems or other cardiac conditions that require immediate attention. Some clinical resources also flag very fast resting rates; one cardiac care provider lists very rapid heart rates, particularly those exceeding 150 beats per minute at rest as a reason for prompt assessment.
Prognosis and outcomes
Most palpitations are not life-threatening, but a minority are linked to serious rhythm disorders. Palpitations can be symptomatic of life-threatening cardiac arrhythmias. However, most palpitations are benign. In a retrospective family-practice study, there was no difference in the rates of morbidity or mortality among patients with palpitations compared with matched control subjects. Similarly, for patients whose heart evaluation is normal, patients with palpitations caused by premature ventricular contractions, who have a normal heart evaluation, have no increased mortality.
Symptoms can nonetheless be persistent and distressing. Palpitations are associated with long-term morbidity with a substantial proportion of patients reporting concern and anxiety despite the exclusion of a significant underlying cause.
Management
Treatment depends on the cause identified. Treatment and follow-up of patients presenting with palpitations as the main complaint will depend on the aetiology and investigation findings. Where a cause is not found, reassurance and follow-up are commonly used, while arrhythmias and structural heart disease are treated according to their specific type. Management decisions are made by clinicians; this entry does not offer treatment recommendations.
Diagnostic challenges
A central difficulty is distinguishing harmless palpitations from those caused by significant arrhythmias. The challenge at the primary healthcare level is differentiating palpitations of a benign aetiology from those related to a significant underlying arrhythmia that requires prompt treatment, investigations and referral. The symptom's subjective nature adds to this. Simultaneous recording of an ECG and symptoms is rarely achieved, which amplifies the diagnostic challenge.
References
- Palpitations: Evaluation and management by primary care practitionersncbi.nlm.nih.gov
- Diagnostic Approach to Palpitationsaafp.org
- What To Expect From A Good Holter Monitor Readingecgedu.com
- Palpitations - Cardiology - Merck Manual Professional Editionmerckmanuals.com
- Palpitations: Evaluation in the Primary Care Settingaafp.org
- How serious are heart palpitations? Causes, symptoms and when to worryheart.org
- Diagnostic Approach to Palpitationsaafp.org
- Palpitations: A Practical Approachncbi.nlm.nih.gov
- Heart palpitations-Heart palpitations - Diagnosis & treatment - Mayo Clinicmayoclinic.org
- graphsearch.epfl.chgraphsearch.epfl.ch
- Understanding Heart Palpitations: When to Worry and When It's Normalcardiaccarepc.com