Palpitations

Background

• Sensation of rapid or irregular heart rate

Red flags

• Cardiac disease
• Known ECG abnormality
• Syncope/pre-syncope
• Exertional palpitations
• Hypotension or relative hypotension
• Heart failure symptoms

Clinical Features

• Sensation of rapid or irregular heart rate
• Syncope or pre-syncope
• Shortness of breath
• Anxiety

Differential Diagnosis

Palpitations

• Arrhythmias:
  • Narrow-complex tachycardias
  • Wide-complex tachycardias
  • AV blocks
    • Second Degree AV Block Type I (Wenckeback)
    • Second Degree AV Block Type II
    • Third Degree AV Block
  • Premature atrial contraction
  • Premature junctional contraction
  • Premature ventricular contraction
  • Sick sinus syndrome
  • Wandering atrial pacemaker
• Non-arrhythmic cardiac causes:
  • Acute coronary syndrome
  • Cardiomyopathy
  • Congenital heart disease
  • Congestive heart failure (CHF)
  • Mitral valve prolapse
  • Pacemaker complication
  • Pericarditis
  • Myocarditis
  • Valvular disease
• Psychiatric causes:
  • Panic attack
  • Anxiety
  • Somatic Symptom Disorder
• Drugs and Medications:
  • Alcohol
  • Caffeine
  • Drugs of abuse (e.g. cocaine)
  • Medications (e.g. digoxin, theophylline)
  • Tobacco
• Misc
  • Anemia
  • Hyperthyroidism
    • Thyroid storm
  • Pulmonary embolism
  • Dehydration
  • Sepsis
  • Pheochromocytoma

Evaluation

Work-Up

• ECG
• CBC
• BMP
• TSH
• CXR
• Troponin in patients with suspicion for underlying heart disease or failure
• Consider extended electrolytes (Mg/Phos)
• Consider toxicologic work-up if concern for intoxications

Diagnosis

• Thyroid exam
• Careful cardiac exam for murmurs
• Cardiac monitoring
• Consider walk test if palpitations primarily present with exertion

Management

• Etiology specific

Disposition

• Etiology specific
• Consideration for Holter monitoring (or similar) with outpatient cardiologist if clinically stable for discharge home
• Recommend avoidance of stimulants and alcohol pending outpatient follow-up
• Criteria for admission from Management of patients with palpitations: a position paper from the European Heart Rhythm Association

Criteria for the hospitalization of patients with palpitations from Management of patients with palpitations: a position paper from the European Heart Rhythm Association, EP Europace, Volume 13, Issue 7, July 2011, Pages 920–934, https://doi.org/10.1093/europace/eur130

See Also

• Atrial Fibrillation