Palpitations

aortic regurgitation and atrial myxoma. Intermittent palpitations are

Octobercommonly
1, 2010 caused by premature atrial and ventricular contractions: postextrasystolic beat is sensed by the patient owing to the increase in
ventricular end-diastolic dimension following the pause in cardiac cycle
Among the most common symptoms encountered
and the increased strength of contraction of that beat. Regular sustained
in medical practice, reported by 16 percent of
palpitations can be caused by regular supraventricular and ventricular
tachycardias. Irregular, sustained palpitations can be caused by atrial
primary care patients.
fibrillation. It is important to note that most arrhythmias are not
Corresponds poorly to demonstrable
associated with palpitations. In general, hyperdynamic cardiovascular
abnormalities of cardiac rate or rhythm.
stress or pheochromocytoma can lead to palpitations. In addition, the
Most palpitations are not accompanied by
enlarged ventricle of aortic regurgitation and accompanying
hyperdynamic precordium frequently lead to sensation of palpitations.
arrhythmias, and most arrhythmias are not

PALPITATIONS

Dr. Ranulfo Javelosa

perceived and reported as palpitations.

Characterized by an awareness of the beating of
the heart.
Commonly described as pounding or fluttering
heartbeats or report a sensation that the heart is
stopping or skipping beats.
May be caused by a change in the hearts rhythm
or rate or by an increase in the force of its
contractions.

Extremely common among patients who present to caregiver and can

best be defined as an intermittent thumping, pounding, or fluttering
sensation in the chest. The sensation can be either intermittent or
sustained, either regular of irregular. Most patients interpret palpitations
as unusual awareness of the heartbeat and become especially
concerned that they are skipped or missing heart beats. Palpitations
are often noted when the patient is quietly resting, during which time
other stimuli are minimal. Palpitations that are positional may reflect a
structural process within (e.g., atrial myxoma) or adjacent to (e.g.,
mediastinal mass) the heart.

Palpitations are brought by these causes:

cardiac causes
*arrhythmia : 40%
*other cardiac causes: 3%
anxiety or panic disorder: 31%
street drugs or prescription & OTC meds: 6%
other non-cardiac causes : 4%
No specific cause : 16%
CARDIAC
Arrhythmias

Atrial fibrillation/flutter
Bradycardia caused by advanced AV block or
sinus node dysfunction
Bradycardia-tachycardia syndrome (sick sinus
syndrome)
Multifocal atrial tachycardia
Premature supraventricular or ventricular
contractions
Sinus tachycardia or arrhythmia
Supraventricular tachycardia
Ventricular tachycardia
Wolff-Parkinson-White syndrome

Non-arrhythmic cardiac causes

Atrial or ventricular septal defect

Cardiomyopathy
Congenital heart disease
Congestive heart failure
Mitral valve prolapse
Pacemaker-mediated tachycardia
Pericarditis
Valvular disease (e.g., aortic insufficiency,
stenosis)

PSYCHIATRIC

Anxiety disorder
Panic attacks
Somatization*

*May occur alone or in combination

Patients with psychiatric causes for palpitations more commonly report a
longer duration of the sensitization (>15min) and other accompanying
symptoms that do patients with other causes.

MISCELLANEOUS
Drugs and Medications

Alcohol
Caffeine
Certain prescription and OTC agents (digitalis,
phenothiazine, theophylline, beta agonists)
Street drugs (e.g., cocaine)
Tobacco

Extracardiac causes

Anemia
Electrolyte imbalance
Fever
Hyperthyroidism
Hypoglycemia
Hypovolemia
Pheochromocytoma
Pulmonary disease
Vasovagal syndrome

Other factors that enhance the strength of myocardial contraction,

including tobacco, caffeine, aminophylline, atropine, thyroxine, cocaine,
and amphetamines, can cause palpitations. Among the miscellaneous
causes of palpitations are included thyrotoxicosis, ethanol, spontaneous
skeletal muscle contractions of the chest wall, pheochromocytoma, and
systemic mastocytosis.

APPROACH TO PATIENT WITH PALPITATIONS

FROM: 2012B TRANS

Goal: Asses if symptoms are cause by life threatening

arrhythmia
o

Patients with pre-existing CAD (Coronary artery

disease) or with risk factor for CAD has high risk for
ventricular arrhythmia causing palpitations

Cardiac causes include premature and ventricular contractions,

supraventricular and ventricular arrhythmias, mitral valve prolapsed,

Ron Rheine Mel

Page 1

Palpitation with syncope or light-headedness

suggest tachyarrhythmias in patients with CAD

Patients with ventricular dysfunction, aortic stenosis,

hypertrophic cardiomyopathy, or mitral stenosis
presents palpitations with dyspnea from increased L
atrial and pulmonary capillary wedge

Most patients presenting palpitations in arrhythmia are

often with no structural associations

Physical Examination

Vital signs, assessment of jugular venous pressure and

pulse, and auscultation of the chest and the precordium
refute arrhythmia as cause of palpitation

Treatment

Benign atrial or ventricular premature contractions can

be managed by beta blockers

Palpitations incited by alcohol, tobacco and illicit drug

use can be prevented by abstention

KEY CLINICAL FINDINGS AND SUGGESTED

DIAGNOSES

Ron Rheine Mel

Evidence of previous myocardial infarction,

Left or right ventricular hypertrophy
Atrial enlargement
Atrial ventricular block
Short PR interval and delta waves
Prolonged QT interval
Isolated PAC or PVC

Other Diagnostic Tests

ECG findings that warrant further cardiac

investigation

Ron Rheine Mel

CBC
Electrolytes
TSH
Stress test
Echocardiography
Holter monitoring
Event monitors
Electrophysiologic studies