Palpitations in a Young Adult
Case: A 27 year old female attorney presents to the office with three days of intermittent “fluttering” sensation in her
chest.
Palpitations: The unpleasant awareness of forceful, rapid or irregular beating of the heart. Account for up to 16%
of complaints in one study of 500 medical outpatients. The characteristics of the palpitations can help identify the
etiology. Examples include rapid fluttering (atrial or ventricular arrhythmias, including sinus tachycardia), flip-
flopping (PACs, PVCs), pounding sensation in the neck (AV dissociation, AVNRT)
Etiology: Differential diagnosis of palpitations is extensive. Although usually benign, palpitations occasionally are a
manifestation of a life-threatening arrhythmia. A university medical center study (Weber and Kapoor) of 190
patients with chief complaint of palpitations determined the etiology of palpitations in 84% of the patients.
Cardiac - 43%
Psychiatric -31%.
Miscellaneous – 10%
Unknown – 16%
CAUSES OF PALPITATIONS
Cardiac – Arrhythmia Psychiatric Miscellaneous
Atrial Fibrillation Panic attack Medications
Supraventricular Tachycardia Panic Disorder - amphetamines
Premature supraventricular or ventricular Anxiety - cocaine
contractions Somatization - caffeine
Atrial Flutter Depression - -blocker (withdrawal)
Ventricular Tachycardia - Alcohol
Multifocal atrial tachycardia - -agonists
Wolff-Parkinson-White Syndrome - theophylline
Bradycardia-Tachycardia Syndrome - digitalis
Cardiac – Nonarrhythmia - vasodilators
Mitral Valve Prolapse Metabolic
Other Valvular Heart disease (AS, AI) - hyperthyroidism
Atrial myxoma - pheochromocytoma
Pacemaker failure - hypoglycemia
CHF High Cardiac Output States
Congenital Heart Disease - anemia
Pericarditis - pregnancy
Cardimyopathy - Fever
- mastocytosis
Diagnostic Evaluation:
History & Physical: Evaluation of the patient should start with a detailed H&P. The history should include a
description of characteristics of palpitations, associated symptoms or situations, drug or medication use, and
comorbid illness.
o Palpitations – rapid & regular suggest paroxysmal SVT or VT; irregular suggest AFib, Aflutter,
tachycardia with variable block.
o Physical Exam – examination for murmurs is critical.
Midsystolic click - Mitral valve prolapse has been associated with SVTs, PVCs, nonsustained
VT, and palpitations are very common with MVP.
Harsh holosystolic murmur at LSB increasing with Valsalva suggests hypertrophic obstructive
cardiomyopathy
o Associated symptoms – dizziness, near-syncope or syncope suggest more serious pathology.
Palpitations induced by exertion or exercise should be followed with a exercise stress test.
o Life style screen: drug or alcohol use, stress or anxiety symptoms
12-lead EKG: recommended in every patient with palpitations. Often may not indicate cause of palpitations but
may capture PACs, PVCs or help identify an underlying arrhythmia or cause for potential arrhythmias - WPW
(short PR, delta wave), HOCM (LVH), prolonged QT syndrome, Q waves.
Laboratory Studies: no current EBM guidelines but reasonable limited testing includes CBC (anemia,
infection), glucose, TSH, electrolytes
Further diagnostic testing: Additional diagnostic testing is recommended in the following groups of patients
o Patients in which initial testing suggests and arrhythmia
o Patients at high risk for an arrhythmia (organic heart disease, myocardial abnormalities that may lead
to serious arrhythmias including dilated CM, clinically significant valvular regurgitant or stenotic lesions,
HOCM, or those with significant family history of sudden cardiac death, syncope or arrhythmias)
o Patients remaining explanation and wanting an explanation for their symptoms
Additional testing includes:
Ambulatory Monitoring devices
o Holter Monitor – 24-48hr EKG recording. Good for patients with daily symptoms. Patient keetps a
diary of symptoms with times of occurrence. $$$, Diagnostic yield 33-35%.
o Transtelephonic Event monitors – Typically two weeks of monitoring. Good for patients without
daily symptoms. Continually records data, but only saves data when activated by patient (when
symptomatic). Data saved for the few minutes prior and few minutes after activated by patient (with
symptoms). Downside - may miss asymptomatic arrhythmias. Another type of telephonic event
monitor is handheld and the patient applies to chest when palpitations perceived and records data
for two minutes. May miss onset of arrhythmia. Diagnostic yield 66%. Much more cost effective
o Implantable loop recorder (ILR) – Subcutaneous monitoring device implanted in left pectoral
region. Stores data when automatically activated by programmed criteria. Good for unexplained
syncope.
Electophysiologic Testing – INVASIVE cardiac electrophysiology for diagnosis of suspected serious
arrhythmias and possible analysis of site of origin or arrhythmia. Also done if palpitations are sustained or
poorly tolerated by patient.
Algorithm for evaluating patients with palpitations (AAFP 2005)
References
1. Weber, BE, Kapoor,WN. Evaluation and outcomes of patients with palpitations. Am J Med 119;100:138-48.
2. Zimetbaum,P, Josephson, ME. Evaluation of patients with palpitations. N Engl J Med 1998; 338:1369-73.
3. Yalmanchili, M, Khurana, A, Smaha, L. Evaluation of palpitations: Etiology and diagnostic methods. Hospital Physician Jan 2003: 53-58.
4. Abbott, A. Diagnostic approach to palpitations. American Family Physician Feb 2005; 71: 743-50.