Overview of palpitations in adults
- Peter J Zimetbaum, MD
Peter J Zimetbaum, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Harvard Medical School
Palpitations are one of the most common problems of outpatients who present to internists and cardiologists, accounting for 16 percent of complaints in one study of 500 medical outpatients . Although the cause is usually benign, palpitations are occasionally a manifestation of potentially life-threatening arrhythmia. As a result, the concern about missing a treatable condition may lead to the inappropriate use of expensive tests with little diagnostic and therapeutic value.
The common presentations of palpitations in adults and a guide to rational diagnostic testing and therapy are reviewed here. The approach to palpitations in children and the management of documented arrhythmias are discussed separately. (See "Approach to the child with tachycardia" and "Arrhythmia management for the primary care clinician".)
Palpitations are a sensory symptom. They are defined as an unpleasant awareness of the forceful, rapid, or irregular beating of the heart. Patients may at times describe the sensation as a rapid fluttering in the chest, flip-flopping in the chest, or a pounding sensation in the chest or neck, and these descriptions may help elucidate the cause of the palpitations . (See 'Description' below.)
The differential diagnosis of palpitations is extensive (table 1), and the etiology varies depending upon the population studied. In a study of 190 patients presenting with a chief complaint of palpitations to a university medical center, an etiology was determined in 84 percent . The cause was cardiac in 43 percent, psychiatric in 31 percent, and miscellaneous (eg, medication-induced, thyrotoxicosis, caffeine, cocaine, anemia, amphetamine, mastocytosis) in 10 percent. A cardiac etiology was more common in patients presenting to the emergency department than to the medical clinic (47 versus 21 percent), while psychiatric etiologies were more common in the medical clinic (45 versus 27 percent). Cardiac etiologies may also be more common among patients who present to a specialist .
Psychiatric disorders — Palpitations may be a feature of several psychiatric disorders, including panic attacks, generalized anxiety disorder, somatization, and depression [5,6]. (See "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Unipolar depression in adults: Assessment and diagnosis" and "Pharmacotherapy for panic disorder and agoraphobia in adults".)
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- Psychiatric disorders
- Cardiac disorders
- - Arrhythmias during catecholamine excess
- DIAGNOSTIC EVALUATION
- - Age of onset
- - Description
- - Onset and offset
- - Positional palpitations
- - Palpitations associated with syncope or presyncope
- - Psychiatric illness
- - Medications and habits
- - Other medical disorders
- Physical examination
- Twelve-lead ECG
- Laboratory testing
- Further diagnostic testing
- - Ambulatory monitoring
- - Electrophysiologic testing
- Diagnostic recommendations