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 with or without agoraphobia in adults".)
- Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med 1990; 150:1685.
- Zimetbaum P, Josephson ME. Evaluation of patients with palpitations. N Engl J Med 1998; 338:1369.
- Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. Am J Med 1996; 100:138.
- Mayou R, Sprigings D, Birkhead J, Price J. Characteristics of patients presenting to a cardiac clinic with palpitation. QJM 2003; 96:115.
- Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. Psychiatric disorders in medical outpatients complaining of palpitations. J Gen Intern Med 1994; 9:306.
- Barsky AJ, Cleary PD, Sarnie MK, Ruskin JN. Panic disorder, palpitations, and the awareness of cardiac activity. J Nerv Ment Dis 1994; 182:63.
- Zeldis SM, Levine BJ, Michelson EL, Morganroth J. Cardiovascular complaints. Correlation with cardiac arrhythmias on 24-hour electrocardiographic monitoring. Chest 1980; 78:456.
- Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. The clinical course of palpitations in medical outpatients. Arch Intern Med 1995; 155:1782.
- Lessmeier TJ, Gamperling D, Johnson-Liddon V, et al. Unrecognized paroxysmal supraventricular tachycardia. Potential for misdiagnosis as panic disorder. Arch Intern Med 1997; 157:537.
- Kinlay S, Leitch JW, Neil A, et al. Cardiac event recorders yield more diagnoses and are more cost-effective than 48-hour Holter monitoring in patients with palpitations. A controlled clinical trial. Ann Intern Med 1996; 124:16.
- Zimetbaum PJ, Kim KY, Josephson ME, et al. Diagnostic yield and optimal duration of continuous-loop event monitoring for the diagnosis of palpitations. A cost-effectiveness analysis. Ann Intern Med 1998; 128:890.
- Zimetbaum P, Kim KY, Ho KK, et al. Utility of patient-activated cardiac event recorders in general clinical practice. Am J Cardiol 1997; 79:371.
- Kennedy HL, Whitlock JA, Sprague MK, et al. Long-term follow-up of asymptomatic healthy subjects with frequent and complex ventricular ectopy. N Engl J Med 1985; 312:193.
- Knudson MP. The natural history of palpitations in a family practice. J Fam Pract 1987; 24:357.
- Varma N, Josephson ME. Therapy of "idiopathic" ventricular tachycardia. J Cardiovasc Electrophysiol 1997; 8:104.
- Bunch TJ, Chandrasekaran K, Gersh BJ, et al. The prognostic significance of exercise-induced atrial arrhythmias. J Am Coll Cardiol 2004; 43:1236.
- Coumel P. Autonomic influences in atrial tachyarrhythmias. J Cardiovasc Electrophysiol 1996; 7:999.
- Schwartz PJ, Priori SG, Spazzolini C, et al. Genotype-phenotype correlation in the long-QT syndrome: gene-specific triggers for life-threatening arrhythmias. Circulation 2001; 103:89.
- Brugada P, Gürsoy S, Brugada J, Andries E. Investigation of palpitations. Lancet 1993; 341:1254.
- Josephson ME, Wellens HJ. Differential diagnosis of supraventricular tachycardia. Cardiol Clin 1990; 8:411.
- Goldreyer BN, Kastor JA, Kershbaum KL. The hemodynamic effects of induced supraventricular tachycardia in man. Circulation 1976; 54:783.
- Leitch JW, Klein GJ, Yee R, et al. Syncope associated with supraventricular tachycardia. An expression of tachycardia rate or vasomotor response? Circulation 1992; 85:1064.
- Barsky AJ, Delamater BA, Clancy SA, et al. Somatized psychiatric disorder presenting as palpitations. Arch Intern Med 1996; 156:1102.
- Düren DR, Becker AE, Dunning AJ. Long-term follow-up of idiopathic mitral valve prolapse in 300 patients: a prospective study. J Am Coll Cardiol 1988; 11:42.
- Wolfe RR, Driscoll DJ, Gersony WM, et al. Arrhythmias in patients with valvar aortic stenosis, valvar pulmonary stenosis, and ventricular septal defect. Results of 24-hour ECG monitoring. Circulation 1993; 87:I89.
- Crawford MH, Bernstein SJ, Deedwania PC, et al. ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the guidelines for ambulatory electrocardiography). Circulation 1999; 100:886.
- Antman EM, Ludmer PL, McGowan N, et al. Transtelephonic electrocardiographic transmission for management of cardiac arrhythmias. Am J Cardiol 1986; 58:1021.
- Krahn AD, Klein GJ, Skanes AC, Yee R. Insertable loop recorder use for detection of intermittent arrhythmias. Pacing Clin Electrophysiol 2004; 27:657.
- Lok NS, Lau CP. Prevalence of palpitations, cardiac arrhythmias and their associated risk factors in ambulant elderly. Int J Cardiol 1996; 54:231.
- Zimetbaum PJ, Josephson ME. The evolving role of ambulatory arrhythmia monitoring in general clinical practice. Ann Intern Med 1999; 130:848.
- Fogel RI, Evans JJ, Prystowsky EN. Utility and cost of event recorders in the diagnosis of palpitations, presyncope, and syncope. Am J Cardiol 1997; 79:207.
- Reiffel JA, Schulhof E, Joseph B, et al. Optimum duration of transtelephonic ECG monitoring when used for transient symptomatic event detection. J Electrocardiol 1991; 24:165.
- Zipes DP, DiMarco JP, Gillette PC, et al. Guidelines for clinical intracardiac electrophysiological and catheter ablation procedures. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Intracardiac Electrophysiologic and Catheter Ablation Procedures), developed in collaboration with the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 1995; 26:555.
- Guidelines for Clinical Intracardiac Electrophysiological and Catheter Ablation Procedures. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. (Committee on Clinical Intracardiac Electrophysiologic and Catheter Ablation Procedures). Developed in collaboration with the North American Society of Pacing and Electrophysiology. Circulation 1995; 92:673.
- Krahn AD, Yee R, Klein GJ, Morillo C. Inappropriate sinus tachycardia: evaluation and therapy. J Cardiovasc Electrophysiol 1995; 6:1124.
- 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