Palpitations are defined as the abnormal awareness of one's own heartbeat. It is a common complaint seen in the outpatient setting in virtually all age groups and demographics. Most palpitations are due to non-arrhythmic aetiologies that occur during normal sinus rhythm.
A significant proportion of palpitations are due to non-life-threatening, treatable cardiac conditions. They include premature ventricular contractions, premature atrial contractions, and supraventricular tachycardias such as atrial fibrillation, atrial flutter, atrioventricular nodal re-entry tachycardia, atrial tachycardia, and atrioventricular re-entry tachycardia or Wolff-Parkinson-White syndrome. Ironically, the most common rhythm seen when evaluating patients for palpitations is sinus rhythm. A heightened sense of normal rhythm can be seen in settings of emotional or physical stress, or in conjunction with use of caffeine, alcohol, or other stimulants.
However, palpitations are occasionally a manifestation of potentially life-threatening conditions, especially in the setting of structural heart disease - for example, ventricular tachycardia, which may lead to sudden cardiac death. Inherited conditions such as hypertrophic cardiomyopathy, Brugada syndrome, and long QT syndrome may also initially present with palpitations and carry a risk of sudden cardiac death.
Palpitations associated with syncope are particularly worrying as they are more likely to be associated with malignant arrhythmias such as VT and should also be urgently evaluated.
The evaluation of palpitations includes a careful and directed history and physical examination and a 12-lead ECG. Further testing and treatment should be guided by this initial evaluation, and includes ambulatory electrocardiographical monitoring and electrophysiological testing.
- Sinus tachycardia
- Atrial tachycardia
- Atrial flutter
- Atrial fibrillation
- Atrioventricular nodal re-entrant tachycardia
- Wolff-Parkinson-White syndrome (WPW)
- Premature ventricular beat
- Premature atrial beat
- Anxiety and panic disorder
- Excess alcohol use (binge drinking)
- Inappropriate sinus tachycardia
- Idiopathic ventricular tachycardia
- Long QT syndrome
- Brugada syndrome
- Hypertrophic cardiomyopathy
- VT in the setting of other structural heart disease
Christopher Pickett, MD
Associate Professor of Medicine
Co-Director of Electrophysiology
Director, Clinical Cardiology
Pat and Jim Calhoun Cardiology Center
University of Connecticut Health Center
CP declares that he has no competing interests.
Peter J. Zimetbaum, MD
Professor of Medicine
Associate Chief and Director, Clinical Cardiology
Beth Israel Deaconess Medical Center
Harvard Medical School
PJZ has received financial compensation for consultation from St Jude Medical and Medtronic; he is also an author of several references cited in this topic.
Brian Olshansky, MD
Professor of Medicine
University of Iowa Hospitals
BO declares that he has no competing interests.
Vias Markides, MB(Hons), BS(Hons), MD, FRCP
Consultant Cardiologist and Chair
Royal Brompton & Harefield NHS Trust
Hon. Senior Lecturer
VM declares that he has no competing interests.
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