Evaluation of palpitations

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 nonarrhythmic etiologies 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 reentry tachycardia, atrial tachycardia, and atrioventricular reentry 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 (VT), 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.[1]Zimetbaum P, Josephson ME. Evaluation of patients with palpitations. N Engl J Med. 1998 May 7;338(19):1369-73 http://www.ncbi.nlm.nih.gov/pubmed/9571258?tool=bestpractice.com [2]Mellor GJ, Behr ER. Cardiac channelopathies: diagnosis and contemporary management. Heart. 2021 Jun 11;107(13):1092-9.​​

Palpitations associated with syncope are particularly worrying as they are more likely to be associated with malignant arrhythmias such as ventricular tachycardia and should also be urgently evaluated.

The evaluation of palpitations includes a careful and directed history and physical exam and a 12-lead ECG. Further testing and treatment should be guided by this initial evaluation, and includes ambulatory electrocardiographic monitoring and electrophysiologic testing.