Palpitations are a commonly reported symptom, often characterized by an increased awareness of one’s heartbeat. Patients may describe these sensations using terms such as racing, pounding, irregular or fluttering.
II. Diagnostic Approach.
A. What is the differential diagnosis for this problem?
Extra-systolic beats (e.g., PACs, PVCs)
Structural heart disease (valvular disease, cardiomyopathy, congenital heart disease)
Stimulants (e.g., caffeine, amphetamines, cocaine)
Withdrawal (e.g., EtOH, benzodiazepines, clonidine, beta-blockers)
Bronchodilators (e.g., beta-2 agonists)
Anticholinergics (e.g., Ipratropium)
B. Describe a diagnostic approach/method to the patient with this problem.
Given the broad differential diagnoses, it is important to determine whether the patient’s symptoms are due to a serious or potentially life-threatening process, or whether they are from a more benign etiology. Evaluation should begin with obtaining a thorough history, including frequency, duration, chronicity, triggers, and associated symptoms.
1. Historical information important in the diagnosis of this problem.
A thorough history is important in evaluation of palpitations. It is important to obtain the circumstances surrounding palpitation episodes including activity, position,and predisposing factors. It is also important to ask about associated symptoms such as syncope or near-syncope, chest pain, nausea, vomiting or diaphoresis. Patient should also be asked to describe the onset of episodes including the speed of onset, duration, and termination. A long-standing history of these symptoms may reflect a chronic, more benign process, whereas an acute presentation may necessitate a more urgent workup. A thorough history of prior medical conditions, family history, medications and drug use, including non-prescription and illcits should be obtained.
2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.
Palpitations can be transient and thus it may be difficult for the physician to have an opportunity to examine the patient during each active episode. Occasionally, there may be specific triggers that are identified, such as position, or with exertion. In these situations, it may be reasonable to attempt to reproduce the symptoms in conjunction with obtaining vital signs and performing a cardiac examination for signs of structural heart disease, or exam findings suggestive of some other systemic disease.
3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.
A CBC, metabolic panel, TSH, and toxicology screen are common labs that should be obtained during the initial workup of palpitations. To evaluate for cardiac causes, an initial EKG should also be obtained. Patients with a history of heart disease or abnormal EKG may be candidates for further evaluation such as ambulatory ECG or Echocardiography to evaluate for structural abnormalities. A stress test can also be performed if the palpitations are triggered by exertional activity. Holter monitors can be considered for patents with almost daily episodes, but event recorders are more cost effective for infrequent episodes of palpitations. Further testing such as cardiac magnetic resonance imaging (MRI) or EP studies should be considered on an individual basis. Inpatient workup for palpitations should be considered if there is evidence to suggest severe structural heart disease or presence of arrhythmias.
C. Criteria for Diagnosing Each Diagnosis in the Method Above.
In addition to pursuing a workup for organic causes, psychiatric etiolgoies should also be considered. Panic/Anxiety disorders can be classified based on DSM IV criteria. Symptoms of a panic attack, in addition to palpitations, include sweating, shaking, shortness of breath, choking sensations, chest discomfort, abdominal discomfort, lightheadedness, feelings of detachment, fear of losing control, fear of death, paresthesias, and chills/hot flashes. The criteria for a panic attack includes four symptoms within 10 minutes. Screening questions related to these other somatic symptoms may be helpful to gauge suspicion for panic/anxiety disorders. It may be helpful to ultimately obtain a psychiatric consultation to assist with a formal diagnosis.
D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.
III. Management while the Diagnostic Process is Proceeding.
A. Management of Clinical Problem Palpitations.
Treatment should be targeted towards the underlying etiology for palpitations. Most patients with palpitations are ultimately found to have either an underlying arrhythmia or anxiety/panic disorder.
Patients who are found to have an underlying panic disorder may ultimately benefit from cognitive behavioral therapy (CBT) or pharmacologically (i.e., SSRI’s, TCA’s, benzodiazepines, MAOI’s).
B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.
Psychiatric and other organic causes for palpitations are not necessarily exclusive of one another. Patients with evidence of underlying psychiatric disorders should not have other causes for palpitations discounted until they are fully worked up and can be excluded.
IV. What's the evidence?
Abbott, AV. “Diagnostic approach to palpitations.”. Am Fam Physician.. vol. 71. 2005. pp. 743-50.
Raviele, A, Giada, F, Bergfeldt, L, Blanc, JJ, Blomstrom-Lundqvist, C, Mont, L. “Management of patients with palpitations: a position paper from the European Heart Rhythm Association”. Europace. vol. 13. 2011.
Zimetbaum, P, Josephson, ME. “Evaluation of patients with palpitations.”. N Engl J Med. vol. 338. 1998. pp. 1369
Brugada, P, Gürsoy, S, Brugada, J, Andries, E.. ” Investigation of palpitations.”. Lancet.. vol. 341. 1993 May 15. pp. 1254-8..
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- I. Problem/Condition.
- II. Diagnostic Approach.
- A. What is the differential diagnosis for this problem?
- B. Describe a diagnostic approach/method to the patient with this problem.
- 1. Historical information important in the diagnosis of this problem.
- 2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.
- 3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.
- C. Criteria for Diagnosing Each Diagnosis in the Method Above.
- D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.
- III. Management while the Diagnostic Process is Proceeding.
- A. Management of Clinical Problem Palpitations.
- B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.
- IV. What's the evidence?