Dusty Narducci, MD; Shivajirao Patil, MD; Matthew Zeitler, MD; Is an underlying cardiac Anne Mounsey, MD Department of Family Medicine & Orthopedics/ condition causing your patient’s Sports Medicine, University of South Florida Health Carol and Frank Morsani palpitations? Center for Advanced Healthcare, Tampa (Dr. Narducci); Department This review lists the questions to ask to obtain important of Family Medicine, East Carolina University, diagnostic clues and provides an algorithm for evaluating Greenville, NC (Dr. Patil); Department of Family palpitations when the initial Dx is not evident on EKG. Medicine, University of North Carolina, Chapel Hill (Drs. Zeitler and Mounsey) Anne_mounsey@med. alpitations, the sensory perception of one’s heartbeat, PRACTICE unc.edu are reported in 16% of primary care patients, from RECOMMENDATIONS The authors reported no causes that are both cardiac (ie, arrhythmias) and non- ❯ Order echocardiography potential conflict of interest P 1 cardiac. Palpitations are usually benign; overall mortality is relevant to this article. for patients who have doi: 10.12788/jfp.0152 palpitations and risk approximately 1% annually. In fact, a retrospective study found factors for structural heart no difference in mortality and morbidity between patients with 2 disease. C palpitations and control patients without palpitations. How- ever, palpitations can reflect a life-threatening cardiac condi- ❯ Order stress testing for patients who have exertional tion, as we discuss in this article, making careful assessment 3 symptoms or multiple risk and targeted, sometimes urgent, intervention important. factors for coronary artery Here, we review the clinical work-up of palpitations, rec- disease. C ommended diagnostic testing, and the range of interventions for cardiac arrhythmias—ectopic beats, ventricular tachycar- ❯ Evaluate all patients who have syncope associated dia (VT), and atrial fibrillation (AF). with their palpitations for a cardiac cause. C Cardiac and noncardiac causes of palpitations Strength of recommendation (SOR) In a prospective cohort study of 190 consecutive patients A Good-quality patient-oriented evidence presenting with palpitations, the cause was cardiac in 43%, B Inconsistent or limited-quality psychiatric in 31%, and of a miscellaneous nature (including patient-oriented evidence medication, thyrotoxicosis, caffeine, cocaine, anemia, am- C Consensus, usual practice, opinion, disease-oriented phetamine, and mastocytosis) in 10%; in 16%, the cause was evidence, case series undetermined.2 In this study, 77% of patients experienced a recurrence of palpitations after their first episode.2 Cardiac arrhythmias, a common cause of palpitations, are differentiated by site of origin—supraventricular and ventricu- lar. Noncardiac causes of palpitations, which we do not discuss here, include metabolic and psychiatric conditions, medica- tions, and substance use. (For a summary of the causes of pal- pitations, see TABLE 1.2-4) ❚ Common complaint: ectopic beats. Premature atrial contractions (PACs; also known as premature atrial beats, atri- al premature complexes, and atrial premature beats) and pre- 60 THE JOURNAL OF FAMILY PRACTICE | MARCH 2021 | VOL 70, NO 2 Palpitations are usually benign. But they can reflect a life-threatening cardiac condition, making careful assessment and targeted, sometimes urgent, intervention important. mature ventricular contractions (PVCs; also structural heart disease and ischemic heart known as ventricular premature complexes disease. Therapy directed toward underlying and ventricular premature beats, and also of heart disease can reduce the frequency of a variety of possible causes) result in a feeling PVCs.7-9 of a skipped heartbeat or a flipping sensation in the chest. The burden of PACs is independently as- The diagnostic work-up sociated with mortality, cardiovascular hos- The most important goal of the evaluation pitalization, new-onset AF, and pacemaker of palpitations is to determine the presence, implantation. In a multivariate analysis, a or risk, of structural heart or coronary ar- PAC burden > 76 beats/d was an indepen- tery disease (CAD) by means of the history, dent predictor of mortality (hazard ratio physical examination, and electrocardiogra- [HR] = 1.4; 95% CI, 1.2-16); cardiovascular phy (EKG). Patients who have an increased hospitalization (HR = 1.3; 95% CI, 1.1-1.5); risk of structural heart disease need further new-onset AF (HR = 1.8; 95% CI, 1.4-2.2); evaluation with echocardiography; those and pacemaker implantation (HR = 2.8; at increased risk of CAD should have stress 95% CI, 1.9-4.2). Frequent PACs can lead to testing. cardiac remodeling, so more intense follow- Hemodynamically unstable patients up of patients with a high PAC burden might need admission; patients who have a history allow for early detection of AF or subclinical of syncope with palpitations usually should cardiac disease.5,6 be admitted for cardiac monitoring. Patients A burden of PVCs > 24% is associated who have had a single episode of palpitations with an increased risk of PVC-induced car- and have normal baseline results of labora- diomyopathy and heart failure. Polymorphic tory testing and a normal EKG, and no risk PVCs are more concerning than monomor- factors for structural heart disease or known phic PVCs because the former suggests the CAD, can usually be observed.3,4,10 Patients presence of more diffuse, rather than local- with an abnormal baseline EKG, recurrent ized, myocardial injury. The presence of palpitations (especially tachyarrhythmia), frequent (> 1000 beats/d) PVCs warrants or significant symptoms during palpitations evaluation and treatment for underlying (syncope, presyncope, dyspnea) need fur- MDEDGE.COM/FAMILYMEDICINE VOL 70, NO 2 | MARCH 2021 | THE JOURNAL OF FAMILY PRACTICE 61 TABLE 1 What causes palpitations?2-4 Underlying condition or state Possible causes Arrhythmia Bradyarrhythmia • Second- and third-degree atrioventricular block • Severe sinus bradycardia • Sinus pauses Supraventricular arrhythmia • Accessory pathway tachycardia (eg, • Atrioventricular nodal reentrant tachycardia Wolff-Parkinson-White syndrome) • Paroxysmal supraventricular tachycardia • Atrial fibrillation • Premature atrial contractions • Atrial flutter • Sinus tachycardia • Atrial tachycardia Ventricular arrhythmia • Premature ventricular contractions • Ventricular fibrillation and long-QT intervala • Ventricular tachycardia High-output states • Anemia • Paget disease • Atrioventricular fistula • Pregnancy • Exercise Medical and metabolic • Hyperkalemia • Hypoglycemia conditions • Hypermagnesemia • Hypokalemia • Hyperthyroidism • Hypomagnesemia • Hypocalcemia • Pheochromocytoma Medications • Anticholinergic drugs • Vasodilators • Serotonin–norepinephrine reuptake • Withdrawal from beta-blockers inhibitors • Sympathomimetic agents Miscellaneous cardiac • Brugada syndrome conditions • Inappropriate tachycardia • Postural orthostatic tachycardia syndrome • Sinus tachycardia Psychosocial • Anxiety • Depression • Panic disorder • Somatization Structural heart disease • Atrial myxoma • Mitral valve prolapse • Cardiomegaly • Myocardial infarction • Congenital heart disease • Stenotic or regurgitant valvular heart disease • Dilated or hypertrophic obstructive cardiomyopathy Substance use • Alcohol • Marijuana • Caffeine intake (excessive) • Nicotine • Illicit drugsb a Increases the risk of torsade de pointes. b Amphetamines, cocaine, Ecstasy (3,4 methylenedioxymethamphetamine [MDMA]). 62 THE JOURNAL OF FAMILY PRACTICE | MARCH 2021 | VOL 70, NO 2 PALPITATIONS ther evaluation with ambulatory monitor- hypertrophic cardiomyopathy, congenital ing3,4,10 (FIGURE). coronary anomalies, and ion channelopa- thies, and can cause sudden cardiac death Take a thorough history; in athletes (estimated incidence, 1-3/100,000 ask these questions person–years12). ❚ Have the patient describe the palpita- ❚ Endeavor to identify underlying car- tions. The history should include the patient’s diac disease. A comprehensive history should detailed characterization of the palpitations also evaluate for risk factors and symptoms (sudden or gradual onset, rhythm, duration, (chest pain, dyspnea, diaphoresis, lighthead- frequency). Certain descriptions provide edness, syncope) of cardiac disease, such as possible diagnostic clues: CAD, valvular disease, cardiomyopathy, and • Palpitations lasting < 5 minutes are congenital heart disease, which increase the less likely to be of cardiac origin likelihood that the presenting complaint is a (likelihood ratio [LR] = 0.38; 95% CI, cardiac arrhythmia (LR = 2; 95% CI, 1.3-3.1).4 0.2-0.6).4 A history of syncope in a patient with palpi- • A patient who has a regular, rapid- tations should prompt evaluation for struc- pounding sensation in the neck has an tural heart disease, such as aortic stenosis or increased probability of atrioventricu- hypertrophic cardiomyopathy, in which out- lar (AV) nodal reentrant tachycardia flow-tract obstruction impairs cardiac output (AVNRT) (LR = 177; 95% CI, 25-1251); and, subsequently, cerebral blood flow. Patients with absence of this sensation decreases ❚ Obtain additional key information. an abnormal the likelihood of AVNRT (LR = 0.07; Determine the following in taking the history: baseline EKG, 95% CI, 0.03-0.2).4 • Is there a family history of inherited recurrent • PACs and PVCs cause a sensation of a cardiac disorders or sudden cardiac palpitations, skipped heartbeat or a flipping sensa- death? or significant tion in the chest; they