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Outpatient Approach to Palpitations RANDELL K Outpatient Approach to Palpitations RANDELL K. WEXLER, MD, MPH; ADAM PLEISTER, MD; and SUBHA RAMAN, MD, MSEE The Ohio State University, Columbus, Ohio Palpitations are a common problem seen in family medicine; most are of cardiac origin, although an underlying psychiatric disorder, such as anxiety, is also common. Even if a psychiatric comorbidity does exist, it should not be assumed that palpitations are of a noncardiac etiology. Discerning cardiac from noncardiac causes is important given the potential risk of sudden death in those with an underlying cardiac etiology. History and physical examination followed by targeted diagnostic testing are necessary to distinguish a cardiac cause from other causes of palpitations. Standard 12-lead electrocardiography is an essential initial diagnostic test. Cardiac imaging is recommended if his- tory, physical examination, or electrocardiography suggests structural heart disease. An intermittent event (loop) monitor is preferred for documenting cardiac arrhythmias, particularly when they occur infrequently. Ventricular and atrial premature contractions are common cardiac causes of palpitations; prognostic significance is dictated by the extent of underlying structural heart disease. Atrial fibrillation is the most common arrhythmia resulting in hos- pitalization; such patients are at increased risk of stroke. Patients with supraventricular tachycardia, long QT syn- drome, ventricular tachycardia, or palpitations associated with syncope should be referred to a cardiologist. (Am Fam Physician. 2011;84(1):63-69. Copyright © 2011 American Academy of Family Physicians.) atients often present to family phy- CARDIAC STRUCTURAL CAUSES sicians with palpitations. However, Mitral valve prolapse is the most common this may mean different things structural heart disease leading to palpita- to different people. Most often, tions and is likely caused by papillary muscle P patients describe a noticeable awareness of fibrosis.10,11 Other valvular lesions, particu- the beating of their heart.1 The description larly congenital lesions to be considered in of the sensation itself may be that of a “flut- ter,” “flip-flop,” “pounding,” or “skip.” It may be fast, slow, regular, or irregular. Hav- Table 1. Cardiac Causes ing patients tap out the rhythm with their of Palpitations fingers or hands may be helpful. Palpitations are often cardiac in nature and can be classi- Atrial fibrillation or flutter fied as structural or arrhythmic (Table 1).2-9 Atrial myxoma Pathophysiology Atrial premature contractions Atrial tachycardia Normal cardiac conduction involves the Atrioventricular nodal reentrant tachycardia spontaneous discharge of an electrical Atrioventricular reentry impulse at the sinoatrial node. The impulse Autonomic dysfunction is then conducted down the wall of the right Cardiomyopathy atrium to the atrioventricular node, and Long QT syndrome then propagated via the His-Purkinje sys- Multifocal atrial tachycardia tem to depolarize the ventricles. Disruption Sick sinus syndrome of the electrical impulse anywhere along the Supraventricular tachycardia route may produce an arrhythmia. Syndrome of inappropriate sinus tachycardia Differential Diagnosis Valvular heart disease, especially mitral valve prolapse In a series of 190 consecutive patients pre- Ventricular premature contractions senting with palpitations, the etiology was Ventricular tachycardia cardiac in 43 percent, psychiatric in 31 per- cent, miscellaneous in 10 percent, and Information from references 2 through 9. unknown in 16 percent.2 Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2011 American Academy of Family Physicians. For the private, noncommercial July 1, 2011use ◆ of Volume one individual 84, Number user of the 1 Web site. All other rights reserved.www.aafp.org/afp Contact [email protected] for copyright questionsAmerican and/or permission Family requests. Physician 63 Palpitations SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References All patients presenting with palpitations C 8, 11, 16 younger patients presenting with palpita- should be evaluated for a cardiac cause. tions, include pulmonary stenosis, atrial A positive history or abnormal results on C 6 septal defects, and bicuspid aortic valve. In physical examination or electrocardiography should prompt evaluation for structural many cases, careful dynamic auscultation heart disease. (having the patient stand or squat to evaluate Supraventricular tachycardia with aberrant C 6 changes in cardiac sounds) helps distinguish conduction may be difficult to distinguish valvular etiologies. from ventricular tachycardia. In the setting of hemodynamic instability or history of CARDIAC ARRHYTHMIC CAUSES heart disease, ventricular tachycardia should be considered. Arrhythmias that begin above the bundle of His are supraventricular, whereas those A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited- originating distal to the bundle of His are quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual ventricular. All tachyarrhythmias are char- practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml. acterized by abnormal impulse initiation (automatic) or impulse conduction (reen- trant), with the latter being the most com- mon.6,7 Patient characteristics that increase the likelihood of an arrhythmic cause of palpitations are Table 2. Likelihood Ratios for an 4 Arrhythmic Cause of Palpitations summarized in Table 2. A family history of panic dis- Based on Clinical Findings order (likelihood ratio = 0.26; 95% confidence interval, 0.07 to 1.0) and palpitations lasting less than five minutes Likelihood ratio (likelihood ratio = 0.38; 95% confidence interval, 0.22 to (95% confidence 0.63) reduce the likelihood of an arrhythmic cause.4 Clinical finding interval) NONCARDIAC CAUSES Visible neck pulsations 2.7 (1.3 to 5.8) Anxiety is the most common noncardiac cause of palpi- Palpitations affecting sleep 2.3 (1.3 to 3.9) tations.2-4 Patients whose symptoms are more likely to be Palpitations at work 2.2 (1.2 to 4.0) of a psychiatric nature are significantly younger (mean Known history of cardiac disease 2.0 (1.3 to 3.1) age of 35.1 versus 45.1 years), more often have a disabil- Male sex 1.7 (1.2 to 2.5) ity, express hypochondrial behavior, and have a somati- Duration of palpitation 1.5 (1.3 to 1.9) 12 longer than five minutes zation disorder. However, it should not be assumed that the underlying behavioral issue is the etiology of palpi- Information from reference 4. tations in patients with psychiatric symptoms, because a nonpsychiatric cause may exist in up to 13 percent of such patients.2,13 Stimulants (e.g., caffeine), thyroid disease, alcohol, Table 3. Selected Other Causes of Palpitations pregnancy, and anemia are noncardiac and nonpsychiat- ric causes of palpitations. Additional noncardiac etiolo- 2-5,12,14,15 Alcohol Hypovolemia gies are listed in Table 3. Anemia Mastocytosis History and Physical Examination Anxiety Medications (see Table 5) Beta-blocker withdrawal Nicotine Discerning cardiac from noncardiac causes is important, Caffeine Paget disease given the potential risk of sudden death in those with an Cocaine Pheochromocytoma underlying cardiac etiology. All patients presenting with 8,11,16 Exercise Pregnancy palpitations should be evaluated for a cardiac cause. Fever Stress A history of panic attacks or anxiety disorder points to 4 Food poisoning Thyroid disorders a psychiatric cause, whereas a family history of hyper- 2-4 Hypoglycemia thyroidism suggests a thyroid disorder. Important car- diac causes, such as long QT syndrome, have a heritable Information from references 2 through 5, 12, 14, and 15. component, underscoring the value of a meticulous fam- ily history. Physicians should ask about the context of 64 American Family Physician www.aafp.org/afp Volume 84, Number 1 ◆ July 1, 2011 Palpitations Table 4. Electrocardiography Findings in Common Arrhythmias That Cause Palpitations Finding Possible rhythm palpitations, noting that cardiac causes may occur either at rest (e.g., vagally mediated Atrioventricular dissociation Ventricular premature contractions, ventricular tachycardia premature ventricular beats) or with exer- Delta wave Wolff-Parkinson-White syndrome, tion (e.g., dehydration exacerbating mitral atrioventricular nodal reentrant valve prolapse). tachycardia Because most patients presenting with Heart rate greater than 250 beats Wolff-Parkinson-White syndrome palpitations are asymptomatic at the time of per minute the visit, the examination is focused primar- Irregularly irregular pattern Atrial fibrillation ily on uncovering abnormalities that may P mitrale, left ventricular hypertrophy, Atrial fibrillation indicate structural heart disease or arrhyth- atrial premature contractions mia. A positive history or abnormal results QTc greater than 460 msec Polymorphic ventricular on physical examination or electrocardiog- for women and greater than tachycardia 440 msec for men raphy (ECG) should prompt evaluation for Q waves Ventricular premature contractions, 6 structural heart disease. Physicians should ventricular tachycardia assess for pulse irregularity, murmurs, point Short PR interval Atrioventricular nodal reentrant of apical impulse, or presence of a pulse dis- tachycardia crepancy as seen in coarctation of the aorta (a pulse rate at the wrist that is lower
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