Diagnostic Approach to Palpitations ALLAN V. ABBOTT, M.D., Keck School of Medicine of the University of Southern California, Los Angeles, California Palpitations—sensations of a rapid or irregular heartbeat—are most often caused by cardiac arrhythmias or anxiety. Most patients with arrhythmias do not complain of palpitations. However, any arrhythmia, including sinus tachycardia, atrial fibrillation, premature ventricular contractions, or ventricular tachycardia, can cause palpitations. Palpitations should be consid- ered as potentially more serious if they are associated with dizziness, near-syncope, or syncope. Nonarrhythmic cardiac problems, such as mitral valve prolapse, pericarditis, and congestive heart failure, and noncardiac problems, such as hyperthyroidism, vasovagal syncope, and hypo- glycemia, can cause palpitations. Palpitations also can result from stimulant drugs, and over-the- counter and prescription medications. No cause for the palpitations can be found in up to 16 percent of patients. Ambulatory electrocardiographic (ECG) monitoring usually is indicated if the etiology of palpitations cannot be determined from the patient’s history, physical examina- tion, and resting ECG. When palpitations occur unpredictably or do not occur daily, an initial two-week course of continuous closed-loop event recording is indicated. Holter monitoring for 24 to 48 hours may be appropriate in patients with daily palpitations. Trans-telephonic event monitors are more effective and cost-effective than Holter monitors for most patients. (Am Fam Physician 2005;743-50,755-6. Copyright© 2005 American Academy of Family Physicians.) ▲ Patient information: n increased or abnormal aware- at a university medical center who com- A handout on heart pal- ness of the heartbeat, palpita- plained of palpitations and were followed for pitations, written by the author of this article, is tions are a common symptom in one year, an etiology was determined in 84 provided on page 755. patients presenting to family phy- percent of the patients. A sicians. Palpitations can be symptomatic of Of these patients, 43 percent had palpita- life-threatening cardiac arrhythmias.1 How- tions caused by cardiac causes (40 percent ever, most palpitations are benign. In one had an arrhythmia, 3 percent had other retrospective study2 in a family practice set- cardiac causes), 31 percent had palpitations ting, there was no difference in the rates of caused by anxiety or panic disorder, 6 percent morbidity or mortality among patients with had palpitations caused by street drugs or palpitations compared with matched control prescription and over-the-counter medica- subjects. tions, and 4 percent had palpitations caused Although there are many possible cardiac by other noncardiac causes. No specific etiologies, palpitations can be associated cause of the palpitations could be identified with noncardiac causes such in 16 percent of the patients. Psychiatric and Palpitations are potentially as fever, anemia, or drug use, emotional illnesses such as anxiety, panic, more serious when they and can occur in anxious but and somatization disorders may be underly- 1 are associated with diz- otherwise normal persons. The ing problems in many patients. differential diagnoses of pal- Although arrhythmias frequently cause ziness, near-syncope, or pitations are summarized in palpitations, most patients with arrhyth- syncope because they sug- Table 1. mias do not actually notice their arrhyth- gest tachyarrhythmia. Consensus or evidence-based mia and are unlikely to report having guidelines for diagnosing and palpitations.3 managing palpitations have not been devel- This article describes the more common oped. However, recent studies of palpitation presentations of palpitations and a rational etiology provide improved evidence that can approach to patient evaluation, and provides guide a family physician through diagnosis. evidence for making decisions about ambu- In a prospective cohort study1 of 190 patients latory monitoring. Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2005 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. STRENGTH OF RECOMMENDATIONS Key clinical recommendation Label References Most patients with palpitations are diagnosed with an arrhythmia or C 1 panic disorder. The identification of panic disorder in patients with palpitations can be C 9 assisted with the use of screening questionnaires. Unless palpitations occur daily, event monitors are more cost effective than 24-hour or 48-hour Holter monitors in the diagnosis of intermittent B 19 arrhythmias. Patients with palpitations caused by premature ventricular contractions, B 23 who have a normal heart evaluation, have no increased mortality. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 639 for more information. Etiology of Palpitations arteriovenous block, or ventricular tachy- CARDIAC ARRHYTHMIAS cardia. Episodes of ventricular tachycardia Palpitations can result from many arrhyth- and supraventricular tachycardia may be mias, including any bradycardia and tachy- perceived as palpitations but also can be cardia, premature ventricular and atrial asymptomatic or lead to syncope. Palpita- contractions, sick sinus syndrome, advanced tions associated with dizziness, near-syn- TABLE 1 Differential Diagnosis of Palpitations Arrhythmias Nonarrhythmic cardiac causes Atrial fibrillation/flutter Atrial or ventricular septal defect Bradycardia caused by advanced arteriovenous Cardiomyopathy block or sinus node dysfunction Congenital heart disease Bradycardia-tachycardia syndrome Congestive heart failure (sick sinus syndrome) Mitral valve prolapse Multifocal atrial tachycardia Pacemaker-mediated tachycardia Premature supraventricular Pericarditis or ventricular contractions Valvular disease (e.g., aortic insufficiency, Sinus tachycardia or arrhythmia stenosis) Supraventricular tachycardia Extracardiac causes Ventricular tachycardia Anemia Wolff-Parkinson-White syndrome Electrolyte imbalance Psychiatric causes Fever Anxiety disorder Hyperthyroidism Panic attacks Hypoglycemia Drugs and medications Hypovolemia Alcohol Pheochromocytoma Caffeine Pulmonary disease Certain prescription and over-the-counter Vasovagal syndrome agents (e.g., digitalis, phenothiazine, theophylline, beta agonists) Street drugs (e.g., cocaine) Tobacco NOTE: The categories of palpitations are arranged from most common to least common; within the categories, condi- tions are listed in alphabetical order. 744 American Family Physician www.aafp.org/afp Volume 71, Number 4 ◆ February 15, 2005 Palpitations Panic Disorder Questionnaire Question Circle one Do you think there is something seriously wrong with your body? 1 2 3 4 5 Do you get the feeling that people are not taking your illness seriously 1 2 3 4 5 enough? Do you find that you are bothered by many different symptoms? 1 2 3 4 5 In the past month, how much have you been aware of a sudden 1 2 3 4 5 feeling of unsteadiness or loss of balance? In the past month, how much have you been aware of being short 1 2 3 4 5 of breath? In the past six months, how much have you been bothered by the following: Feeling faint or dizzy? 1 2 3 4 5 Pains in your heart or chest? 1 2 3 4 5 Numbness, tingling, or burning in parts of your body? 1 2 3 4 5 Feeling weak in parts of your body? 1 2 3 4 5 Not feeling well most of the time in the past few years? 1 2 3 4 5 Scoring: 1 = not at all; 2 = a little bit; 3 = moderately; 4 = quite a bit; 5 = a great deal. A total score of more than 21 suggests underlying panic disorder (57 percent positive predictive value and 93 percent negative predictive value in a typical population where 25 percent of patients with palpitations have a panic disorder). Figure 1. Questionnaire to identify panic disorder in patients with palpitations. Adapted with permission from Barsky AJ, Ahern DK, Delamater BA, Clancy SA, Bailey ED. Differential diagnosis of palpitations: preliminary development of a screening instrument. Arch Fam Med 1997;6:244. cope, or syncope suggest tachyarrhythmia A screening questionnaire (Figure 1)9 to and are potentially more serious. help identify patients whose palpitations are Some patients notice “pounding” or “jump- more likely to result from panic disorder was ing” palpitations when they are quietly sitting validated among patients referred for Holter or lying down. This symptom may result monitoring. A score of more than 21 points from premature contractions, especially pre- on the questionnaire is 81 percent sensitive mature ventricular contractions. Orthostatic and 80 percent specific for panic disorder. intolerance or inadequate cerebral perfusion To explain it another way, if, overall, 25 per- on upright posture may result in palpitations, cent of patients have panic disorder as the tachycardia, altered mentation, headache, cause of their palpitations, then 57 percent nausea, pre-syncope, and, occasionally, syn- with more than 21 points have panic disor- cope. Orthostatic intolerance is most com- der compared with only 7 percent of those mon in women of childbearing age.4 with 21 or fewer points.9 A simpler screening tool for panic disor- ANXIETY OR PANIC DISORDER der, consisting of a single