Palpitations: Evaluation in the Primary Care Setting RANDELL K. WEXLER, MD, MPH; ADAM PLEISTER, MD; and SUBHA V. RAMAN, MD, MSEE The Ohio State University Wexner Medical Center, Columbus, Ohio Palpitations are a common problem in the ambulatory primary care setting, and cardiac causes are the most concern- ing etiology. Psychiatric illness, adverse effects of prescription and over-the-counter medications, and substance use should also be considered. Distinguishing cardiac from noncardiac causes is important because of the risk of sudden death in those with an underlying cardiac etiology. A thorough history and physical examination, followed by tar- geted diagnostic testing, can distinguish cardiac conditions from other causes of palpitations. Persons with a history of cardiovascular disease, palpitations at work, or palpitations that affect sleep have an increased risk of a cardiac cause. A history of cardiac symptoms, a family history concerning for cardiac dysrhythmias, or abnormal physical examination or electrocardiography findings should prompt a more in-depth evaluation for heart disease. Ischemic symptoms may signal coronary heart disease and associated ventricular premature contractions that may warrant exercise stress testing. Exertional symptoms accompanied by elevated jugular venous pressure, rales, or lower extrem- ity edema should raise concern for heart failure; imaging may be required to assess for functional and structural heart disease. (Am Fam Physician. 2017;96(12):784-789. Copyright © 2017 American Academy of Family Physicians.) CME This clinical content atients often present to family phy- Differential Diagnosis conforms to AAFP criteria sicians with a “flopping” sensation Although the most pressing concern during for continuing medical in the chest or an awareness of the evaluation of a patient with palpitations education (CME). See CME Quiz on page 772. palpitations that may be fast, slow, is to uncover any underlying cardiac cause, Author disclosure: No rel- Pregular, or irregular. Cardiac causes are clas- noncardiac causes may also contribute and evant financial affiliations. sified as structural or arrhythmic, with test- are potentially treatable (Table 1).2,4,5,7,9,10,13-19 ▲ Patient information: ing guided by clinical suspicion.1-8 Determining the cause is important to assess A handout on this topic is risk. Palpitations account for 16% of visits available at http://family Pathophysiology to generalist physicians and are the second doctor.org/familydoctor/ 16 en/diseases-conditions/ Ordinary cardiac transmission involves leading cause of visits to cardiologists. heart-palpitations.html. the spontaneous discharge of an electrical Table 2 lists the relative frequencies of causes impulse at the sinoatrial node. The impulse of palpitations.11,16 is then propagated down the wall of the right atrium to the atrioventricular node, then disseminated via the His-Purkinje system to depolarize the ventricles. Dis- WHAT IS NEW ON THIS TOPIC: turbance of the electrical impulse any- PALPITATIONS where along these pathways may produce Supraventricular premature complexes, an arrhythmia. Noncardiac factors (e.g., which can be distinguished from ventricular thyroid disease, pheochromocytoma, psy- premature contractions when nonsinus atrial depolarizations are followed by narrow QRS chiatric disorders, medications) may affect complexes, are associated with significant this process. Hyperthyroidism and hypo- increases in atrial fibrillation, stroke, thyroidism can affect cardiac function by cardiovascular disease, and death, even if impairing cardiac pliability and oxygen asymptomatic. demand, resulting in arrhythmia.9,10 Panic In addition to cocaine, methamphetamine, attacks, anxiety, and somatization disorder and 3,4-methylenedioxymethamphetamine (MDMA or Ecstasy), marijuana use can can cause palpitations due to autonomic cause arrhythmias and should be assessed in 11 activation. Pheochromocytoma can also patients presenting with palpitations. lead to catecholamine excess.12 784Downloaded American from the Family American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2017 American AcademyVolume of Family96, Number Physicians. 12 For◆ December the private, 15,noncom 2017- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Palpitations SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References All patients presenting with palpitations should be evaluated for an ischemic cause. C 3, 5, 16 Nonspecific ST-segment and T-wave changes in symptomatic patients should not be C 25 considered normal and should prompt further evaluation for a cardiac cause. Patients who have syncope associated with palpitations should undergo tilt-table testing. C 15, 17, 19 Transthoracic echocardiography should be considered to evaluate for heart failure or C 3 structural heart disease in patients with palpitations accompanied by elevated jugular venous pressure, rales, or lower extremity edema. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort. Clinical Diagnosis a patient with palpitations. Syncope should raise concern HISTORY for arrhythmias, such as ventricular tachycardia, or struc- All patients presenting with palpitations should be eval- tural heart disease (e.g., hypertrophic cardiomyopathy) uated for an ischemic cause.3,5,7,8,16 Many cardiac causes, with outflow tract obstruction impairing cardiac output to both arrhythmic and structural, have a genetic compo- the extent that cerebral blood flow is impaired. Although nent, underscoring the value of a thorough family his- syncope or presyncope can occur with vasovagal syncope, tory focused on early cardiac death and inherited cardiac its occurrence during exertion in an athlete is of partic- conditions. Physicians should ask whether the palpita- ular concern because of the increased risk of malignant tions are associated with activity. Palpitations with car- ventricular arrhythmia that may result in sudden cardiac diac causes may occur at rest (e.g., vagal nerve–mediated death. In young athletes, the incidence of sudden cardiac ventricular premature contractions [VPCs]) or with death is estimated to be one to three cases per 100,000 exertion (e.g., dehydration exacerbating mitral valve person-years.20 Etiologies include cardiomyopathies, con- prolapse cardiomyopathy, exertional syncope), which genital coronary anomalies, and ion channelopathies.20 suggests more worrisome etiologies. Medication and Substance Use. A history of all pre- A systematic review concluded that a history of car- scription and over-the-counter medications should be diovascular disease, palpitations occurring at work, or obtained. Medications used to treat attention-deficit/ palpitations that affect sleep have an increased risk of a hyperactivity disorder and rescue inhalers for asthma cardiac cause (positive likelihood ratio [LR+] = 2.0 to may cause palpitations. Over-the-counter nasal decon- 2.3).3 Symptoms of a regular, rapid, pound- ing sensation in the neck, although rare, are strongly associated with atrioventricular Table 1. Cardiac and Noncardiac Causes of Palpitations nodal reentrant tachycardia (LR+ = 177); this diagnosis is also supported by visible Cardiac Noncardiac 3 neck pulsations (LR+ = 2.7). Atrial fibrillation/flutter Alcohol The patient should be asked about any Atrial myxoma Anemia history of panic attacks or anxiety disorder, Atrial premature contractions Anxiety/stress 4 which may signal a psychiatric etiology but Atrioventricular reentry Beta-blocker withdrawal may also accompany arrhythmic presen- Atrioventricular tachycardia Caffeine tations. Thyroid dyscrasia may exacerbate Autonomic dysfunction Cocaine arrhythmias, and signs and symptoms should Cardiomyopathy Exercise 2-4 prompt consideration of a thyroid disorder. Long QT syndrome Fever Position. Patients who have palpitations Multifocal atrial tachycardia Medications due to atrioventricular nodal reentrant Sick sinus syndrome Nicotine tachycardia may find that their symptoms are Supraventricular tachycardia Paget disease of bone triggered by standing up after bending over. Valvular heart disease Pheochromocytoma They may also notice symptoms while lying Ventricular premature contractions Pregnancy in bed. This most often represents supraven- Ventricular tachycardia Thyroid dysfunction tricular tachycardia (SVT) or VPCs.20 Syncope and Presyncope. Loss of conscious- Information from references 2, 4, 5, 7, 9, 10, and 13 through 19. ness is an important factor when evaluating December 15, 2017 ◆ Volume 96, Number 12 www.aafp.org/afp American Family Physician 785 Palpitations Table 2. Frequency of Etiologies of Palpitations Etiology Frequency (%) Psychosomatic 31 palpitations. This includes pulmonary stenosis, atrial Atrial fibrillation 16 septal defects, and bicuspid aortic valve. Supraventricular tachycardia 10 Medication/illicit substances 6 Diagnostic Testing Systemic disease 4 Figure 1 provides an overview of the diagnostic evalua- Structural heart disease 3 tion of patients with palpitations.7,14,15,17,24 Baseline labo- Ventricular tachycardia 2 ratory testing should include a complete blood count; blood urea nitrogen,