II. Definition

  1. Awareness of the heart beat

III. Symptoms

  1. Pounding or fluttering sensation in the chest
  2. Sensation of skipping or missing a beat
  3. Sensation that heart is stopping or jumping

IV. Exam

  1. Full Vital Signs
  2. Thyroid exam
  3. Careful cardiopulmonary exam
    1. Examine heart while standing and squatting to accentuate murmurs
    2. Evaluate for signs of Cardiomyopathy
    3. Evaluate for mid-systolic click
    4. Irregular pulse

V. Red Flags: Symptoms suggestive of serious cause

  1. Syncope or Near Syncope
  2. Palpitations on exertion
  3. Associated cardiopulmonary symptoms (Dyspnea, Orthopnea, Leg Edema)
  4. Prolonged QT interval or other EKG abnormality (see below)
  5. Known heart disease

VI. Risk Factors: Arrhythmia cause of Palpitations (with Likelihood Ratio)

  1. Visible neck pulsations (LR: 2.7)
  2. Palpitations affect sleep (LR 2.3)
  3. Palpitations at work (LR 2.2)
  4. Known heart disease history (LR 2.0)
  5. Male gender (LR 1.7)
  6. Palpitations last >5 minutes (LR 1.5)

VII. Risk factors: Psychiatric cause of Palpitations

  1. Precaution: Panic may be comorbid with organic cause (up to 13% of cases)
  2. Family History of Panic Disorder
  3. Palpitations <5 minutes
  4. Younger age (typically <40 years old)
  5. Comorbid Disability
  6. Somatization or Hypochondriasis history

VIII. Causes

  1. See Palpitation Causes
  2. Causes by category
    1. Cardiac (43%)
      1. Structural heart disease (e.g. Mitral Valve Prolapse)
      2. Arrhythmia
    2. Psychiatric (31%)
      1. Anxiety Disorder
    3. Miscellaneous (10%)
    4. idiopathic (16%)
    5. Weber (1996) Am J Med 100(2): 138-48 [PubMed]

X. Dignostics: Electrocardiogram

  1. Prior Myocardial Infarction
  2. Left Ventricular Hypertrophy
  3. Right Ventricular Hypertrophy
  4. Atrial Fibrillation
  5. Atrial enlargement
  6. AV nodal block
  7. Prolonged QT Interval (QTc >460 in men, QTc >440 in men)
  8. Delta Waves
    1. Wolff-Parkinson-White Syndrome
  9. Short PR Interval
    1. AV Nodal reentry rhythm

XI. Diagnostics: Other

  1. Ambulatory EKG monitoring
    1. Continuous EKG Monitor (Holter Monitor for 24-48 hours)
    2. Event Monitor (loop recorder for intermittent episodes over 1 month)
  2. Consider additional testing when indicated
    1. Exercise Stress Test
      1. Exercise induced Palpitations or associated cardiopulmonary symptoms
      2. Known heart disease or significant risk factors
      3. Abnormal Ekg
    2. Echocardiogram
      1. Suspected structural heart disease
      2. Nondiagnostic evaluation
      3. Palpitations with cardiopulmonary symptoms
    3. Electrophysiologic Study
      1. Syncope
      2. Life threatening arrhythmia suspected
      3. Wolff-Parkinson-White

XII. Management

  1. Evaluate for cardiac causes specific causes
    1. Exclude cardiac causes first as they have the potential to be life threatening
    2. Consider cardiology Consultation
  2. Manage specific causes
    1. Extrasystoles
      1. Refer if 25% of beats are PVCs (risk of Cardiomyopathy) or associated with structural heart disease
      2. Intermittent PVCs and PACs are common, benign, and typically respond to general measures below
    2. Supraventricular Tachycardia
      1. Paroxysmal Supraventricular Tachycardia (PSVT)
      2. Wolff-Parkinson-White (WPW)
    3. Atrial Fibrillation or Atrial Flutter
    4. Ventricular Tachycardia
    5. Long QT Interval
  3. General measures for symptomatic relief of benign causes
    1. Exercise program (if evaluation negative)
    2. Eliminate Caffeine, Alcohol, and Tobacco
    3. Maximize hydration
    4. Stress reduction
    5. Consider Beta Blocker (e.g. Propranolol, Metoprolol)

XIII. References

  1. Braunwald (2001) Heart Disease, Saunders, p. 37-38
  2. Degowin (1987) Diagnostic Exam, MacMillan, p. 334
  3. Goroll (2000) Primary Care, Lippincott, p. 141-6
  4. Thavendiranathan (2009) JAMA 302(19): 2135-43 [PubMed]
  5. Wexler (2011) Am Fam Physician 84(1): 63-9 [PubMed]

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Ontology: Palpitations (C0030252)

Definition (NCI_CTCAE) A disorder characterized by an unpleasant sensation of irregular and/or forceful beating of the heart.
Definition (NCI_NCI-GLOSS) A rapid or irregular heartbeat that a person can feel.
Definition (NCI) An unpleasant sensation of irregular and/or forceful beating of the heart.
Concepts Finding (T033)
ICD9 785.1
ICD10 R00.2
SnomedCT 207004005, 207006007, 158334000, 139224009, 158336003, 139222008, 139227002, 161965005, 161970003, 161967002, 80313002
LNC LA16997-1
English PALPITATION, HEART THROBBING, Palpitation, Palpitation(s), Palpitations NOS, [D]Palpitations (context-dependent category), [D]Palpitations NOS (context-dependent category), [D]Palpitations, [D]Palpitations NOS, palpitations (symptom), palpitations, palpitations (diagnosis), heart irregularities, Heart throbbing, heart throb, heart throbbing, [D]Palpitations NOS (situation), [D]Palpitations (situation), Palpitations NOS (finding), PALPITATIONS, palpitation, Palpitations (finding), Palpitations
Italian Palpitazioni, Sensazione di cuore che pulsa, Palpitazione
Dutch hartklopping, hartbonzen, Palpitaties, hartkloppingen
French Palpitations cardiaques, Palpitation, PALPITATIONS, Palpitations
German Palpitation, pochendes Herz, HERZKLOPFEN, HERZSCHLAGEN VERSTAERKT, Palpitationen
Portuguese Palpitações cardíacas, Palpitação, PALPITACAO CARDIACA, PALPITACOES, Palpitações
Spanish Palpitación, Palpitaciones cardiacas, [D]palpitaciones (categoría dependiente del contexto), [D]palpitaciones, SAI (categoría dependiente del contexto), PALPITACIONES, Palpitations NOS, palpitaciones, SAI (hallazgo), [D]palpitaciones, SAI (situación), [D]palpitaciones (situación), [D]palpitaciones, SAI, palpitaciones, SAI, [D]palpitaciones, palpitaciones (hallazgo), palpitaciones, Palpitaciones
Japanese 動悸, ドウキ
Czech Palpitace, Bušení srdce
Korean 두근거림
Hungarian Szívdobogásérzés, Palpitatio, Lüktető szív