Palpitations

Palpitation
Artistic impression of a woman experiencing syncope, which may accompany heart palpitations
Specialty	Cardiology
Differential diagnosis	Tachycardia

Palpitations are perceived abnormalities of the

Symptoms include a rapid pulsation, an abnormally rapid or irregular beating of the heart.[1] Palpitations are a sensory symptom and are often described as a skipped beat, rapid fluttering in the chest, pounding sensation in the chest or neck, or a flip-flopping in the chest.^[1]

Palpitation can be associated with anxiety and does not necessarily indicate a structural or functional abnormality of the heart, but it can be a symptom arising from an objectively rapid or irregular heartbeat. Palpitation can be intermittent and of variable frequency and duration, or continuous. Associated symptoms include dizziness, shortness of breath, sweating, headaches and chest pain.

Palpitation may be associated with

PVC (a type of palpitation) recording

An audio clip recording of a PVC symptom, made with a cardiac event monitor.

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Three common descriptions of palpitation are "flip-flopping" (or "stop and start"), often caused by premature contraction of the atrium or ventricle, with the perceived "stop" from the pause following the contraction, and the "start" from the subsequent forceful contraction; rapid "fluttering in the chest", with regular "fluttering" suggesting supraventricular or

1. Extra-cardiac stimulation of the
   poor posture, can also irritate the vagus nerve
   causing palpitations)
2. Sympathetic overdrive (
   antihistamines (levocetirizine), low red blood cell count, heart failure, mitral valve prolapse).^[5]
3. high body temperature, low red blood cell count, pregnancy
   ).
4. Abnormal heart rhythms (ectopic beat, premature atrial contraction, junctional escape beat, premature ventricular contraction, atrial fibrillation, supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, heart block
   ).
5. Pectus Excavatum, also known as funnel chest, is a chest wall deformity. When the breastbone (sternum) and attached ribs are sunken in enough to put excess pressure on the heart and lungs which can cause tachycardia and skipped beats.

Palpitations can occur during times of catecholamine excess, such as during exercise or at times of stress.^[1] The cause of the palpitations during these conditions is often a sustained supraventricular tachycardia or ventricular tachyarrhythmia.^[1] Supraventricular tachycardias can also be induced at the termination of exercise when the withdrawal of catecholamines is coupled with a surge in the vagal tone.^[1] Palpitations secondary to catecholamine excess may also occur during emotionally startling experiences, especially in patients with a long QT syndrome.^[1]

Psychiatric problems

Anxiety and stress elevate the body's level of cortisol and adrenaline, which in turn can interfere with the normal functioning of the parasympathetic nervous system resulting in overstimulation of the vagus nerve.^[6] Vagus nerve induced palpitation is felt as a thud, a hollow fluttery sensation, or a skipped beat, depending on at what point during the heart's normal rhythm the vagus nerve fires. In many cases, the anxiety and panic of experiencing palpitations cause a patient to experience further anxiety and increased vagus nerve stimulation. The link between anxiety and palpitation may also explain why many panic attacks involve an impending sense of cardiac arrest. Similarly, physical and mental stress may contribute to the occurrence of palpitation, possibly due to the depletion of certain micronutrients involved in maintaining healthy psychological and physiological function.^[7] Gastrointestinal bloating, indigestion and hiccups have also been associated with overstimulation of the vagus nerve causing palpitations, due to branches of the vagus nerve innervating the GI tract, diaphragm, and lungs.^{[citation needed]}

Many psychiatric conditions can result in palpitations including

The most important initial clue to the diagnosis is one's description of palpitation. The approximate age of the person when first noticed and the circumstances under which they occur are important, as is information about caffeine intake (tea or coffee drinking), and whether continual palpitations can be stopped by deep breathing or changing body positions. It is also very helpful to know how they start and stop (abruptly or not), whether or not they are regular, and approximately how fast the pulse rate is during an attack. If the person has discovered a way of stopping the palpitations, that is also helpful information.^[1]

A complete and detailed history and physical examination are two essential elements of the evaluation of a patient with palpitations.

Palpitations that have been a condition since childhood are most likely caused by a supraventricular tachycardia, whereas palpitations that first occur later in life are more likely to be secondary to structural heart disease.[1] A rapid regular rhythm is more likely to be secondary to paroxysmal supraventricular tachycardia or ventricular tachycardia, and a rapid and irregular rhythm is more likely to be an indication of atrial fibrillation, atrial flutter, or tachycardia with variable block.^[1] Supraventricular and ventricular tachycardia is thought to result in palpitations with abrupt onset and abrupt termination.^[1] In patients who can terminate their palpitations with a Valsalva maneuver, this is thought to indicate possibly a supraventricular tachycardia.^[1] Palpitations associated with chest pain may suggest myocardial ischemia.^[1] Lastly, when lightheadedness or syncope accompanies the palpitations, ventricular tachycardia, supraventricular tachycardia, or other arrhythmias should be considered.^[1]

The diagnosis is usually not made by a routine

Positive orthostatic vital signs may indicate dehydration or an electrolyte abnormality.^[1] A mid-systolic click and heart murmur may indicate mitral valve prolapse.^[1] A harsh holo-systolic murmur best heard at the left sternal border which increases with Valsalva may indicate hypertrophic obstructive cardiomyopathy.^[1] An irregular rhythm indicates atrial fibrillation or atrial flutter.^[1] Evidence of cardiomegaly and peripheral edema may indicate heart failure and ischemia or a valvular abnormality.^[1]

Blood tests, particularly tests of

The next level of diagnostic testing is usually 24-hour (or longer) ECG monitoring, using a recorder called a Holter monitor, which can record the ECG continuously during a 24-hour or 48-hour period. If symptoms occur during monitoring it is a simple matter to examine the ECG recording and see what the cardiac rhythm was at the time. For this type of monitoring to be helpful, the symptoms must be occurring at least once a day. If they are less frequent, the chances of detecting anything with continuous 24- or even 48-hour monitoring are substantially lowered. More recent technology such as the Zio Patch allows continuous recording for up to 14 days; the patient indicates when symptoms occur by pushing a button on the device and keeps a log of the events.^{[citation needed]}

Other forms of monitoring are available, and these can be useful when symptoms are infrequent. A continuous-loop event recorder monitors the ECG continuously, but only saves the data when the wearer activates it. Once activated, it will save the ECG data for a period of time before the activation and for a period of time afterwards – the

Further diagnostic testing is recommended for those in whom the initial diagnostic evaluation (history, physical examination, and EKG) suggest an arrhythmia, those who are at high risk for an arrhythmia, and those who remain anxious to have a specific explanation of their symptoms.[1] People considered to be at high risk for an arrhythmia include those with organic heart disease or any myocardial abnormality that may lead to serious arrhythmias.^[1] These conditions include a scar from myocardial infarction, idiopathic dilated cardiomyopathy, clinically significant valvular regurgitant, or stenotic lesions and hypertrophic cardiomyopathies.^[1]

An aggressive diagnostic approach is recommended for those at high risk and can include ambulatory monitoring or electrophysiologic studies.^[1] There are three types of ambulatory EKG monitoring devices: Holter monitor, continuous-loop event recorder, and an implantable loop recorder.^[1]

People who are going to have these devices checked should be made aware of the properties of the devices and the accompanying course of the examination for each device.^[1] The Holter monitor is a 24-hour monitoring system that is worn by exam takers themselves and records and continuously saves data.^[1] Holter monitors are typically worn for a few days.^[1] The continuous-loop event recorders are also worn by the exam taker and continuously record data, but the data is saved only when someone manually activates the monitor.^[1] The continuous-loop recorders can be long worn for longer periods of time than the Holter monitors and therefore have been proven to be more cost-effective and efficacious than Holter monitors.^[1] Also, because the person triggers the device when he/she feel the symptoms, they are more likely to record data during palpitations.^[1] An implantable loop recorder is a device that is placed subcutaneously and continuously monitors for cardiac arrhythmias.^[1] These are most often used in those with unexplained syncope and can be used for longer periods of time than the continuous loop event recorders. An implantable loop recorder is a device that is placed subcutaneously and continuously monitors for the detection of cardiac arrhythmias.^[1] These are most often used in those with unexplained syncope and are a used for longer periods of time than the continuous loop event recorders.^[1] Electrophysiology testing enables a detailed analysis of the underlying mechanism of the cardiac arrhythmia as well as the site of origin.^[1] EPS studies are usually indicated in those with a high pretest likelihood of a serious arrhythmia.^[1] The level of evidence for evaluation techniques is based upon consensus expert opinion.^[1]

Treatment

Treating palpitation will depend on the severity and cause of the condition.

People who present to the emergency department who are asymptomatic, with unremarkable physical exams, have non-diagnostic EKGs and normal laboratory studies, can safely be sent home and instructed to follow up with their primary care provider or cardiologist.[1] Patients whose palpitations are associated with syncope, uncontrolled arrhythmias, hemodynamic compromise, or angina should be admitted for further evaluation.^[1]

Palpitation that is caused by heart muscle defects will require specialist examination and assessment. Palpitation that is caused by vagus nerve stimulation rarely involves physical defects of the heart. Such palpitations are extra-cardiac in nature, that is, palpitation originating from outside the heart itself. Accordingly, vagus nerve induced palpitation is not evidence of an unhealthy heart muscle.^{[citation needed]}

Treatment of vagus nerve induced palpitation will need to address the cause of irritation to the vagus nerve or the

Direct-to-consumer options for monitoring heart rate and heart rate variability have become increasingly prevalent using smartphones and smartwatches.^[1] These monitoring systems have become increasingly validated and may help provide early identification for those at risk for a serious arrhythmia such as atrial fibrillation.^[1]

Palpitations can be a very concerning symptom for people.

Palpitations are a common complaint in the general population, particularly in those affected by structural heart disease.[1] Clinical presentation is divided into four groups: extra-systolic, tachycardic, anxiety-related, and intense.^[1] Anxiety-related is the most common.^[1]

See also

• Cardiac dysrhythmia

References