Approach to palpitations - RACGP
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CLINICAL
Approach to palpitations
Alex JA McLellan, Jonathan M Kalman PALPITATIONS are one of the most common be a normal response to stress, including
presentations to general practice, and episodes of anxiety, and it is important
while they are usually benign, they may to elucidate cause and effect. Age of
Background
Palpitations are one of the most
also have life-threatening significance. the patient may give some indication
common presentations to general Palpitations have been estimated to regarding the arrhythmia mechanism if
practice. While they are usually benign, account for 16% of general practice supraventricular tachycardia is suspected;
they may be associated with an adverse presentations and are the second most atrioventricular re-entrant tachycardia
prognosis. common presentation to cardiologists (AVRT; Wolf-Parkinson-White syndrome)
Objectives
after chest pain.1 Although the vast becomes less likely with increasing age,
This article presents a systematic majority are benign, there are some whereas atrioventricular nodal re-entrant
approach to the patient with palpitations clinical and electrocardiographic tachycardia (AVNRT), atrial fibrillation
and addresses considerations of signs that determine when further and atrial tachycardia become more likely
aetiology, history and examination; investigations may be necessary. Only (Figure 1).5
appropriate diagnostic work-up; rarely will palpitations be associated with
cardiology/electrophysiology referral
risk of serious cardiac events.2 This article
and management strategies. History and physical examination
presents a systematic approach to the
Discussion patient with palpitations and addresses History
Not all palpitations are due to consideration of the aetiology, history A thorough history is essential given
arrhythmia, and because of the
and examination; appropriate diagnostic the overwhelming majority of patients
transitory nature of palpitations, the
workup; cardiology/electrophysiology will present in sinus rhythm, between
work-up will usually be performed
between episodes. Direction from referral and management strategies. episodes of arrhythmia.1 Palpitations are
history, examination and 12-lead subjective and have been defined as ‘a
electrocardiography will guide further disagreeable sensation of pulsation or
investigations and will often include Aetiology movement in the chest and/or adjacent
an echocardiogram and ambulatory Not all patients with palpitations will areas’;4 it is important to clarify whether
electrocardiographic monitoring.
have a cardiac or arrhythmic cause. the patient’s symptom is palpitations
The intensity of ambulatory
electrocardiographic monitoring and
In patients presenting to a university rather than a non-arrhythmic cardiac
diagnostic work-up will be dictated by medical centre with palpitations, 41% symptom (eg chest pain, shortness of
the frequency, nature and severity of had an arrhythmic aetiology, 31% breath, pre-syncope) or a non-cardiac
symptoms, and will sometimes require had palpitations in the context of symptom. Sometimes it is useful to get
incorporation of new technologies and psychological disorder such as anxiety, the patient to tap or clap out the heart
electrophysiology referral. Ultimately, and in 16% no cause was identified.2 In rhythm during their typical episode.
management must be tailored on a
an emergency population, a cardiac cause Once clarified, the history should focus
case-by-case basis depending on
the cause of palpitations and of palpitations was identified in 34% on the nature of the symptoms and
symptom severity. of patients.3 It is important to caution circumstances around the time of the
labelling a patient’s palpitations as being palpitations (Box 1).
due to anxiety/panic disorder or stress,
as 54% of this group will eventually be Subjective awareness of a
diagnosed with an arrhythmic cause, and normal heartbeat
the time delay until arrhythmia diagnosis One of the causes of palpitations is simply
is 3.3 years.4 Sinus tachycardia may also an increased awareness of normal sinus
204 | REPRINTED FROM AJGP VOL. 4 8, NO. 4, APRIL 2019 © The Royal Australian College of General Practitioners 2019APPROACH TO PALPITATIONS CLINICAL
rhythm.6 The patient may describe a increased under conditions of anxiety, be an abnormal heart rate on a heart
forceful beating in the chest or neck that fatigue and inter-current illness. Although rate device such as a fitness tracker or
is not particularly fast; they may be able doctors frequently recommend patients exercise monitor worn around the chest.
to hear their own heartbeat, particularly with ectopic beats to avoid caffeine, there is Patients may be concerned that their
at night in bed. Although there may very little evidence that this is beneficial.8 resting heart rate is higher than a friend’s
occasionally be secondary causes, in the When asked how long their palpitations or relative’s and wonder whether this
vast majority of cases this is benign. It may last, patients with repetitive ectopy may say signifies a problem. It is important to be
often occur at times of heightened anxiety. that they occur over a period of minutes able to reassure patients that a wide range
to many hours. It is important to establish of resting heart rates can be within the
Momentary palpitations: Ectopic beats that this is a recurrent, intermittent event normal spectrum. These different devices
Another frequent cause of palpitations is rather than continuous rapid palpitations. are also prone to error, particularly during
benign ectopic beats, which can be atrial Previous studies suggest that up to 100 exercise, and can erroneously give very
or ventricular.7 Patients describe these ventricular ectopic beats in a 24-hour high or very low readings.10 The key clue
as a momentary skipped or missed beat. period (24-hour Holter monitor) are within as to whether the heart rate recorded
They are frequently associated with an normal limits.9 More frequent ectopic beats indicates a genuine health problem is the
unusual, momentary sensation in the require further investigation; however, presence of associated symptoms.
patient’s throat or chest. Patients usually even when a patient has thousands of
become aware of ventricular ectopic beats ectopic beats per 24-hour period, these will Sustained palpitations
because of a compensatory pause after the most usually be benign and not signify an Sustained rapid palpitations of gradual
ectopic beat, with an associated increase increased risk of adverse cardiovascular onset and offset over minutes or longer
in diastolic filling and supra-normal stroke outcomes. periods of time may represent sinus
volume of the post-ectopic sinus beat. tachycardia. This is also usually benign,
Ectopic beats may occur repetitively in Heart rate devices particularly at times of anxiety or stress.
patterns (bigeminal, trigeminal, etc) or It is also common for patients to seek Less often, sinus tachycardia may
may be isolated. The frequency of ectopic medical attention for ‘palpitations’ when signify an underlying disorder such as
beats will vary day to day and may be they have recorded what they think may thyrotoxicosis or anaemia.
Sustained rapid palpitations of sudden
onset may be regular or irregular.
Patients describe a sudden onset of rapid
palpitations that may last from minutes to
hours continuously. In the case of atrial
fibrillation, this may continue for days or
be continuous until treated.
Rapid regular palpitations
In the vast majority of patients, presenting
with sudden-onset regular sustained
rapid palpitations will signify episodes
of supraventricular tachycardia (SVT); in
contrast, patients with sinus tachycardia
Box 1. Palpitations: Key questions in
history-taking
Onset and offset: sudden or gradual
Duration: momentary or sustained
(how long?)
Frequency
Figure 1. Common types of SVT and representative circuits Triggers (frequently may not be obvious)
The small circuit in dots represents typical AVNRT, short dashes represent (orthodromic) AVRT Associated symptoms
(via a right free wall pathway represented by the red dashes), and long dashes represent atrial • Pre-syncope/syncope
flutter. The yellow arc represents the AV node. • Breathlessness
AVNRT, atrioventricular nodal re-entrant tachycardia; AVRT, atrioventricular re-entrant tachycardia; • Chest pain (possibly ischaemic in nature)
RA, right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle
Existing cardiac conditions
© The Royal Australian College of General Practitioners 2019 REPRINTED FROM AJGP VOL. 48, NO. 4, APRIL 2019 | 205CLINICAL APPROACH TO PALPITATIONS
may have a more gradual onset.11 SVT cardiac function in patients presenting with the development of cardiomyopathy
may classically be induced by sudden with palpitations, as abnormalities can and cardiac arrhythmia such as atrial
movements, particularly bending. Many significantly affect management and fibrillation.14 Family history should be
younger patients, including athletes, may prognosis. explored, particularly regarding genetic
describe a sudden onset of excessive heart arrhythmia syndromes and history of
rate during exertion that may interfere Rapid irregular palpitations: sudden cardiac death.
with their ability to compete. However, Atrial fibrillation A systematic review identified
many patients find no particular trigger, Patients with paroxysmal or persistent atrial only six factors from the history that
and events can occur at rest. While SVT fibrillation may present with sustained significantly correlated with arrhythmia:
may cause sudden light-headedness at palpitations. These are usually described age of >60 years, regular palpitations,
onset, syncope is unusual. Patients may as heartbeats that are very irregular or ‘all palpitations affected by sleep, regular
also complain of chest discomfort or over the place’. Patients frequently have pounding sensation in neck (atrial
breathlessness during the event. associated exertional breathlessness. contraction against a closed tricuspid
Patients with sustained palpitations Syncope due to a rapid ventricular rate valve as in atrioventricular nodal re-entry
and significant associated symptoms in atrial fibrillation is unusual. When tachycardia), visible neck pulsations,
(eg pre-syncope, breathlessness or patients with paroxysmal atrial fibrillation and vasovagal symptoms (pallor or
chest pain) require early referral for have syncope, this is frequently due to diaphoresis).12
evaluation. Patients presenting with a significant sinus pause at the time of
syncope or ongoing chest pain should be spontaneous reversion (ie tachycardia- Examination
transferred to an emergency department bradycardia syndrome). While chest pain Examination will also usually be performed
by ambulance. during atrial fibrillation may be solely in between episodes of arrhythmia, and
Young patients with rapid palpitations, secondary to a rapid ventricular response it should address any cardiac or systemic
particularly young women, may be rate, if the pain is ischaemic in nature it illness that might be implicated in the
misdiagnosed as having panic attacks. may reflect underlying coronary artery development of arrhythmia including
Anxiety and distress may be a normal disease. Polyuria may be associated with weight (obesity may contribute to
response to an episode of SVT, and the paroxysmal atrial fibrillation because of atrial fibrillation), resting heart rate,
history will clarify whether the SVT or the associated release of atrial natriuretic hypertension, signs of heart failure,
anxiety occurred first. peptide.12 Atrial fibrillation onset during cardiac murmurs (valvular heart disease),
Patients with SVT can frequently (but the night may suggest a vagal mechanism thyroid examination and signs of anaemia.
not universally) terminate an event with or be a sign of associated sleep-disordered Fluid status and postural blood pressure/
vagal manoeuvres. These include the breathing (eg obstructive sleep apnoea). heart rate should also be measured, given
Valsalva technique or cold stimulus to An understanding of the frequency and the association of hypovolaemia with
the face. duration of palpitations over the patient’s sinus tachycardia and the possibility of
life is required, as the symptomatic burden autonomic dysfunction when there is
Does ventricular tachycardia will often define the management strategy an inappropriate sinus tachycardia with
present as recurrent palpitations? (eg conservative management versus postural change. In a systematic review,
Patients with ventricular tachycardia medications or electrophysiology study). the only clinical sign that significantly
infrequently present with palpitations The history should include review correlated with arrhythmia was abnormal
as an isolated presenting symptom. The of background medical issues that resting heart rate (100 beats per minute).12
uncommon idiopathic ventricular cardiovascular disease, thyroid illness),
tachycardia, particularly when it is psychiatric history, medication history
recurrent and non-sustained. In most and illicit substances that may contribute Diagnostic work-up
cases, ventricular tachycardia occurs in to arrhythmia (eg stimulant, weight The gold standard diagnostic technique
the context of underlying structural heart loss medication). Alcohol history is for a patient with palpitations is
disease (most commonly prior myocardial important given the association of alcohol to be monitored using a 12-lead
infarction), and patients present with consumption with the risk of atrial electrocardiogram (ECG) at the time of
features of haemodynamic compromise. fibrillation.13 Although some patients symptoms. However, due to the transitory
This may include syncope, diaphoresis, describe palpitations associated with nature of arrhythmia, this method tends
chest pain and breathlessness. Such caffeine intake, a recent study identified to be the exception rather than the rule.
patients would usually be transferred no increased risk of any arrhythmia with All patients presenting between symptoms
directly to an emergency department caffeine intake, even after adjustment should have a 12-lead ECG, because the
when sustained events occur. As structural for confounders.8 An exercise history sinus rhythm ECG can sometimes infer
heart disease may cause palpitations could be helpful given that extreme an arrhythmic mechanism (Table 1).
(and vice versa), it is important to assess endurance exercise can be associated Ambulatory electrocardiographic
206 | REPRINTED FROM AJGP VOL. 4 8, NO. 4, APRIL 2019 © The Royal Australian College of General Practitioners 2019APPROACH TO PALPITATIONS CLINICAL monitoring (eg Holter monitor, external the arrhythmia, though can often be recorder can be considered for patients loop recorder, implantable loop recorder, performed following specialist referral. with sporadic palpitations (
CLINICAL APPROACH TO PALPITATIONS
Table 2. Ambulatory ECG monitoring: Choice of investigation
Investigation of choice:
Investigation symptom frequency Advantages Disadvantages
12-lead ECG - Readily available Rarely performed during arrhythmia
Inexpensive
24–48 hour Holter Daily to every second day Usually available Low yield other than for daily arrhythmias
monitor Does not require activation:
asymptomatic arrhythmia
can be detected
Loop/event recorder Weekly–monthly Increased yield and cost Most units only record ECG if patient triggered;
(range of 1–4 weeks) effectiveness (versus Holter) not useful for asymptomatic arrhythmia or
syncope
Loop/event recorder for
Generally only one-week recorders available
one week
Patient discomfort for longer-term monitoring
Implantable loop Months to year/s High yield Cost
recorder Long-term monitoring Not available in all centres
approximately three years Currently only approved for diagnosis of syncope
Automatic bradycardia/ or cryptogenic stroke
tachycardia storage plus
patient-triggered episodes
Handheld ECG Months to year High yield Cost to patient
Permanently available Time for activation of device before arrhythmia
to patient termination
Potential large volume of data to interpret, no
Medicare rebate
Data ownership with some systems, sometimes
requiring subscription
ECG, electrocardiography
Authors 2. Weber BE, Kapoor WN. Evaluation and outcomes 9. Ng GA. Treating patients with ventricular ectopic
Alex JA McLellan MBBS, PhD, Cardiology of patients with palpitations. Am J Med beats. Heart 2006;92(11): 1707–12. doi: 10.1136/
Department, Royal Melbourne Hospital, Vic; 1996;100(2):138–48. hrt.2005.067843
Cardiology Department, St Vincent’s Hospital 3. Probst MA, Mower WR, Kanzaria HK, Hoffman JR, 10. Reddy RK, Pooni R, Zaharieva DP, et al. Accuracy
Melbourne, Vic; Baker Heart & Diabetes Institute, Vic Buch EF, Sun BC. Analysis of emergency of wrist-worn activity monitors during common
department visits for palpitations (from the
Jonathan M Kalman MBBS, PhD, Cardiology daily physical activities and types of structured
National Hospital Ambulatory Medical Care
Department, Royal Melbourne Hospital, Vic; exercise: Evaluation study. JMIR Mhealth Uhealth
Survey). Am J Cardiol 2014;113(10):1685–90.
Cardiology Department, St Vincent’s Hospital 2018;6(12):e10338. doi: 10.2196/10338.
doi: 10.1016/j.amjcard.2014.02.020.
Melbourne, Vic; Baker Heart & Diabetes Institute, Vic;
4. Lessmeier TJ, Gamperling D, Johnson-Liddon V, 11. Raviele A, Giada F, Bergfeldt L, et al. Management
Faculty of Medicine, Dentistry, and Health Sciences,
et al. Unrecognized paroxysmal supraventricular of patients with palpitations: A position paper
University of Melbourne, Vic. jon.kalman@mh.org.au
tachycardia. Potential for misdiagnosis as panic from the European Heart Rhythm Association.
Competing interests: None.
disorder. Arch Intern Med 1997;157(5):537–43. Europace 2011;13(7):920–34. doi: 10.1093/
Funding: Dr McLellan is supported by an Australian europace/eur130.
5. Porter MJ, Morton JB, Denman R, et al.
National Heart Foundation postdoctoral fellowship. Influence of age and gender on the mechanism 12. Thavendiranathan P, Bagai A, Khoo C,
Professor Kalman is supported by a practitioner of supraventricular tachycardia. Heart Dorian P, Choudhry NK. Does this patient
fellowship from the National Health and Medical Rhythm 2004;1(4):393–96. doi: 10.1016/j.
Research Council. This research is supported in with palpitations have a cardiac arrhythmia?
hrthm.2004.05.007.
part by the Victorian Government’s Operational JAMA 2009;302(19):2135–43. doi: 10.1001/
6. Thavendiranathan P, Bagai A, Khoo C, jama.2009.1673.
Infrastructure.
Dorian P, Choudhry NK. Does this patient
Provenance and peer review: Commissioned, 13. Voskoboinik A, Prabhu S, Ling LH,
with palpitations have a cardiac arrhythmia?
externally peer reviewed. JAMA 2009;302(19):2135–43. doi: 10.1001/ Kalman JM, Kistler PM. Alcohol and atrial
jama.2009.1673. fibrillation: A sobering review. J Am Coll
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1. Raviele A, Giada F, Bergfeldt L, et al. Management
of patients with palpitations: A position paper 8. Dixit S, Stein PK, Dewland TA, et al. Consumption 14. Flannery MD, Kalman JM, Sanders P, La Gerche A.
from the European Heart Rhythm Association. of caffeinated products and cardiac ectopy. J Am State of the art review: Atrial fibrillation in athletes.
Europace 2011;13(7):920–34. doi: 10.1093/ Heart Assoc 2016;5(1). pii: e002503. doi: 10.1161/ Heart Lung Circ 2017;26(9):983–89. doi: 10.1016/j.
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208 | REPRINTED FROM AJGP VOL. 4 8, NO. 4, APRIL 2019 © The Royal Australian College of General Practitioners 2019APPROACH TO PALPITATIONS CLINICAL
History, examination, ECG
Echocardiogram if cardiovascular symptoms/risk factors
Holter monitor for frequent palpitations
Diagnosis confirmed, structurally
Unexplained palpitations
normal heart, normal ECG
Structural heart
Structurally normal
Yes No disease/abnormal
heart/ECG
ECG
Manage as appropriate, No further
Cardiology/EP
consider referral if sustained Consider cardiology/EP Cardiology/EP management if
referral if frequent
palpitations or warning referral referral infrequent and not
and distressing
signs* distressing
Figure 2. Approach to the patient with palpitations1
ECG, electrocardiogram; EP, electrophysiology
*Refer to Box 2
Box 2. Which patients to refer or ‘When to worry’
Patients with frequent or persistent palpitations
Sustained rapid palpitations
Significant associated symptoms:
• Pre-syncope/syncope (consider situational context)
• Breathlessness
• Chest pain
Family history of recurrent syncope or of sudden death
Significant resting 12-lead electrocardiography or echocardiographic
abnormalities
• Wolff–Parkinson–White syndrome (pre-excitation including short PR
interval and delta wave)
• Signs of structural or electrical abnormalities:
–– T wave abnormalities
–– Prior myocardial infarction (Q waves)
–– Long or short QT interval, Brugada pattern, early
repolarisation pattern
correspondence ajgp@racgp.org.au
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