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Approach to the child with palpitations

Approach to the child with palpitations
Literature review current through: Jan 2024.
This topic last updated: Jan 09, 2023.

INTRODUCTION — This topic will review the differential diagnosis and approach to the child with palpitations.

The differential diagnosis of tachycardia in children who do not have palpitations is discussed elsewhere. (See "Approach to the child with tachycardia".)

DEFINITION — Palpitations describe a noticeable heartbeat that may be concerning to the patient (eg, too fast, irregular, or too strong). In adults, palpitations occasionally herald serious underlying cardiac events [1]. However, palpitations in children typically arise from physiologic stimuli, such as fever, exercise, anxiety, or anemia, rather than life-threatening causes (eg, cardiac arrhythmia). In addition, children with serious arrhythmias may report no palpitations.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of palpitations encompasses rare etiologies that are life-threatening and common causes (algorithm 1 and table 1).

Life-threatening causes — Children with a serious underlying cause for their palpitations often have a history of syncope, congenital heart disease, or cardiac surgery (table 1) [2-6].

Arrhythmias — Arrhythmias are a very uncommon cause of palpitations in children with structurally normal hearts but are frequently seen in children with surgically corrected structural heart disease [6]. Arrhythmias may be broadly classified as fast or slow. The child with tachyarrhythmia and shock should be triaged and managed per the American Heart Association (AHA) guidelines for assessment of cardiopulmonary instability espoused in the Pediatric Advanced Life Support (PALS) course [7]. (See "Approach to the child with tachycardia".)

A key component of this assessment requires categorization of the QRS complex from the cardiorespiratory (CR) monitor or 12-lead electrocardiogram (ECG) as narrow or wide (algorithm 2) [2]. A 12-lead ECG before and after intervention is preferable if patient status allows. Supraventricular tachycardia (SVT) is the most common non-sinus tachyarrhythmia of childhood and often presents with palpitations in verbal children [2,8]. Most infants with SVT are asymptomatic although feeding problems, pallor, or dyspnea, especially with feeding, may occur [8]. Ventricular tachycardia is rare in children with structurally normal hearts. (See "Management of supraventricular tachycardia (SVT) in children" and "Management and evaluation of wide QRS complex tachycardia in children" and "Sustained monomorphic ventricular tachycardia: Clinical manifestations, diagnosis, and evaluation".)

Symptomatic sinus bradycardia in children often arises from respiratory failure with hypoxemia. Sick sinus syndrome, Mobitz type II atrioventricular blockage, and complete atrioventricular dissociation are usually seen in children with structural heart disease, including children with pacemaker malfunction. (See "Bradycardia in children".)

Myocarditis — Myocarditis is most commonly viral in origin, with Coxsackie virus B and other enteroviruses accounting for most cases. Clinical findings of myocarditis include tachycardia out of proportion to fever, poor perfusion, and signs of heart failure. Patients with myocarditis may develop a variety of tachy- and bradyarrhythmias. Children with fulminant myocarditis may rapidly develop cardiogenic shock. (See "Clinical manifestations and diagnosis of myocarditis in children", section on 'Clinical manifestations'.)

Hypertrophic cardiomyopathy — Hypertrophic cardiomyopathy (HCM) manifests as a hypertrophied, nondilated left ventricle and septum. Patients with HCM may present with palpitations or syncope during strenuous exercise caused by atrial fibrillation or ventricular arrhythmia. The subset of HCM patients who present with syncope are at significant risk for sudden death [9]. (See "Causes of syncope in children and adolescents" and "Hypertrophic cardiomyopathy: Clinical manifestations, diagnosis, and evaluation".)

Hypoglycemia — The early manifestations of hypoglycemia in children and adolescents are caused by the autonomic response to hypoglycemia and may include tachycardia with palpitations, sweating, weakness, tremor, and feelings of nervousness and/or hunger. These symptoms and signs usually occur at higher blood glucose concentrations (between 40 and 70 mg/dL [2.2 and 3.9 mM]) than the neuroglycopenic signs and symptoms (lethargy, irritability, behavioral abnormalities, seizures, or coma), and may function as a "warning system." (See "Approach to hypoglycemia in infants and children", section on 'Clinical features'.)

Poisoning — Toxin exposures have the potential to cause life-threatening tachy- and bradyarrhythmias. The specific arrhythmia depends on the characteristics of the toxic agent (table 2).

Pheochromocytoma — Pheochromocytoma and paragangliomas are rare neoplasms in children. Tumors that arise from the adrenal medulla are termed pheochromocytomas, and those with extraadrenal origins are called paragangliomas. The classic triad of symptoms in these disorders consists of episodic headache, sweating, and tachycardia, usually accompanied by hypertension. Malignant hypertension can occur, with its associated complications (eg, increased intracranial pressure, encephalopathy). (See "Pheochromocytoma and paraganglioma in children" and "Moderate to severe hypertensive retinopathy and hypertensive encephalopathy in adults".)

Common causes — See the following table for a differential diagnosis of palpitations: (table 1).

Increased metabolic rate — Increased metabolic rate accompanies fever and anemia. The resulting sinus tachycardia and hyperdynamic cardiac activity may cause palpitations.

Catecholamine release — Palpitations may also follow the catecholamine release associated with exercise, emotional arousal, and psychiatric distress (eg, anxiety, panic attack) [10]. Hypoglycemia is a life-threatening cause of catecholamine release that warrants rapid recognition and treatment. (See 'Hypoglycemia' above.)

Hyperventilation — Hyperventilation, breathing in excess of physiologic requirement to maintain oxygenation and ventilation, may occur without obvious underlying etiology in adolescents [11-14]. Patients with hyperventilation often have associated symptoms of dyspnea, chest tightness, chest pain, paresthesias, and palpitations (often described as a "racing" heart) [13]. Frequently they attribute their symptoms to a life-threatening problem and appear very anxious. In addition, children with hyperventilation may have a past medical history of asthma [12].

While clinical findings reveal no serious cardiac or pulmonary abnormalities, patients with severe hyperventilation may display a positive Chvostek or Trousseau sign, laryngospasm, or spontaneous carpopedal spasm [11,14]. Ancillary studies (eg, venous or arterial blood gas and electrolytes) typically show respiratory alkalosis. Rarely, T wave changes, including ST segment depression, T wave flattening, and T wave inversion may appear on ECG during the hyperventilation episode [14].

Once serious etiologies, such as status asthmaticus, metabolic acidosis pain, central nervous system disorders, and drug intoxication are excluded, treatment consists of reassurance [13,14]. Additional measures may be necessary to end the acute episode such as placement of a partial rebreather oxygen mask with oxygen flow set below 5 liters per minute allows the patient to rebreathe carbon dioxide without causing hypoxia or benzodiazepine administration (eg, diazepam 0.2 mg/kg up to adult dose of 5 mg) [14].

Patients with hyperventilation need close follow-up and counseling. Up to 40 percent of patients with hyperventilation will have repeated episodes into adulthood [14].

Drug-induced — Drug induced palpitations, as opposed to toxic exposures (table 2), involve medications and substances with sympathomimetic or anticholinergic properties that increase heart rate and cardiac contractility with routine dosing [15-18]. Implicated agents include albuterol, caffeine, tobacco, cough and cold preparations, dietary supplements that contain ephedra, herbal medications, energy drinks, recreational drugs, and isotretinoin.

Postural orthostatic tachycardia syndrome — Postural orthostatic tachycardia syndrome (POTS) is defined as a form of orthostatic intolerance characterized by an excessive increase in heart rate (>30 bpm over baseline or to >120 bpm in adults) that occurs on standing without arterial hypotension. POTS is a common disorder among teenage girls that manifests as palpitations, anxiety, dizziness, and tremulousness. (See "Postural tachycardia syndrome".)

Premature atrial contractions — Premature atrial contractions (PACs), the most common sinus arrhythmia of childhood, result from premature depolarization of an atrial focus. Patients often describe that they feel like their heart "stops" or "flip-flops." PACs are benign [3].

Premature ventricular contractions — Premature ventricular contractions (PVCs) result from premature depolarization of a ventricular focus or reentry. Once structural heart disease and ventricular dysfunction are excluded by ancillary testing, PVCs can be considered benign [3].

Other causes — See table the following table for a differential diagnosis of palpitations: (table 1).

Hyperthyroidism frequently presents with palpitations in children. Goiter, diaphoresis, weight loss, heat intolerance, tachycardia, and widened pulse pressure comprise common additional findings. (See "Clinical manifestations and diagnosis of Graves disease in children and adolescents", section on 'Clinical manifestations'.)

Acute rheumatic fever (ARF) is a delayed, nonsuppurative sequela of a pharyngeal infection with the group A streptococcus. Fever and pancarditis are clinical manifestations of this disease that can cause tachycardia. Other findings include arthralgia, arthritis, erythema marginatum, subcutaneous nodules, and chorea. Testing for recent streptococcal infection is essential to establish the diagnosis. (See "Acute rheumatic fever: Clinical manifestations and diagnosis".)

Mitral valve prolapse is associated with a wide variety of clinical features. Palpitations are a common presenting complaint in MVP. The evaluation of patients with symptomatic palpitations is similar to that in patients without MVP. Palpitations are often associated with ventricular premature beats, but supraventricular arrhythmias can also occur. (See "Mitral valve prolapse: Overview of complications and their management".)

HISTORY — A careful history helps to identify patients at higher risk for a life-threatening cause for their palpitations.

Palpitation description – Palpitations caused by life threatening tachyarrhythmias often start and stop abruptly (like turning a light switch on and off). Children may feel like there is a butterfly in their chest or like their heart is beating so fast that it will come out of the chest. These palpitations generally are of short duration (seconds to minutes).

Palpitations due to cardiac hyperdynamic states with sinus tachycardia are often described as a rushing or pounding in the ears, particularly when the patient is supine. Exercise, fever, anemia, pharmaceuticals, nutraceuticals, caffeine drinks, and emotional arousal may produce this sensation of increased ventricular stroke volume that often lasts minutes to hours.

Children with premature atrial or ventricular contractions may note the increased stroke volume of the compensatory heart beat as a "flip-flop" or say that their heart "stops". A similar sensation may be produced in patients with bradycardia and high grade (Type II or Type III) atrioventricular block due to escape beats. (See "Irregular heart rhythm (arrhythmias) in children".)

Palpitations associated with diaphoresis, headache, flushing and hypertensions suggest pheochromocytoma. Palpitations associated with heat intolerance and diaphoresis suggest hyperthyroidism.

Congenital heart disease, repaired or unrepaired – Palpitations in this setting have a high likelihood of cardiac arrhythmia as an underlying cause [6,19].

Syncope – A history of palpitations with syncope, especially in association with exercise, raises concern for a primary cardiac etiology such as cardiac arrhythmia, hypertrophic cardiomyopathy, or myocardial ischemia (usually related to congenital anomaly of a coronary artery). (See "Suspected heart disease in infants and children: Criteria for referral", section on 'Timing of referral'.)

In children with intermittent tachyarrhythmias (eg, prolonged QT syndrome or Wolff-Parkinson-White syndrome), palpitations with abrupt syncope may be described. Triggers for these events involve intrinsic catecholamine stimulation such as exercise, sudden exposure to cold water (diving), or sudden surprise. Unlike vasovagal syncope, patients usually fall without protecting themselves from injury. Unlike seizures, patients usually recover full mental status without a postictal phase as long as the arrhythmia is of short duration. (See "Emergency evaluation of syncope in children and adolescents".)

Illness/fever – A history of viral illness or fever in conjunction with respiratory distress or myocardial dysfunction suggests myocarditis, especially if tachycardia is out of proportion to the degree of fever or is present after defervescence. (See "Clinical manifestations and diagnosis of myocarditis in children".)

A history of a recent streptococcal infection in the febrile patient with tachycardia raises clinical suspicion for acute rheumatic fever. If signs of carditis, such as a new murmur of mitral valve regurgitation or pericardial rub are present, then the patient meets Jones criteria for the diagnosis of acute rheumatic fever. (See "Acute rheumatic fever: Clinical manifestations and diagnosis".)

Family history – Family history of sudden cardiac death or deafness raises clinical suspicion for genetic disorders such as long QT syndrome and hypertrophic cardiomyopathy that may cause sudden onset of ventricular tachycardia with palpitations and syncope.

PHYSICAL EXAMINATION — Ill-appearing patients with palpitations need rapid assessment for hypoxemia, hypoglycemia, and hemodynamic instability. Clinicians should emergently treat the patient with cardiovascular collapse per American Heart Association guidelines for cardiopulmonary resuscitation (algorithm 1 and algorithm 2 and algorithm 3) [7]. (See "Bradycardia in children" and "Approach to the child with tachycardia".)

Vital signs — Several vital sign changes provide important findings in children with palpitations:

Tachycardia is defined as the presence of a heart rate value greater than expected for age. In addition to the values published for specific age groups [20], clinicians may use the basic guideline of >160 BPM for infants (< 2 years), >140 BPM for children (2 to 10 years), and >100 BPM for children over 10 years of age, adolescents, and young adults to define tachycardia (table 3).

Conversely, bradycardia means a heart rate measurement that is less than expected for age or <90 BPM for infants, <70 BPM for children, and <60 BPM for adolescents and adults [20].

An orthostatic increase in heart rate >30 BPM over baseline without hypotension defines postural orthostatic tachycardia.

An elevated blood pressure for age may be seen in patients with anxiety, panic attacks, hyperventilation, or pheochromocytoma.

Hypertension with a widened pulse pressure suggests hyperthyroidism.

Fever should prompt evaluation for other findings consistent with myocarditis or acute rheumatic fever.

Cardiovascular findings — Most stable patients with palpitations have a normal cardiac examination.

Patients with fever or anemia may demonstrate short systolic flow murmurs of medium to high pitch.

Patients with mitral valve prolapse may display a midsystolic click or multiple clicks followed by a midsystolic to late systolic murmur at the apex of the left ventricle over the mitral area (movie 1 and movie 2). These findings may be transient depending in part upon loading conditions, such as squatting, that increase blood flow to the heart (table 4). (See "Auscultation of cardiac murmurs in adults" and "Physiologic and pharmacologic maneuvers in the differential diagnosis of heart murmurs and sounds".)

The pancarditis of acute rheumatic fever may manifest as a pericardial rub or the murmur of mitral regurgitation. (See "Auscultation of cardiac murmurs in adults".)

Myocarditis may be evident based on the presence of a gallop or murmur of mitral or tricuspid insufficiency in association with other signs of heart failure. (See "Clinical manifestations and diagnosis of myocarditis in children".)

Patients with congenital heart disease may have a variety of cardiac findings, depending on the physiologic status of their cardiac lesion, including cyanosis, pathologic murmurs, and evidence of cardiac failure.

Noncardiovascular findings — Other important findings in patients with palpitations include:

Conjunctival pallor that suggests anemia.

Exophthalmos with or without goiter that indicates hyperthyroidism.

Hyperventilation that consists of markedly rapid breathing or deep breathing, often accompanied by sighing, without an obvious etiology.

Tachypnea with rales that implies pulmonary congestion from left sided heart failure seen in patients with myocarditis or congenital heart disease.

Hepatomegaly and jugular venous distension that suggests right-sided heart failure seen in patients with myocarditis or congenital heart disease.

Diaphoresis with flushing that is found in patients with pheochromocytoma.

High levels of emotional distress without life-threatening findings seen in patients with anxiety, panic attack, or hyperventilation.

ANCILLARY STUDIES — In the acutely symptomatic patient with palpitations, monitoring and assessment of the cardiac rhythm is vital.

Standard bedside cardiac monitors often do not provide satisfactory rhythm tracings to allow detailed decision making. Thus, a standard 12-lead electrocardiogram (ECG) and rhythm strip should be obtained upon presentation and concurrent with any attempts at cardioversion or defibrillation to guide therapy and to provide valuable data should the patient require pediatric cardiology consultation [21].

Even in the patient who is asymptomatic on presentation, continuous monitoring during initial evaluation and a standard ECG is often helpful since an ECG is essential in the diagnosis of Wolff-Parkinson-White and long QT syndromes and may be helpful in the diagnosis of premature atrial and ventricular beats.

Readily available hemoglobin or hematocrit measurement can confirm clinical suspicion of anemia.

Clinical findings suggestive of hyperthyroidism can be confirmed by serum thyroid testing. Serum levels of thyroxine (T4) and triiodothyronine (T3) are elevated, and TSH secretion is suppressed in hyperthyroidism. (See "Clinical manifestations and diagnosis of Graves disease in children and adolescents".)

If the patient presents with an acute tachyarrhythmia, the clinician should obtain an echocardiogram to evaluate myocardial function, as well as to evaluate for underlying structural heart disease soon after normal sinus rhythm is established, preferably within a few days. In the hemodynamically unstable patient, this study should be performed on an emergent basis as the information will impact therapeutic decision making.

Cardiac troponin levels (troponin-I and -T) may be elevated in myocarditis. However, myocardial enzymes (creatine kinase [CK], MB isoenzyme of CK [CK-MB]) levels are generally not helpful as they are rarely abnormal. Serum PCR identification of a viral infection, or viral isolation from other body sites, such as the oropharynx or gastrointestinal tract, can support the diagnosis. (See "Clinical manifestations and diagnosis of myocarditis in children", section on 'Cardiac biomarkers (troponin)' and "Troponin testing: Clinical use".)

Pharyngeal Group A Streptococcus culture, Antistreptolysin O (ASO), anti-deoxyribonuclease B (anti-DNase B), and/or antihyaluronidase titers are essential for documenting antecedent streptococcal infection as part of the diagnosis of rheumatic fever. (See "Acute rheumatic fever: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

Twenty-four-hour ambulatory ECG (Holter) monitors, longer-term event and insertable cardiac monitors (sometimes referred to as implantable cardiac monitors or implantable loop recorders) are helpful for sporadic events [22], but prescription of these should be limited to a pediatric cardiologist. (See "Irregular heart rhythm (arrhythmias) in children", section on 'Ambulatory electrocardiogram monitoring'.)

ALGORITHMIC APPROACH — Ill-appearing patients require rapid assessment of airway, breathing, and circulation (algorithm 1). The evaluation should focus on identifying and treating hypoxia, hypoglycemia, shock, and arrhythmia (algorithm 2 and algorithm 3). (See "Approach to the child with tachycardia".)

Children with a history of palpitations, but who are not acutely symptomatic, should be placed on continuous cardiac monitoring and undergo a 12-lead electrocardiogram (ECG).

Patients with a history of syncope, congenital heart disease, or cardiac surgery are at higher risk of having a cardiac arrhythmia as the cause of their palpitations [19]. These children warrant involvement of a pediatric cardiologist early in their evaluation so that an echocardiogram looking for cardiac structural abnormality and advanced testing for cardiac rhythm disturbance occur. (See "Suspected heart disease in infants and children: Criteria for referral", section on 'Timing of referral'.)

Poisoned patients with palpitations are also at high risk for cardiac arrhythmia. Drugs associated with rhythm disturbance following overdose are listed in the table (table 2).

Additional findings help distinguish among the life-threatening causes of palpitations:

The diagnosis of Wolff-Parkinson-White syndrome is made if ventricular preexcitation (delta wave) and a short PR interval are present on 12-lead ECG [2]. (See "Wolff-Parkinson-White syndrome: Anatomy, epidemiology, clinical manifestations, and diagnosis", section on 'Electrocardiographic findings'.)

A prolonged corrected QT interval (QTc) identifies the presence of long QT syndrome [20,23,24]. (See "Congenital long QT syndrome: Diagnosis" and "Acquired long QT syndrome: Definitions, pathophysiology, and causes".)

Sinus bradycardia with SA block or SA arrest identifies sick sinus syndrome. Children with pacemaker malfunction often have bradyarrhythmia. Causes include poor capture, battery failure, and lead misplacement. (See "Bradycardia in children" and "Pacing system malfunction: Evaluation and management".)

Fever with heart failure is found in children with myocarditis. (See "Clinical manifestations and diagnosis of myocarditis in children".)

The ECG may also document premature extrasystoles. If the history is convincing for periodic episodes of palpitations, but the initial workup is unrevealing, clinicians should refer the patient to a pediatric cardiologist for further evaluation and testing. Potential methods that a cardiologist will use to identify the cardiac rhythm during the palpitation episode include 24 hour ambulatory ECG (Holter) monitors, longer term event recorders, and insertable cardiac monitors [22,25].

Children with palpitations, headache, diaphoresis, and hypertension should undergo evaluation for pheochromocytoma. (See "Pheochromocytoma and paraganglioma in children".)

Well-appearing patients with a single episode of palpitations typically have a benign cause, such as fever, anemia, ingestion of medications and substances with sympathomimetic or anticholinergic effects, postural tachycardia syndrome, or hyperventilation (algorithm 1).

Some patients with significant psychiatric distress due to anxiety, panic attack, or other mental illness may also present with palpitations. These patients warrant appropriate workup for potential organic causes, such as hyperthyroidism, and further mental health assessment and support.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Supraventricular arrhythmias".)

SUMMARY AND RECOMMENDATIONS

Definition – Palpitations describe a noticeable heartbeat that is usually concerning to the patient (eg, too fast, irregular, or too strong). (See 'Definition' above.)

Differential diagnosis – Palpitations in children typically arise from physiologic stimuli, such as fever, exercise, anxiety, or anemia, rather than life-threatening causes (eg, cardiac arrhythmia) (table 1). (See 'Differential diagnosis' above.)

History – Children with a serious underlying cause for their palpitations often have a history of syncope, congenital heart disease, or cardiac surgery. Palpitations caused by life threatening tachyarrhythmias often start and stop abruptly (like turning a light switch on and off). (See 'History' above.)

Approach – Ill-appearing patients with palpitations need rapid assessment for hypoxemia, hypoglycemia, and hemodynamic instability. Clinicians should emergently treat the patient with cardiovascular collapse per American Heart Association guidelines for cardiopulmonary resuscitation (algorithm 1 and algorithm 2 and algorithm 3). (See 'Physical examination' above and 'Algorithmic approach' above.)

All patients with palpitations warrant cardiac monitoring and a 12-lead electrocardiogram (ECG) during evaluation. Additional testing is guided by physical findings. (See 'Ancillary studies' above.)

Patients with a history of syncope, congenital heart disease, or cardiac surgery are at higher risk of having a cardiac arrhythmia as the cause of their palpitations. These children warrant involvement of a pediatric cardiologist early in their evaluation so that an echocardiogram looking for cardiac structural abnormality and advanced testing for cardiac rhythm disturbance occur. (See 'Algorithmic approach' above.)

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