Evaluation of palpitations in adults

INTRODUCTION — 

Palpitations are one of the most common symptoms of patients presenting to primary care clinicians and cardiologists [1]. Although the cause is usually benign, palpitations are occasionally a manifestation of a concerning or potentially life-threatening arrhythmia. Thus, patients with palpitations require a thoughtful and appropriate evaluation to guide further workup and treatment and minimize unnecessary testing.

The common etiologies for palpitations and a rational guide to the diagnostic evaluation of palpitations in adults are reviewed here. The approach to palpitations in children and the management of documented arrhythmias in children and adults are discussed separately. (See "Approach to the child with palpitations" and "Approach to the child with tachycardia" and "Arrhythmia management for the primary care clinician" and "Overview of the acute management of tachyarrhythmias" and "Premature ventricular complexes: Clinical presentation and diagnostic evaluation" and "Supraventricular premature beats".)

DEFINITION — 

Palpitations are a subjective symptom. They are defined as an unpleasant awareness of a forceful, rapid, or irregular beating of the heart. Patients may additionally describe the sensation as a rapid fluttering or a flip-flopping in the chest or a pounding sensation in the chest or neck. The patient's precise description of their sensations may help the clinician determine the cause of the palpitations [2].

ETIOLOGIES — 

The cause of palpitations can be determined in most patients. The most common causes of palpitations include cardiac disorders, medical conditions including endocrine and metabolic abnormalities, psychiatric disorders, medication effects, and drug or other substance use effects (table 1). As an example, in a study of 190 consecutive patients presenting with a chief complaint of palpitations, an etiology was determined in 84 percent [3]. Among all patients, the cause was classified as cardiac in 43 percent, psychiatric in 31 percent, miscellaneous (eg, medication induced, thyrotoxicosis, caffeine, cocaine, anemia, amphetamine, mastocytosis) in 10 percent, and unknown in the remaining 16 percent [3].

●Cardiac disorders – Cardiac disorders are a common cause of palpitations, and the incidence of arrhythmias is increased in those with underlying heart disease. Most patients with palpitations who undergo ambulatory monitoring are found to have supraventricular or ventricular ectopy or normal sinus rhythm [4-7]. Normal sinus rhythm is correlated with symptomatic palpitations in up to 30 percent of patients. However, the possibility of a more serious underlying cardiac etiology generates concern for many clinicians [7].

Other cardiac causes of palpitations include [8]:

•Arrhythmia – Cardiac arrhythmias include the development of a new arrhythmia or a significant change in the rate of a previously stable arrhythmia (such as atrial fibrillation). Cardiac arrhythmias may develop due to underlying structural heart disease (eg, cardiomyopathy, previous myocardial infarction) or an identifiable conduction system abnormality (eg, long QT syndrome, Wolff-Parkinson-White syndrome, complete heart block), or they may be idiopathic. (See 'Personal and family history of cardiac disease' below.)

Arrhythmias causing palpitations include tachyarrhythmias, bradyarrhythmias, and ectopic beats.

•Other causes – Less common cardiac causes include valvular heart disease (eg, mitral valve prolapse), pacemaker syndrome (ie, atrioventricular dyssynchrony due to single-chamber [ventricular] pacing), atrial myxoma, and high-output cardiac states. (See "Modes of cardiac pacing: Nomenclature and selection", section on 'Pacemaker syndrome' and "Clinical manifestations, diagnosis, and management of high-output heart failure", section on 'Clinical manifestations' and "Mitral valve prolapse: Clinical manifestations and diagnosis", section on 'MVP syndrome'.)

In one study of outpatients with palpitations, features that predicted a cardiac etiology included male sex, description of an irregular heartbeat, a personal history of heart disease, and event duration greater than five minutes [3].

●Psychiatric disorders – Palpitations are a clinical feature of several psychiatric disorders, including panic attacks, generalized anxiety disorder, and somatic symptom disorder [9,10]. Individuals with these disorders are commonly seen in primary care settings and often present with physical symptoms. (See 'Coexisting psychiatric disorders' below.)

●Other causes – Other important causes of palpitations are related to medication effects, drug or other substance effects, endocrine disorders, and metabolic abnormalities (table 1). (See 'Medications' below and 'Caffeine, nicotine, and other substance use' below and 'Coexisting medical conditions' below.)

INITIAL EVALUATION — 

We perform a focused medical history, physical examination, 12-lead electrocardiogram (ECG), and limited laboratory testing as the initial evaluation of palpitations. In most patients, this approach reveals an etiology of the palpitations or guides further evaluation with ambulatory cardiac rhythm monitoring or other testing [11,12].

Patients experiencing palpitations at time of evaluation — We initially assess all patients to determine if they are currently experiencing palpitations at the time of the evaluation. If so, we immediately obtain a 12-lead ECG and perform a focused physical examination with specific attention to the cardiovascular system:

●ECG shows arrhythmia – Individuals whose ECG confirms an arrhythmia require an assessment for hemodynamic stability and management of the specific arrhythmia and any underlying cause or complication (eg, hypotension or heart failure in a patient with atrial fibrillation [AF] with rapid ventricular response). (See "Arrhythmia management for the primary care clinician".)

●ECG or examination shows premature beats – In patients with no arrhythmia identified on the 12-lead ECG, we perform a cardiac examination. Some arrhythmias, particularly infrequent premature beats (eg, premature atrial complexes [PACs; also referred to as premature atrial beats, premature supraventricular complexes, or premature supraventricular beats] and premature ventricular complexes/contractions [PVCs; also referred to as premature ventricular beats or premature ventricular depolarizations]), are not captured due to the brief nature of the ECG but may be detected during several minutes of cardiac auscultation. (See "Supraventricular premature beats" and "Premature ventricular complexes: Clinical presentation and diagnostic evaluation".)

The diagnosis of PVCs or PACs is likely if the cardiac examination is consistent with premature contractions, the patient describes the palpitations as an occasional "skipped beat" followed by a pause, and the palpitations do not occur during exercise (or resolve with exercise) (see "Supraventricular premature beats", section on 'Physical examination' and "Premature ventricular complexes: Clinical presentation and diagnostic evaluation", section on 'Clinical presentation and ECG findings'). In these individuals, clinicians should evaluate the ECG for other abnormalities and elicit a medical history to assess the characteristics of the palpitations and evaluate for coexisting disease and other contributory factors. The evaluation and management of patients with PVCs and PACs are discussed separately. (See "Premature ventricular complexes: Clinical presentation and diagnostic evaluation" and "Supraventricular premature beats" and "Arrhythmia management for the primary care clinician".)

●ECG and examination do not confirm a diagnosis – For patients in whom the initial ECG or physical examination does not provide a diagnosis, we proceed with the evaluation described below.

Other patients

History — For patients who are not currently symptomatic, we elicit detailed characteristics of the palpitations and obtain a relevant clinical history that includes a personal and family history of heart disease, medications, alcohol and substance use, and a focused review of systems (eg, symptoms of hyperthyroidism or other endocrine disorders).

Palpitation characteristics — Several characteristics of the palpitations can provide diagnostic clues to their etiology:

●Age of onset – Although age does not appear to be an independent predictor of the presence or absence of a cardiac etiology of palpitations [3], the age at which palpitations begin may help to narrow the differential diagnosis of likely causative arrhythmias:

•Childhood onset – Patients with episodes of rapid palpitations since childhood are likely to have a supraventricular tachycardia (SVT), probably an atrioventricular reentrant tachycardia (AVRT) with an accessory pathway or an atrioventricular nodal reentrant tachycardia (AVNRT). (See "Narrow QRS complex tachycardias: Clinical manifestations, diagnosis, and evaluation" and "Atrioventricular reentrant tachycardia (AVRT) associated with an accessory pathway" and "Atrioventricular nodal reentrant tachycardia".)

•Older onset – Patients in whom palpitations begin at an older age are more likely to have paroxysmal SVT (PSVT), atrial tachycardia, AF, or atrial flutter. (See "Narrow QRS complex tachycardias: Clinical manifestations, diagnosis, and evaluation" and "Focal atrial tachycardia" and "Multifocal atrial tachycardia" and "Atrial fibrillation: Overview and management of new-onset atrial fibrillation" and "Atrial flutter: Overview of diagnosis and management".)

Older age of onset is also a risk factor for life-threatening ventricular arrhythmias, as these are more likely to occur in patients with structural heart disease. However, idiopathic ventricular tachycardia (VT) occasionally occurs in adolescence, and many cases of torsades de pointes due to congenital long QT syndrome occur before the age of 20. (See "Ventricular tachycardia in the absence of apparent structural heart disease" and "Congenital long QT syndrome: Epidemiology and clinical manifestations".)

●Duration of palpitations – Palpitations that last for an "instant" or are described as an occasional skipped beat are more likely to represent PVCs or PACs. Sustained palpitations that last for minutes (or longer) are more consistent with supraventricular or ventricular arrhythmias. (See "Supraventricular premature beats" and "Premature ventricular complexes: Clinical presentation and diagnostic evaluation".)

●Abruptness of onset and resolution – Palpitations that occur randomly and episodically and last for an instant are generally due to premature beats, while a gradual onset and resolution of palpitations suggests sinus tachycardia. Palpitations described as abrupt in onset and termination may be caused by an SVT or VT. Of note, we find the abruptness of resolution to be more useful information since many patients, even those with sinus tachycardia, do not appreciate the gradual onset of symptoms.

●Heart rate and rhythm regularity – Asking the patient to describe (or quantify, if possible) the rate and degree of regularity of the palpitations may help to identify their cause. It may be helpful for the patient to tap out the rhythm with the fingers. The clinician can also provide examples of rapid and regular rhythms, rapid and irregular rhythms, slow and regular rhythms, and slow and irregular rhythms. As an example, a heart rate of >160 bpm is unlikely to be due to sinus tachycardia.

Rapid and regular rhythms are suggestive of PSVT or VT. (See "Narrow QRS complex tachycardias: Clinical manifestations, diagnosis, and evaluation", section on 'Paroxysmal and incessant SVT' and "Nonsustained ventricular tachycardia: Clinical manifestations, evaluation, and management".)

Rapid and irregular rhythms suggest paroxysmal AF, atrial flutter, or atrial tachycardia with variable block. (See "Paroxysmal atrial fibrillation" and "Atrial flutter: Overview of diagnosis and management" and "Focal atrial tachycardia" and "Multifocal atrial tachycardia".)

●Additional sensations – Other descriptions of the person's subjective sensations can provide helpful information. As examples:

•Rapid fluttering – A feeling of rapid fluttering in the chest is typically seen in sustained ventricular or supraventricular arrhythmias, including sinus tachycardia. The regularity or irregularity of the palpitation may indicate the probable arrhythmic etiology; as examples, AF is irregular while sinus tachycardia and AVNRT are regular.

•"Flip-flopping" or heart "stopping" – A sensation of "flip-flopping" in the chest, the experience of a pounding, or very strong heartbeat followed by the heart briefly "stopping" may be caused by premature supraventricular or ventricular beats. The sensation that the heart has stopped results from the pause following the premature contraction, and the pounding or flipping sensation results from the forceful contraction following the pause. (See "Supraventricular premature beats" and "Premature ventricular complexes: Clinical presentation and diagnostic evaluation".)

•"Pounding" or "pulsations" in the neck – An irregular, pounding feeling in the neck may be experienced by patients with PVCs, complete heart block, pacemaker syndrome, or VT. It is caused by atrioventricular dissociation, with independent contraction of the atria and ventricles, resulting in occasional atrial contraction against a closed tricuspid and mitral valve. (See "Premature ventricular complexes: Clinical presentation and diagnostic evaluation" and "Acquired third-degree (complete) atrioventricular block", section on 'Clinical presentation' and "Modes of cardiac pacing: Nomenclature and selection", section on 'Pacemaker syndrome' and "Nonsustained ventricular tachycardia: Clinical manifestations, evaluation, and management", section on 'History'.)

A sense of rapid and regular neck pulsations is typical of reentrant supraventricular arrhythmias, particularly AVNRT (or AVNRT due to a preexcitation syndrome). AVNRT, the most common form of PSVT, is three times as common in women as in men [13]. In the typical form of AVNRT, the atria and ventricles are activated simultaneously at a rate of 160 to 180 beats per minute; as a result, the atria are always contracting against a closed or partially closed mitral and tricuspid valve. (See "Wolff-Parkinson-White syndrome: Anatomy, epidemiology, clinical manifestations, and diagnosis" and "Atrioventricular nodal reentrant tachycardia" and "Atrioventricular reentrant tachycardia (AVRT) associated with an accessory pathway".)

●Associated presyncope or syncope – Lightheadedness, presyncope, or syncope may accompany palpitations and should prompt a search for a hemodynamically significant and potentially serious arrhythmia, most importantly VT. (See "Nonsustained ventricular tachycardia: Clinical manifestations, evaluation, and management", section on 'History' and "Sustained monomorphic ventricular tachycardia: Clinical manifestations, diagnosis, and evaluation", section on 'History and associated symptoms'.)

Occasionally, syncope is associated with SVT, particularly upon initiation of the episode. This type of syncope is believed to result from acute vasodilation, rapid heart rate with low cardiac output, or both [14,15]. Other tachyarrhythmias including AF and atrial flutter may cause palpitations and presyncope. (See "Syncope in adults: Epidemiology, pathogenesis, and etiologies", section on 'Cardiac arrhythmias' and "Atrial flutter: Overview of diagnosis and management", section on 'Clinical presentation'.)

●Patient self-termination of palpitations – Patients may report successful attempts at self-termination of their palpitations with carotid sinus massage or other vagal maneuvers, such as the Valsalva maneuver. This mode of termination is suggestive of SVTs, particularly AVNRT or AVRT with a bypass tract. (See "Atrioventricular nodal reentrant tachycardia" and "Atrioventricular reentrant tachycardia (AVRT) associated with an accessory pathway".)

●Effect of positional changes – Some positional changes may precipitate arrhythmias, and in other cases, some positional changes may simply make palpitations more noticeable to the patient. As examples:

Among patients with AVNRT, the arrhythmia may be precipitated by standing up straight after bending over; the arrhythmia may then terminate when the patient becomes recumbent. (See "Atrioventricular nodal reentrant tachycardia".)

Patients may experience an intermittent heart pounding sensation while lying in bed, particularly while in the supine or left lateral decubitus position. This is commonly due to premature supraventricular or ventricular beats, which occur more frequently at slow heart rates. In addition, in the left lateral decubitus position, the apex of the heart is closer to the chest wall, which may account for the greater awareness of palpitations in this position. (See "Supraventricular premature beats" and "Premature ventricular complexes: Clinical presentation and diagnostic evaluation".)

●Association with exercise or emotional stress – A number of sustained SVTs and VTs may be provoked by sympathetic stimulation and catecholamine excess, as occurs during exercise or at times of stress. In studies involving exercise testing, nonsustained premature supraventricular and ventricular beats were more common than sustained arrhythmias. (See "Prognostic features of stress testing in patients with known or suspected coronary disease", section on 'Ventricular arrhythmias' and "Prognostic features of stress testing in patients with known or suspected coronary disease", section on 'Atrial arrhythmias'.)

On the other hand, idiopathic VT, especially when it arises from the right ventricular outflow tract, may occur during exercise in patients with structurally normal hearts; this arrhythmia most often presents during the second and third decades of life as palpitations, dizziness, or syncope [16]. (See "Ventricular tachycardia in the absence of apparent structural heart disease".)

SVTs, including AF, can be induced during exercise or at the termination of exercise when withdrawal of catecholamines is coupled with a surge in vagal tone [17]. AF occurring during this relative increase in vagal tone is particularly common in athletic men in the third to sixth decade of life [18]. (See "Paroxysmal atrial fibrillation", section on 'Autonomic nervous system'.)

Arrhythmias may also occur during emotionally startling experiences. As an example, patients with the long QT syndrome, especially congenital type 1 or 2 (an inherited abnormality of myocardial repolarization), characteristically present with palpitations during periods of vigorous exercise or emotional stress; polymorphic VT (known as torsades de pointes) is the classic arrhythmia seen [19]. (See "Congenital long QT syndrome: Epidemiology and clinical manifestations".)

Inappropriate sinus tachycardia is a rare disorder that manifests as palpitations during periods of minimal physical exertion or with emotional stress. This arrhythmia is characterized by an inappropriate increase in the sinus rate and is most frequently seen in young women; it may result from a hypersensitivity to beta-adrenergic stimulation. (See "Sinus tachycardia: Evaluation and management", section on 'Inappropriate sinus tachycardia'.)

Patient characteristics — In addition to collecting information regarding the details of the palpitations and any associated symptoms, the patient's personal and family history of heart disease, coexisting medical and psychiatric disease, medications, use of alcohol or other substances, and a focused review of symptoms may help narrow the diagnostic possibilities.

Personal and family history of cardiac disease — We inquire about a personal or family history of heart disease, including mitral valve prolapse (MVP), structural heart disease (including cardiomyopathy), myocardial infarction, and other cardiac disorders, including prolonged QT syndrome, Wolff-Parkinson-White syndrome, pacemaker device, or sudden cardiac death.

●MVP – Although most individuals with MVP are asymptomatic, virtually every type of supraventricular arrhythmia, as well as premature ventricular depolarizations and nonsustained VT, have been described in those with MVP. The subset of patients with MVP who have significant mitral regurgitation is at increased risk of developing AF. (See "Mitral valve prolapse: Overview of complications and their management" and "Mitral valve prolapse: Clinical manifestations and diagnosis", section on 'MVP syndrome'.)

●Structural heart disease – A personal or family history of structural heart disease (including cardiomyopathy or myocardial infarction) is associated with many arrhythmias and raises the level of concern for life-threatening ventricular arrhythmias. (See "Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy", section on 'Underlying structural myocardial disease' and "Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy", section on 'Myocardial ischemia' and "Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy", section on 'Mechanical factors' and "Hypertrophic cardiomyopathy: Clinical manifestations, diagnosis, and evaluation", section on 'Arrhythmias'.)

●Personal or family history of cardiac conduction system disease – We inquire about a personal or family history of cardiac conduction system disease, such as Wolff-Parkinson-White syndrome or congenital (genetic) prolonged QT syndrome. Wolff-Parkinson-White syndrome increases the likelihood of a variety of SVTs (which may degenerate into life-threatening ventricular fibrillation). Prolonged QT syndrome is associated with polymorphic VT (torsades de pointes). (See "Wolff-Parkinson-White syndrome: Anatomy, epidemiology, clinical manifestations, and diagnosis", section on 'Familial WPW' and "Wolff-Parkinson-White syndrome: Anatomy, epidemiology, clinical manifestations, and diagnosis", section on 'Arrhythmias associated with WPW' and "Congenital long QT syndrome: Epidemiology and clinical manifestations", section on 'Types of arrhythmias'.)

In patients with known AF and a "controlled" heart rate, palpitations may represent episodes of poorly controlled ventricular response due to increased atrioventricular nodal conduction in the setting of increased sympathetic stimulation. (See "Atrial fibrillation: Overview and management of new-onset atrial fibrillation".)

A family history of sudden cardiac death is not diagnostic of a familial arrhythmogenic cardiac disorder but does alert the clinician to the possibility that one may be present. (See "Approach to sudden cardiac arrest in the absence of apparent structural heart disease", section on 'Familial SCD' and "Cardiac evaluation of the survivor of sudden cardiac arrest", section on 'Evaluation of family members'.)

The presence of a pacemaker, particularly a device with single chamber (ventricular) pacing, raises the possibility of pacemaker syndrome (atrioventricular dyssynchrony). (See "Modes of cardiac pacing: Nomenclature and selection", section on 'Pacemaker syndrome'.)

Coexisting medical conditions — We evaluate patients for a history of or symptoms consistent with medical conditions that may be associated with palpitations (eg, high-output cardiac states, metabolic and endocrine causes, and chronic obstructive pulmonary disease [COPD]) (table 1).

●High-output cardiac state – Palpitations due to increased cardiac contractility and tachyarrhythmias (sinus tachycardia and others) may occur in conditions associated with a high-output cardiac state. These include fever, anemia, pregnancy, hyperthyroidism, Paget disease of bone, and vascular shunts (intra- or extracardiac). (See "Causes and pathophysiology of high-output heart failure", section on 'Causes and their mechanisms'.)

●Pregnancy related – In addition to palpitations related to the high-output state associated with pregnancy, peripartum cardiomyopathy may lead to arrhythmias, particularly AF and ventricular arrhythmias. (See "Supraventricular arrhythmias during pregnancy" and "Peripartum cardiomyopathy: Treatment and prognosis", section on 'Arrhythmia'.)

●Metabolic and endocrine causes – Several metabolic and endocrine disorders are associated with palpitations.

•Hypoglycemia – Hypoglycemia (related to diabetes treatment, insulinoma, or another cause) may cause palpitations in addition to other symptoms, including tremor, diaphoresis, weakness, confusion. The palpitations are typically due to sinus tachycardia secondary to catecholamine excess. (See "Hypoglycemia in adults without diabetes mellitus: Clinical manifestations, causes, and diagnosis", section on 'Symptoms' and "Hypoglycemia in adults with diabetes mellitus", section on 'Symptoms'.)

•Hyperthyroidism – Hyperthyroidism, characterized by sweating, unintentional weight loss, tremors, and heat intolerance, may cause palpitations due to sinus tachycardia or AF. (See "Overview of the clinical manifestations of hyperthyroidism in adults", section on 'Cardiovascular'.)

•Pheochromocytoma – Patients with pheochromocytoma may experience episodic palpitations in addition to sweating, tremor, headache and dyspnea, all symptoms of catecholamine excess. (See "Clinical presentation and diagnosis of pheochromocytoma", section on 'Symptoms and signs'.)

●COPD – Palpitations may occur in patients with COPD due to the relatively high frequency of arrhythmias that occur among these patients. Commonly seen arrhythmias include multifocal atrial tachycardia (MAT), AF, and ventricular arrhythmias; the prevalence of arrhythmias is likely related to the severity of lung disease. (See "Arrhythmias in COPD", section on 'Specific arrhythmias associated with COPD'.)

Coexisting psychiatric disorders — All patients should be evaluated for a coexisting psychiatric disorder that may be associated with palpitations, including generalized anxiety disorder, panic disorder, and somatic symptom disorder (table 1). Persons with anxiety or panic disorder often find it difficult to discern whether the feeling of anxiety or panic preceded or resulted from the palpitations. Palpitations associated with psychiatric conditions are not necessarily associated with an objective arrhythmia. However, psychiatric illness may coexist with a nonpsychiatric (cardiac or other) cause of palpitations [3,20,21]. (See "Panic disorder in adults: Epidemiology, clinical manifestations, and diagnosis" and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Somatic symptom disorder: Epidemiology, clinical features, and course of illness", section on 'Clinical features'.)

Medications — We obtain a history of all medications, including over-the-counter medications. In particular, palpitations due to SVTs occur with the use of sympathomimetic agents, vasodilators, anticholinergic drugs, or during withdrawal from beta blockers.

Caffeine, nicotine, and other substance use — We ask about consumption of caffeine, nicotine-containing products, and other drugs (eg, alcohol, cocaine, or amphetamines) and, if used, establish the temporal relationship between their use and the palpitations.

Typical caffeine consumption does not seem to increase the risk of arrhythmias, although excessive use in sensitive individuals may increase this risk. Cocaine may induce supraventricular and ventricular arrhythmias, and amphetamines may cause SVTs. Cigarette smoking or the use of nicotine replacement products such as nicotine lozenges may cause palpitations. Withdrawal from some drugs (eg, alcohol) can also cause palpitations. (See "Cardiovascular effects of caffeine and caffeinated beverages", section on 'Other arrhythmias' and "Clinical manifestations, diagnosis, and management of the cardiovascular complications of cocaine use", section on 'Arrhythmias and conduction abnormalities' and "Methamphetamine: Acute intoxication", section on 'Tachycardia' and "Pharmacotherapy for smoking cessation in adults", section on 'Nicotine replacement therapy' and "Epidemiology, risk factors, and prevention of atrial fibrillation" and "Epidemiology, risk factors, and prevention of atrial fibrillation", section on 'Alcohol'.)

Focused physical examination — Although the clinician rarely has the opportunity to examine a patient during an episode of palpitations, the physical examination is often useful in defining potential abnormalities that may provide an indication of their etiology. The following physical examination findings, when present, may provide useful clues to the etiology of the patient's palpitations.

We check temperature, blood pressure, pulse, oxygen saturation, and respiratory rate.

●Elevated temperature raises the possibility of infection, malignancy, and even intracardiac myxoma. An increased heart rate is a normal physiologic response in the setting of a fever.

●Elevated blood pressure and pulse may be consistent with pheochromocytoma, substance use, beta blocker withdrawal, or another condition associated with catecholamine excess. (See 'Coexisting medical conditions' above and 'Caffeine, nicotine, and other substance use' above and 'Medications' above.)

In addition to checking vital signs, we perform a careful cardiovascular examination, with attention to the following:

●A midsystolic click (and possibly a late systolic murmur), which is associated with MVP. (See 'Personal and family history of cardiac disease' above and "Mitral valve prolapse: Clinical manifestations and diagnosis".)

●A harsh holosystolic murmur heard along the left sternal border that increases with the Valsalva maneuver suggests hypertrophic obstructive cardiomyopathy. (See 'Personal and family history of cardiac disease' above.)

●A diastolic tumor "plop" may be heard with the classic left atrial myxoma. In addition, signs of systemic embolization may be evident. (See 'Personal and family history of cardiac disease' above and "Cardiac tumors".)

●Clinical evidence of a dilated cardiomyopathy and heart failure: Other than a diffuse and laterally displaced point of maximal impulse, well-compensated dilated cardiomyopathy may be difficult to discern on physical examination. Conversely, patients with dilated cardiomyopathy complicated by heart failure typically demonstrate evidence of volume overload (pulmonary congestion, peripheral edema, and elevated jugular venous pressure) and additionally may have an audible S3 gallop. (See 'Personal and family history of cardiac disease' above.)

●In patients with AF, a cardiac examination after ambulation can be very useful for evaluating palpitations. Although palpitations may not be present at rest when the ventricular response is slow, even minimal exertion may unmask a poorly controlled ventricular response. (See 'Personal and family history of cardiac disease' above.)

A pulmonary examination can provide important clinical information in a patient with palpitations:

●We assess for COPD (eg, prolonged expiratory phase of respiration, wheezing, lung hyperinflation, decreased breath sounds). (See "Chronic obstructive pulmonary disease: Diagnosis and staging", section on 'Physical examination' and 'Coexisting medical conditions' above.)

We also evaluate for signs of endocrine abnormalities, particularly hyperthyroidism:

●Signs of hyperthyroidism include sweating, fine tremor, exophthalmos, thyromegaly, and brisk deep tendon reflexes. (See 'Coexisting medical conditions' above and "Diagnosis of hyperthyroidism", section on 'Physical examination'.)

12-lead ECG — The initial evaluation of palpitations should include a 12-lead ECG for all patients.

If the ECG documents an arrhythmia, the arrhythmia should be managed as indicated. (See "Arrhythmia management for the primary care clinician".)

Although most patients are in sinus rhythm when the initial ECG is obtained, we examine the ECG for specific findings that may help to narrow the differential diagnosis [13]. These include the following:

●A short PR interval and delta waves (Wolff-Parkinson-White syndrome), consistent with ventricular preexcitation, suggest SVT (waveform 1).

●Marked left ventricular hypertrophy with deep septal Q waves in I, aVL, and V4 through V6 suggests hypertrophic obstructive cardiomyopathy. Left ventricular hypertrophy with evidence of left atrial abnormality (as indicated by a terminal P wave force in V1 more negative than 0.04 msec and notched in lead II) suggests a likely substrate for AF. (See "Hypertrophic cardiomyopathy: Clinical manifestations, diagnosis, and evaluation".)

●The presence of Q waves characteristic of a prior myocardial infarction suggests the possibility of nonsustained or sustained VT. (See "Pathogenesis and diagnosis of Q waves on the electrocardiogram" and "Ventricular arrhythmias during acute myocardial infarction: Incidence, mechanisms, and clinical features", section on 'Late arrhythmias'.)

●Isolated supraventricular and/or ventricular ectopy may occasionally be seen on the 12-lead ECG. The morphology of the PVCs, particularly in patients without heart disease, can indicate the risk of serious consequences (eg, development of life-threatening arrhythmias or cardiomyopathy). (See "Premature ventricular complexes: Treatment and prognosis", section on 'Premature ventricular complex characteristics'.)

●Prolongation of the QT interval and abnormal T wave morphology may suggest long QT syndrome (waveform 2). (See "Congenital long QT syndrome: Epidemiology and clinical manifestations".)

●Bradycardia of any etiology can be accompanied by premature ventricular depolarizations and associated palpitations. In particular, complete heart block can be associated with premature ventricular depolarizations or a prolonged QT interval and torsades de pointes.

Limited laboratory testing — There are no evidence-based guidelines to direct the laboratory workup of patients with palpitations. In most patients, we perform limited laboratory testing to rule out anemia and hyperthyroidism. If the history or examination suggests substance use or withdrawal, we perform toxicology testing.

ADDITIONAL TESTING IN SELECTED PATIENTS — 

We use the clinical history, along with the results of the physical examination, 12-lead ECG, and echocardiography (if appropriate) to determine the need for further evaluation, including ambulatory cardiac rhythm monitoring.

Concern for structural heart disease — We obtain an echocardiogram in persons whose history, physical examination, or ECG raises concern for structural heart disease. These include any of the following:

●A family history, symptoms, or ECG concerning for hypertrophic cardiomyopathy

●ECG with Q waves suggesting prior myocardial infarction, a left bundle branch block, or changes consistent with ventricular hypertrophy

●Murmur on physical examination that suggests valvular heart disease (eg, aortic stenosis or mitral regurgitation)

These conditions are discussed separately. (See "Hypertrophic cardiomyopathy: Clinical manifestations, diagnosis, and evaluation", section on 'Electrocardiography' and "Left bundle branch block", section on 'ECG findings and diagnosis' and "Left ventricular hypertrophy: Clinical findings and ECG diagnosis", section on 'Electrocardiographic findings: General'.)

Patients at low risk for concerning arrhythmias — Individuals at low risk of concerning arrhythmias include those whose palpitations are unsustained and well tolerated and who do not have evidence of heart disease by history, physical examination, or 12-lead ECG. In these patients, we generally do not obtain ambulatory rhythm monitoring. We counsel the patient regarding the low risk of a serious cardiac arrhythmia and the limited utility of further testing. However, if the patient remains very concerned about their symptoms despite counseling, we perform two weeks of event monitoring.

Regardless of whether ambulatory rhythm monitoring is performed, we educate the patient about concerning symptoms and ask them to alert us for any increase in the pattern or severity of their symptoms. (See 'Management' below.)

Patients at high risk for concerning arrhythmias — We obtain ambulatory cardiac rhythm monitoring for all persons whose initial diagnostic evaluation suggests a high risk for concerning arrhythmias, specifically, a disorder that is associated with the development of ventricular tachycardia [22]. This includes patients with any of the following:

●Palpitations that are sustained, poorly tolerated, or associated with syncope or presyncope

●Organic heart disease (eg, scar formation from myocardial infarction, dilated cardiomyopathy of any cause, clinically significant valvular heart disease, hypertrophic cardiomyopathy)

●A personal or family history of arrhythmia, syncope, sudden death, cardiomyopathy, or long QT syndrome

Patients with frequent symptoms and associated syncope often benefit from expedited evaluation in an inpatient setting.

Selection of ambulatory cardiac rhythm monitoring — Ambulatory ECG monitoring is the most important tool for diagnosing unexplained palpitations [11,23] (see "Ambulatory ECG monitoring"). Three methods exist for ambulatory cardiac rhythm monitoring: a 24- or 48-hour continuous Holter monitor, a two- to four-week continuous loop event recording, and an implantable continuous loop event recorder, which can be kept in place for up to two years.

●Continuous loop event recording – For most individuals with palpitations, we prefer two weeks of continuous loop event recording as the method of ambulatory monitoring. Continuous loop devices have a higher diagnostic yield than Holter monitors (66 to 83 percent versus 33 to 35 percent) and are likely more cost-effective [4,24,25].

Continuous loop event recorders continuously record data but typically save the data for the preceding and subsequent two minutes (or for other time periods as programmed), but only when the patient manually activates the monitor. These recording devices are capable of direct transmission of the ECG as an audio signal via the telephone [26]. Continuous loop recorders can be used for longer periods than Holter monitors; since most patients with palpitations do not have them daily, this method is more likely to record data during palpitations. Furthermore, with event recorders, symptoms can be directly correlated with the cardiac rhythm since the patient activates the monitor. (See "Ambulatory ECG monitoring", section on 'Event (loop) monitor'.)

●Holter monitoring – A Holter monitor can be useful in patients with frequent, daily palpitations, particularly if the patient is likely to have trouble activating the loop recorder. The Holter monitor is a 24- or 48-hour monitoring system that records and saves data continuously. The device is worn for one or two days while the patient keeps a diary recording the time and characteristics of symptoms.

Holter monitors are limited by the short duration of time available for monitoring. In addition, arrhythmias may be identified that are unrelated to the palpitations. This was illustrated in a study of over 1400 older adult patients aged 60 to 94 years, 8.3 percent of whom complained of palpitations [27]. Arrhythmias, predominantly conduction abnormalities and sinus bradycardia, were found in 12.6 percent. However, the prevalence of palpitations was similar in those with and without documented arrhythmias. In another study of 518 patients who underwent 24-hour ambulatory rhythm monitoring, 34 percent experienced typical palpitations, but the corresponding cardiac rhythm was normal [7]. (See "Ambulatory ECG monitoring" and "Ambulatory ECG monitoring", section on 'When to choose continuous ECG (Holter) monitoring'.)

●Implantable continuous loop monitoring (ICM) – An implantable event recorder can be used in selected patients with extremely infrequent but symptomatic palpitations (eg, typically those associated with presyncope or syncope).

The ICM is a subcutaneous monitoring device for the detection of cardiac arrhythmias [28]. The device is typically implanted in the left pectoral region and stores events when the device is activated automatically according to programmed criteria or manually with magnet application. The ICM is most often used for patients with unexplained syncope, but it may have a role for those in whom other methods have failed to document the cause of palpitations. (See "Ambulatory ECG monitoring", section on 'Insertable cardiac monitor'.)

Duration of monitoring — Regardless of the method, two weeks of event monitoring is sufficient to make a diagnosis in the vast majority of patients with palpitations and is less costly than the standard monitoring period of one month. As an example, in a retrospective analysis of 5000 patients who had undergone event recording with a continuous loop monitor, 87 percent had an initial transmission corresponding to palpitations in the first two weeks of monitoring [29]. An additional 9 percent of initial transmissions occurred by four weeks of monitoring. In a second report of 105 outpatients with palpitations referred for event monitoring, the diagnostic yield was 1.04 diagnoses per patient in week 1, 0.15 in week 2, and 0.01 diagnoses per patient in week 3 and beyond [5]. The cost-effectiveness ratio increased from USD $98 per new diagnosis in week one, to $576 and $5832 in weeks 2 and 3, respectively.

Referral for electrophysiologic testing — We reserve referral for an electrophysiologic study for patients whose ambulatory rhythm monitoring is unrevealing, especially those with sustained or poorly tolerated palpitations or a high pretest likelihood of a serious arrhythmia (eg, patients with structural heart disease) [30]. (See "Invasive diagnostic cardiac electrophysiology studies".)

MANAGEMENT — 

The management of patients with palpitations depends upon the suspected or identified cause.

●Documented arrhythmia – For patients with palpitations associated with a documented arrhythmia, the arrhythmia is managed as appropriate. (See "Arrhythmia management for the primary care clinician".)

●Initial evaluation suggests medical or medication-related cause – For patients in whom the initial evaluation suggests a likely medical or medication-related cause as the etiology of their palpitations, we proceed with an intervention as appropriate. As examples:

•If hypoglycemia is suspected as the cause, we ask patients to check a simultaneous capillary blood glucose at the time of palpitations. If hypoglycemia is documented and palpitations resolve with correction of hypoglycemia (in the absence of other risk factors for arrhythmias), we do not pursue further evaluation. (See "Hypoglycemia in adults with diabetes mellitus", section on 'Symptoms' and "Hypoglycemia in adults with diabetes mellitus", section on 'Strategies to manage hypoglycemia'.)

•If palpitations begin in temporal association with initiation of a medication known to cause palpitations (eg, methylphenidate, dextroamphetamine) or upon abrupt discontinuation of a beta blocker, we discontinue the new medication or resume the beta blocker if safe and appropriate to do so. If the palpitations resolve and the medication is the most likely cause of the palpitations, we typically do not pursue further evaluation. (See "Attention deficit hyperactivity disorder in adults: Treatment overview", section on 'Choosing a stimulant' and "Tapering and discontinuing antihypertensive medications", section on 'Withdrawal syndromes'.)

●Initial evaluation suggests psychiatric disorder – For individuals whose initial evaluation suggests a possible psychiatric disorder, we evaluate for anxiety disorders (eg, panic attack, panic disorder, or generalized anxiety disorder) or somatic symptom disorder. The evaluation for psychiatric disorders that commonly cause palpitations is discussed separately. (See "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Screening, assessment, and diagnosis' and "Panic disorder in adults: Epidemiology, clinical manifestations, and diagnosis", section on 'Assessment'.)

If the diagnosis of a psychiatric disorder is confirmed, we prioritize its treatment. For individuals with severe psychiatric symptoms or in whom diagnostic uncertainty exists, we refer to a behavioral medicine specialist. (See "Generalized anxiety disorder in adults: Management" and "Panic disorder in adults: Treatment overview".)

In addition, we advise these patients to monitor for any increase in frequency or severity of palpitations or the development of any associated symptoms. If these develop, we typically reassess the patient and pursue ambulatory cardiac rhythm monitoring.

●No identified cause after initial evaluation – For patients with palpitations that have no cause identified despite extensive evaluation, we offer reassurance and explore the role of a possible psychiatric disorder.

●Sinus rhythm on ambulatory rhythm monitoring – For patients whose palpitations are associated with a normal initial evaluation and documented sinus rhythm on ambulatory rhythm monitoring, we offer reassurance as to the benign nature of their symptoms. We ask them to monitor their palpitations for an increase in frequency, severity, or development of any associated symptoms as these may be indications for repeat or further evaluation.

SUMMARY AND RECOMMENDATIONS

●Definition – Palpitations are defined as an unpleasant awareness of the forceful, rapid, or irregular beating of the heart. Patients may additionally describe the sensation as a rapid fluttering or a flip-flopping in the chest, or a pounding sensation in the chest or neck; the precise description of the subjective sensations experienced by the patient may help the clinician determine the cause of the palpitations. (See 'Definition' above.)

●Etiologies – Common etiologies appear in the table (table 1). (See 'Etiologies' above.)

•Common cardiac causes include supraventricular or ventricular ectopy, the development of a new arrhythmia, or a significant change in the rate of a previously stable arrhythmia. Less common cardiac causes include valvular heart disease, pacemaker syndrome, atrial myxoma, and high-output cardiac states.

•Palpitations are also a clinical feature of several psychiatric disorders, including panic attacks, generalized anxiety disorder, and somatic symptom disorder.

•Other important causes of palpitations are related to medication effects, drug or other substance effects, endocrine disorders, and metabolic abnormalities.

●Approach to diagnosis – A focused medical history, physical examination, 12-lead ECG, and limited laboratory testing can determine the etiology of palpitations in most patients. (See 'Initial evaluation' above.)

•Patients symptomatic on presentation – In patients who are experiencing palpitations at the time of the evaluation, we immediately obtain a 12-lead ECG and perform a focused physical examination with specific attention to the cardiovascular system (see 'Patients experiencing palpitations at time of evaluation' above):

-Individuals whose ECG confirms an arrhythmia require an assessment for hemodynamic stability and management of the specific arrhythmia and any underlying cause or complication.

-If no arrhythmia is identified on the 12-lead ECG, a cardiac examination may detect arrhythmias, particularly infrequent premature ventricular complexes or premature atrial complexes, that are not captured due to the brief nature of the ECG but may be detected during several minutes of cardiac auscultation.

•Patients without symptoms on presentation – For patients who are not currently symptomatic, we elicit detailed characteristics of the palpitations and obtain a relevant clinical history that includes a personal and family history of heart disease, medications, alcohol and drug use, and a focused review of systems (eg, symptoms of hyperthyroidism or other endocrine disorders). (See 'History' above.)

•Focused physical examination – The physical examination may reveal abnormalities that suggest the etiology of the palpitations. We check temperature, blood pressure, pulse and respiratory rate, and perform a careful cardiovascular examination. A pulmonary examination can provide clues to the presence of chronic obstructive pulmonary disease. We also evaluate for signs of endocrine abnormalities. (See 'Focused physical examination' above.)

•ECG for all patients – All patients with palpitations require a 12-lead ECG as part of the initial evaluation. Although most patients are in sinus rhythm when the initial ECG is obtained, the ECG should be examined for findings suggestive of underlying structural heart disease or electrical system disturbance. (See '12-lead ECG' above.)

•Limited laboratory testing – There are no evidence-based guidelines to direct the laboratory workup of individuals with palpitations. In most patients, we perform limited laboratory testing to rule out anemia and hyperthyroidism and perform toxicology testing when substance use is suspected. (See 'Limited laboratory testing' above.)

•Echocardiography for some patients – We obtain an echocardiogram in patients whose history, physical examination, or ECG raise concern for structural heart disease. These include persons with a family history, symptoms, or ECG concerning for hypertrophic cardiomyopathy; who have a murmur on physical examination; or who have an ECG with Q waves suggesting prior myocardial infarction, a left bundle branch block, or changes consistent with ventricular hypertrophy. (See 'Concern for structural heart disease' above.)

●Need for ambulatory monitoring – We use the clinical history and results of the physical examination, the 12-lead ECG, and echocardiography (if appropriate) to determine the need for further evaluation, including ambulatory cardiac rhythm monitoring. (See 'Selection of ambulatory cardiac rhythm monitoring' above.)

•We obtain ambulatory cardiac rhythm monitoring for all patients whose initial diagnostic evaluation suggests the possibility of a disorder known to be associated with the development of ventricular tachycardia:

-Palpitations that are sustained, poorly tolerated, or associated with syncope or presyncope

-Organic heart disease (eg, scar formation from myocardial infarction, dilated cardiomyopathy of any cause, clinically significant valvular heart disease, hypertrophic cardiomyopathy)

-A personal or family history of arrhythmia, syncope, sudden death, cardiomyopathy, or long QT syndrome.

An inpatient evaluation may be more appropriate for those patients with frequent symptoms and associated syncope.

•For patients who are at low risk of concerning arrhythmias (eg, those whose palpitations are unsustained and well tolerated and who do not have evidence of heart disease by history, physical examination, or 12-lead ECG), we generally do not obtain ambulatory rhythm monitoring. If a patient is very concerned about their symptoms and requires reassurance, however, we will perform two weeks of event monitoring.

●Referral for electrophysiologic testing – When ambulatory rhythm monitoring is unrevealing, we refer patients for an electrophysiologic study if their palpitations are sustained or poorly tolerated or they have a high pretest likelihood of a serious arrhythmia (eg, patients with structural heart disease). (See 'Referral for electrophysiologic testing' above.)

●Management – Management of patients with palpitations depends upon the suspected or identified cause. (See 'Management' above.)

•For patients in whom the initial evaluation suggests a likely medical cause as the etiology of their palpitations, we proceed with treatment or intervention as appropriate.

•For patients with palpitations that have no cause identified, we assess for common psychiatric disorders that can cause palpitations, such as anxiety or panic disorder. If appropriate, the underlying psychiatric condition should be treated or the patient referred to a behavioral medicine provider for further evaluation and management.

•For those patients with palpitations that are associated with documented sinus rhythm on ambulatory rhythm monitoring and with an otherwise normal evaluation, we offer reassurance as to the benign nature of their symptoms and ask them to monitor their palpitations for an increase in frequency or severity or the development of new associated symptoms as these may be indications for further evaluation.