Copyright 2005 Gale Group, Inc.
ASAP
Copyright 2005 American Academy of Family Physicians
American Family Physician

February 15, 2005

SECTION: No. 4, Vol. 71; Pg. 743 ; ISSN: 0002-838X

IAC-ACC-NO: 129353014

LENGTH: 4098 words

HEADLINE: Diagnostic approach to palpitations.

BYLINE: Abbott, Allan V.

AUTHOR-ABSTRACT:
Palpitations--sensations of a rapid or irregular heartbeat--are most often
caused by cardiac arrhythmias or anxiety. Most patients with arrhythmias do not
complain of palpitations. However, any arrhythmia, including sinus tachycardia,
atrial fibrillation, premature ventricular contractions, or ventricular
tachycardia, can cause palpitations. Palpitations should be considered as
potentially more serious if they are associated with dizziness, near-syncope, or
syncope. Nonarrhythmic cardiac problems, such as mitral valve prolapse,
pericarditis, and congestive heart failure, and noncardiac problems, such as
hyperthyroidism, vasovagal syncope, and hypoglycemia, can cause palpitations.
Palpitations also can result from stimulant drugs, and over-the-counter and
prescription medications. No cause for the palpitations can be found in up to 16
percent of patients. Ambulatory electrocardiographic (ECG) monitoring usually is
indicated if the etiology of palpitations cannot be determined from the patient
's history, physical examination, and resting ECG. When palpitations occur
unpredictably or do not occur daily, an initial two-week course of continuous
closed-loop event recording is indicated. Holter monitoring for 24 to 48 hours
may be appropriate in patients with daily palpitations. Trans-telephonic event
monitors are more effective and cost-effective than Holter monitors for most
patients.

BODY:

    An increased or abnormal awareness of the heartbeat, palpitations are a
common symptom in patients presenting to family physicians. Palpitations can be
symptomatic of life-threatening cardiac arrhythmias. (1) However, most
palpitations are benign. In one retrospective study (2) in a family practice
setting, there was no difference in the rates of morbidity or mortality among
patients with palpitations compared with matched control subjects.

    Although there are many possible cardiac etiologies, palpitations can be
associated with noncardiac causes such as fever, anemia, or drug use, and can
occur in anxious but otherwise normal persons. The differential diagnoses of
palpitations are summarized in Table 1.

    Consensus or evidence-based guidelines for diagnosing and managing
palpitations have not been developed. However, recent studies of palpitation
etiology provide improved evidence that can guide a family physician through
diagnosis. In a prospective cohort study (1) of 190 patients at a university
medical center who complained of palpitations and were followed for one year, an
etiology was determined in 84 percent of the patients.

    Of these patients, 43 percent had palpitations caused by cardiac causes (40
percent had an arrhythmia, 3 percent had other cardiac causes), 31 percent had
palpitations caused by anxiety or panic disorder, 6 percent had palpitations
caused by street drugs or prescription and over-the-counter medications, and 4
percent had palpitations caused by other noncardiac causes. No specific cause of
the palpitations could be identified in 16 percent of the patients. Psychiatric
and emotional illnesses such as anxiety, panic, and somatization disorders may
be underlying problems in many patients. (1)

    Although arrhythmias frequently cause palpitations, most patients with
arrhythmias do not actually notice their arrhythmia and are unlikely to report
having palpitations. (3)

    This article describes the more common presentations of palpitations and a
rational approach to patient evaluation, and provides evidence for making
decisions about ambulatory monitoring.

    Etiology of Palpitations

    CARDIAC ARRHYTHMIAS

    Palpitations can result from many arrhythmias, including any bradycardia and
tachycardia, premature ventricular and atrial contractions, sick sinus syndrome,
advanced arteriovenous block, or ventricular tachycardia. Episodes of
ventricular tachycardia and supraventricular tachycardia may be perceived as
palpitations but also can be asymptomatic or lead to syncope. Palpitations
associated with dizziness, near-syncope, or syncope suggest tachyarrhythmia and
are potentially more serious.

    Some patients notice "pounding" or "jumping" palpitations when they are
quietly sitting or lying down. This symptom may result from premature
contractions, especially premature ventricular contractions. Orthostatic
intolerance or inadequate cerebral perfusion on upright posture may result in
palpitations, tachycardia, altered mentation, headache, nausea, pre-syncope,
and, occasionally, syncope. Orthostatic intolerance is most common in women of
childbearing age. (4)

    ANXIETY OR PANIC DISORDER

    The prevalence of panic disorder in patients with palpitations is 15 to 31
percent. (1,5,6) Panic disorder is diagnosed on the basis of information in the
patient's history and is characterized by recurrent unexpected panic attacks.
Panic disorder is more likely to be diagnosed in women of childbearing age
because these patients somatize more frequently, present to emergency
departments more often, and have increased hypochondriacal concerns about their
health. (7) Palpitations are most persistent in persons who have many minor
daily irritants and are highly sensitive to bodily sensations. (8)

    A screening questionnaire (Figure 1) (9) to help identify patients whose
palpitations are more likely to result from panic disorder was validated among
patients referred for Holter monitoring. A score of more than 21 points on the
questionnaire is 81 percent sensitive and 80 percent specific for panic
disorder. To explain it another way, if, overall, 25 percent of patients have
panic disorder as the cause of their palpitations, then 57 percent with more
than 21 points have panic disorder compared with only 7 percent of those with 21
or fewer points. (9)

    A simpler screening tool for panic disorder, consisting of a single
question, also has been developed. The question is, "Have you experienced brief
periods, for seconds or minutes, of an overwhelming panic or terror that was
accompanied by racing heartbeats, shortness of breath, or dizziness?" (10) The
physician must remember that panic disorder and significant arrhythmias are not
mutually exclusive, and that cardiac evaluation still may be necessary in
patients with suspected panic disorder. In addition, some patients or physicians
may find it difficult to determine whether the feeling of anxiety or panic
started before or after the palpitations. Therefore, true arrhythmic causes must
be ruled out before the diagnosis of anxiety or panic disorder can be accepted
as the cause of the palpitations. (1,11,12)

    Some physicians may prematurely blame palpitations on anxiety. In one study
(13) of patients with supraventricular tachycardia, two thirds of the patients
were diagnosed with panic, stress, or anxiety disorder, and one half of the
patients had an unrecognized arrhythmia on the initial evaluation; this was
particularly true among young women.

    Catecholamines increase at times of intense emotional experience, with
intense exercise, and in conditions such as pheochromocytoma. Ventricular
tachycardias or supraventricular tachycardias can be triggered by this
catecholamine increase. An increase of vagal tone after exercise occasionally
can lead to episodes of atrial fibrillation. (14) Thus, even in cases where
panic disorder is suggested, electrocardiography (ECG) or ambulatory ECG
monitoring is important.

    NONARRHYTHMIC CARDIAC CAUSES

    Conditions in this category include valvular diseases such as aortic
insufficiency or stenosis, atrial or ventricular septal defect, congestive heart
failure, cardiomyopathy, and congenital heart disease. These conditions can
predispose the patient to arrhythmia and to palpitations. Pericarditis, a rare
cause of palpitations, can cause chest pain that may change with position.

    EXTRACARDIAC CAUSES

    The physician should examine the patient for extracardiac causes. The
patient may have obvious associated illness with fever, dehydration,
hypoglycemia, anemia, or evidence of thyrotoxicosis. Use of drugs such as
cocaine, and alcohol, caffeine, and tobacco can precipitate palpitations. The
use of ephedra and ephedrine also has been associated with palpitations. (15)
Many prescription medications, including digitalis, phenothiazine, theophylline,
and beta agonists, can cause palpitations.

    Initial Clinical Evaluation

    HISTORY AND PHYSICAL EXAMINATION

    The cause of palpitations often can be determined through a careful history
and physical examination. Patients may describe palpitations in a variety of
ways, such as a fluttering, pounding, or uncomfortable sensation in the chest or
neck, or simply an increased awareness of the heartbeat. Because the patient's
description is often vague, knowing the circumstances, precipitating factors,
and associated symptoms may be helpful for the physician in diagnosis. For
example, a patient who describes single "skipped" beats is likely to be having
benign premature ventricular contractions. The physician should consider the
differential diagnoses of palpitations (Table 1) while questioning the patient.
Certain clinical findings and possible associated conditions are listed in Table
2.

    Because physicians usually do not get the chance to examine the patient
during an episode of palpitations, the physical examination primarily serves to
determine if there are cardiac or other abnormalities present that might
predispose the patient to palpitations. Careful examination of the heart may
reveal murmurs, extra sounds, or cardiac enlargement. Mitral valve prolapse,
which is commonly associated with palpitations, is suggested by a midsystolic
click. (16) The physician should look for evidence of hyperthyroidism (e.g.,
nervousness, heat intolerance), drug use, or other serious illnesses. Finally,
in the occasional patient who has palpitations with exercise, examination of the
patient after he or she exercises may reveal an arrhythmia or murmur that is
exacerbated by the resulting increased heart rate and cardiac output.

    ECG EVALUATION

    A 12-lead ECG evaluation is appropriate in all patients who complain of
palpitations. In the event that the patient is experiencing palpitations at the
time of the ECG, the physician may be able to confirm the diagnosis of
arrhythmia. Many ECG findings warrant further cardiac investigation. These
findings include evidence of previous myocardial infarction, left or right
ventricular hypertrophy, atrial enlargement, atrial ventricular block, short PR
interval and delta waves (Wolff-Parkinson-White syndrome), or prolonged QT
interval. Occasionally, the finding of an isolated premature ventricular
contraction or premature atrial contraction warrants further monitoring or
exercise testing. Some common arrhythmias associated with palpitations are shown
in Figures 2 through 5.

    [FIGURES 2-5 OMITTED]

    Further Diagnostic Testing

    In patients at low risk for coronary heart disease who have no
palpitation-associated symptoms such as dizziness, and who have negative
physical examination and ECG findings, palpitations may need no further
evaluation unless the episodes persist or the patient remains anxious for an
explanation. Blood tests may be appropriate in the following conditions:
complete blood cell count for suspected anemia or infection, electrolytes for
arrhythmia from suspected electrolyte imbalance, and thyroid-stimulating hormone
for suspected hyperthyroidism or hypothyroidism.

    ECG exercise testing is appropriate in patients who have palpitations with
physical exertion and patients with suspected coronary artery disease or
myocardial ischemia. Findings from the physical examination or ECG may suggest
the need for echocardiography to evaluate structural abnormalities and
ventricular function.

    High-risk patients, who require ECG monitoring, include those with organic
heart disease or any heart abnormality that could predispose the patient to
arrhythmias. Patients with a family history of arrhythmia, syncope, or sudden
death also may be at higher risk. The results of one study (17) of 24-hour ECG
monitoring showed that ventricular tachycardia was associated with previous
myocardial infarction, idiopathic dilated cardiomyopathy, significant valvular
lesions, and hypertrophic cardiomyopathies.

    If the etiology of palpitations is not apparent after the history, physical
examination, and ECG are completed, the physician should consider ambulatory
cardiac monitoring. Figure 6 is an algorithm that can be used in the evaluation
of patients with palpitations.

    [FIGURE 6 OMITTED]

    CONTINUOUS ECG MONITORS

    The Holter monitor is a simple ECG monitoring device that is worn
continuously to record data for 24 or 48 hours. The patient must keep a diary of
any symptoms that occur during the monitoring. (17) Holter monitors typically
are the most expensive of the monitoring devices, and are maintained and
operated by hospitals or larger outpatient clinics.

    TRANSTELEPHONIC EVENT MONITORS

    Transtelephonic event monitors transmit recordings by telephone to a central
station. As with Holter monitors, patients wear continuous-loop event monitors,
but unlike Holter monitors, these save data only for the previous and subsequent
few minutes when the patient manually activates the monitor. These monitors are
smaller than a Holter monitor (i.e., the size of a beeper) and may miss
arrhythmias that are asymptomatic, or that occur during sleep or with syncope.
Another type of transtelephonic monitor is not worn continuously but is carried
by the patient and held to the chest when palpitations are perceived. This
monitor records ECG data for about two minutes and is likely to miss the onset
of arrhythmia.

    Choosing an Ambulatory Monitoring Device

    The results of a review (18) of studies comparing Holter monitors and
transtelephonic event monitors in the diagnosis of palpitations found that the
diagnostic yield was 66 to 83 percent when event monitors were used for
monitoring, and 33 to 35 percent when Holter monitors were used. Furthermore,
event monitors have been found to be significantly more cost effective than
Holter monitors. (19,20) The results of retrospective and prospective trials
(19,20) showed that 83 to 87 percent of patients had diagnostic transmissions
within the first two weeks of using a transtelephonic event monitor.

    Evidence supports the use of an initial two-week course of continuous
closed-loop event recording to monitor for palpitations. Holter monitoring for
24 hours is an alternative to event monitoring in patients who reliably
experience palpitations every day, or who are not willing to wear an event
monitor for two weeks, and if event monitoring is not available locally. When
palpitations are sustained or poorly tolerated, a referral to a cardiologist for
an electrophysiologic evaluation may be warranted. (21)

    Management

    In patients with arrhythmias, the most common finding on ambulatory
monitoring is benign atrial or ventricular ectopic beats associated with normal
sinus rhythm. (20-22) Normal sinus rhythm alone is found in about one third of
patients. Many patients with palpitations have ventricular premature
contractions or brief episodes of ventricular tachycardia; if the evaluation of
the heart is otherwise normal, these findings are not associated with increased
mortality. (23) Appropriate patient education is indicated in these patients.
The treatment of sustained arrhythmias involves pharmacologic or invasive
electrophysiologic management and is beyond the scope of this article.

    If the patient is diagnosed with a non-cardiac, psychiatric, or
nonarrhythmia cardiac etiology, the underlying condition is managed according to
the diagnosis. In some patients, a thorough history, physical examination,
diagnostic testing, and cardiac monitoring all fail to reveal any abnormality or
etiology for palpitations. These patients should be advised to abstain from
caffeine and alcohol, as well as foods or stressful situations that appear to
trigger palpitations. Fortunately, the majority of patients with palpitations
have benign diagnoses and can be treated with reassurance.

   STRENGTH OF RECOMMENDATIONS



   Key clinical recommendation                      Label     References



   Most patients with palpitations are diagnosed

     with an arrhythmia or panic disorder.          C         1

   The identification of panic disorder in

     patients with palpitations can be

     assisted with the use of screening

     questionnaires.                                C         9

   Unless palpitations occur daily, event

     monitors are more cost effective

     than 24-hour or 48-hour Holter

     monitors in the diagnosis of

     intermittent

     arrhythmias.                                   B         19

   Patients with palpitations caused by

     premature ventricular contractions,

     who have a normal heart evaluation,

     have no increased mortality.                   B         23



   A = consistent, good-quality patient-oriented evidence;

   B = inconsistent or limited-quality patient-oriented evidence;

   C = consensus, disease-oriented evidence, usual practice,

   opinion, or case series. See page 639 for more  information.



   TABLE 1



   Differential Diagnosis of Palpitations



   Arrhythmias



   Atrial fibrillation/flutter

   Bradycardia caused by advanced arteriovenous

     block or sinus node dysfunction

   Bradycardia-tachycardia syndrome

     (sick sinus syndrome)

   Multifocal atrial tachycardia

   Premature supraventricular

     or ventricular contractions

   Sinus tachycardia or arrhythmia

   Supraventricular tachycardia

   Ventricular tachycardia

   Wolff-Parkinson-White syndrome



   Psychiatric causes



   Anxiety disorder

   Panic attacks



   Drugs and medications



   Alcohol

   Caffeine

   Certain prescription and over-the-counter

     agents (e.g., digitalis, phenothiazine,

     theophylline, beta agonists)

   Street drugs (e.g., cocaine)

   Tobacco



   Nonarrhythmic cardiac causes



   Atrial or ventricular septal defect

   Cardiomyopathy

   Congenital heart disease

   Congestive heart failure

   Mitral valve prolapse

   Pacemaker-mediated tachycardia

   Pericarditis

   Valvular disease (e.g., aortic insufficiency,

     stenosis)



   Extracardiac causes



   Anemia

   Electrolyte imbalance

   Fever

   Hyperthyroidism

   Hypoglycemia

   Hypovolemia

   Pheochromocytoma

   Pulmonary disease

   Vasovagal syndrome



   NOTE: The categories of palpitations are arrang ed from

   most common to least common; within the categor ies,

   conditions are listed in alphabetical order.



   TABLE 2



   Key Clinical Findings with Palpitations

   and Suggested Diagnoses



   Finding                         Suggested diagn osis



   Single "skipped" beats          Benign ectopy

   Feeling of being unable to      Ventricular pre mature contractions

     catch one's breath

   Single pounding sensations      Ventricular pre mature contractions

   Rapid, regular pounding in      Supraventricula r arrhythmias

     neck

   Palpitations that are worse     Benign ectopy o r atrial fibrillation

     at night

   Palpitations associated with    Psychiatric eti ology or

     emotional distress              catecholamine-sensitive arrhythmia

   Palpitations associated with    Coronary heart  disease

     activity

   General anxiety                 Panic attacks

   Medication or recreational      Drug-induced palpitations

     drug use

   Rapid palpitations with         Supraventricula r arrhythmia, atrial

     exercise                        fibrillation

   Positional palpitations         Atrioventricula r nodal tachycardia,

                                     pericarditis

   Heat intolerance, tremor,       Hyperthyroidism

     thyromegaly

   Palpitations since              Supraventricula r tachycardia

     childhood

   Rapid, irregular rhythm         Atrial fibrilla tion, tachycardia with

                                     variable bloc k

   Palpitations terminated by      Supraventricula r tachycardia

     vagal maneuvers

   Heart murmur                    Heart valve dis ease

   Midsystolic click               Mitral valve pr olapse

   Friction rub                    Pericarditis



   NOTE: The information in this table is based on  clinical

   experience and not on the results of clinical t rials.

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    * Patient information: A handout on heart palpitations, written by the
author of this article, is provided on page 755.

    ALLAN V. ABBOTT, M.D., is professor of clinical family medicine at the Keck
School of Medicine of the University of Southern California, Los Angeles, where
he is associate dean for curriculum and continuing medical education. Dr. Abbott
received his medical degree from Indiana University School of Medicine and
completed a residency in family medicine at UCLA San Bernardino Medical Center,
Calif.

    Address correspondence to Allan V. Abbott, M.D., 1975 Zonal Ave., KAM 317,
Los Angeles, CA 90033 (e-mail: [email protected]). Reprints are not available from
the author.

    The author indicates that he does not have any conflicts of interest.
Sources of funding: none reported.

    Figures 2 through 5 used with permission from Allan V. Abbott, M.D.

    This article is one in a series on problem-oriented diagnosis coordinated by
the Department of Family Medicine at the University of Southern California, Los
Angeles, Calif.