Palpitations

Defined as sensation of heart pounding or fluttering, oftentimes rapidly but not necessarily

………………..Diagnostic Work-Up

History

Palpitations only last seconds:  Extra Heart Beats, never serious, very common
Lasting minutes or more:  Anxiety; Arrhythmias (usually not serious)

Sense of about to faint (or actual faint)  →   Arrhythmias (quite possibly serious)

Only at night, in bed  →   Surely Anxiety

Start, & esp. Stop, abruptly  →   Arrhythmia (not serious)

Irregular heart rhythm  →   Arrhythmia (serious or non-serious)

Heart Rate >160 (if able to count pulse)  →  Arrhythmia (serious or not serious)

Occurs with Exercise  →   If completely new, may be an Arrhythmia
            Hearts normally beat fast with exercise, but shouldn’t be a new occurrence
Goes Away with Exercise  →   Anxiety most likely

Certain maneuvers make palpitations with very rapid heart rate go away  →  Arrhythmia (not serious)

Family History of unexplained sudden death, or Wolff-Parkinson-White disease  →  could be those same diseases

Exam in Clinic

Only useful if symptoms present at time of exam

Electrocardiogram (EKG)

If Symptoms Present at time of test  →  EKG will make diagnosis if cause is cardiac

No Symptoms present  →  EKG may have clues to likely diagnosis if cardiac cause

Blood Tests:  Rarely useful

• TSH for Hyperthyroidism
• CBC for Anemia
• Only test for Pheochromocytoma if severe Hypertension
• Suspect Hypoglycemia if patient on insulin or certain meds for Diabetes

Ambulatory EKG (portable; brief showers OK)

• Done for 1-2 days, or 2-4 weeks (or ongoing — see below)
• Finds heart Arrhythmias (or not) at moment of symptoms

………………..Diagnostic Work-Up

Palpitations only last seconds  →   Extra Heart Beats

• This is Normal.  No tests or treatment. No worry

Blood Tests are Positive  →   Diagnose those conditions (see above)

Arrhythmia found  →   See link for the different types

• If palpitations occurred during time of Arrhythmia, that’s the Diagnosis
• If no palpitations during time of arrhythmia:
  • Anxiety likely cause of symptoms (unless serious type of Arrythmia)

No Arrhythmia with up to 2-4 week Ambulatory EKG:

• If palpitations occurred during monitoring  →   Anxiety is likely cause
• If no palpitations occurred during monitoring, we consider an ongoing monitor (implanted under the skin).  Usually only for patients who:
  • Faint (with or without palpitations); or
  • Feel like they’re about to Faint; or
  • Palpitations infrequent but disabling (e.g. with shortness of breath / chest pain).

………………..About Anxiety

If palpitations do occur during Ambulatory EKG monitoring, but there are no arrhythmias found at that time, then the cause is like Anxiety.  This can be ongoing chronic anxiety, or merely temporary stressors that act subconsciously.  Oftentimes nothing is actually identified, and the palpitations go away with time.