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Last updated date: 09-Feb-2023

Originally Written in English

Palpitations Definition, Treatment, Causes & Symptoms

    Palpitations are characterized as fast pulsations or unusually quick or irregular heartbeats. They are frequently characterized as a skipped beat, fast fluttering in the chest, or a flip-flopping sensation in the chest. Palpitations are a frequent, nonspecific symptom that can be either a symptom or a diagnosis. While the cause of palpitations is typically harmless, there are several underlying life-threatening diseases that can induce palpitations. 

    Palpitations were noted by around 16% of individuals who saw their primary care physician. Palpitations are asymptomatic and can be either a symptom or a diagnosis. While palpitations are usually harmless, they might be a symptom of a life-threatening illness.

    The heart normally beats 60 to 100 times per minute. People who exercise often or use heart-slowing medications may experience a reduction in heart rate below 60 beats per minute.

    Tachycardia occurs when your heart rate is too rapid (more than 100 beats per minute). A heart rate slower than 60 beats per minute is referred to as bradycardia. Extrasystole is the term used to describe an occasional additional heartbeat that is out of rhythm.

    Most of the time, palpitations are not serious. Symptoms of an abnormal cardiac rhythm (arrhythmia) may be more dangerous.

     

    Etiology

    The brain mechanisms involved for the sense of the heartbeat are not well understood at the moment. It has been proposed that these routes contain several components situated both intracardiac and extracardiac. Palpitations are a common symptom, especially in patients with structural heart disease.

    Palpitations have a large list of etiologies, and in certain situations, the etiology cannot be established. In one research, 43 percent of palpitations were found to have a cardiac etiology, 31 percent to have a mental etiology, and roughly 10 percent to have a heterogeneous etiology (medication induced, thyrotoxicosis, caffeine, cocaine, anemia, amphetamine, mastocytosis).

    The most dangerous causes of palpitations are cardiac in nature and include ventricular sources (premature ventricular contractions, ventricular tachycardia, and ventricular fibrillation), atrial sources (atrial fibrillation, atrial flutter), high output states (anemia, AV fistula, Paget's disease, or pregnancy), structural abnormalities (congenital heart disease cardiomegaly, aortic aneurysm, or acute left ventricular failure), and (postural orthostatic tachycardia syndrome POTS, Brugada syndrome, and sinus tachycardia).

    Palpitations can occur when there is an excess of catecholamines, such as during exercise or stress. Palpitations during these circumstances are frequently caused by a prolonged supraventricular tachycardia or ventricular tachyarrhythmia.

    Supraventricular tachycardias can also be generated towards the end of exercise when catecholamine withdrawal is combined with a rise in vagal tone. Palpitations caused by catecholamine excess can also occur after emotionally upsetting situations, particularly in individuals with a long QT syndrome.

    Palpitations can be caused by a variety of mental disorders, including depression, generalized anxiety disorder, panic attacks, and somatization. According to one study, up to 67 percent of patients diagnosed with a mental health problem exhibited arrythmia. 

    Palpitations can be caused by a variety of metabolic disorders, including hyperthyroidism, hypoglycemia, hypocalcemia, hyperkalemia, hypokalemia, hypermagnesemia, hypomagnesemia, and pheochromocytoma.

    Palpitations are most commonly caused by sympathomimetic medicines, anticholinergic drugs, vasodilators, and withdrawal from beta blockers. Excess caffeine or marijuana use are other common etiologies. Cocaine, amphetamines, Ectasy or MDMA, and other illegal drugs can induce palpitations.

     

    Epidemiology

    Palpitations are a common problem in the general population, and especially in individuals suffering from structural heart disease. Extrasystolic, tachycardic, anxiety-related, and severe clinical presentations are classified. The most common is anxiety-related.

     

    Pathophysiology

    Palpitations can be caused by extrasystoles or tachyarrhythmias. It is extremely seldom observed as a result of bradycardia. There are several ways to explain palpitations. The most typical descriptions are chest flip-flopping, fast fluttering, and neck hammering. The symptoms' description may offer information on the etiology of the palpitations, and the pathophysiology of each of these descriptions is regarded to be distinct.

    Extra systoles, such as supraventricular or ventricular premature contractions, are considered to induce palpitations in patients who report them as a short flip-flopping in the chest. The flip-flop sensation is considered to be caused by the strong contraction that follows the pause, while the sense that the heart has stopped is thought to be caused by the pause. A persistent ventricular or supraventricular arrhythmia is considered to cause the impression of fast fluttering in the chest.

    Furthermore, the abrupt termination of this arrythmia may be indicative of paroxysmal supraventricular tachycardia. This is strengthened if the patient can halt the palpitations using Valsalva procedures. The rhythm of the palpitations may reveal the cause of the palpitations (irregularly irregular palpitations indicate atrial fibrillation as a source of the palpitations).

    Atrioventricular dissociation can create an irregular hammering feeling in the neck, and the following atria contract against closed tricuspid and mitral valves, creating cannon A waves. Exercise-induced palpitations may be indicative of cardiomyopathy, ischemia, or channelopathies.

     

    Signs and symptoms

    A comprehensive and detailed history, as well as a physical examination, are two critical components in evaluating a patient with palpitations. A detailed history should include the following elements: age of onset, description of symptoms including rhythm, situations that commonly result in symptoms, mode of onset (rapid or gradual), duration of symptoms, factors that relieve symptoms (rest, Valsalva), positions, and other associated symptoms such as chest pain, lightheadedness, or syncope.

     

    If a patient is not currently experiencing the symptoms, they can tap out the rhythm to assist demonstrate.

    All drugs, including over-the-counter pharmaceuticals, should be discussed with the patient. It is also necessary to identify one's social history, which includes exercise routines, coffee intake, alcohol and illegal drug usage. In addition, previous medical history and family history may give clues to the origin of the palpitations.

    Palpitations that have been present from childhood are most likely the result of supraventricular tachycardia, but palpitations that appear later in life are more likely to be the result of structural heart disease. A quick regular rhythm is more likely to be caused by paroxysmal supraventricular or ventricular tachycardia, whereas a rapid and irregular rhythm is more likely to be caused by atrial fibrillation, atrial flutter, or tachycardia with varying block.

    Palpitations with an abrupt beginning and abrupt cessation are considered to be caused by supraventricular and ventricular tachycardia. Patients who can stop their palpitations using a Valsalva technique are considered to have supraventricular tachycardia.

    Palpitations accompanied with chest discomfort may indicate myocardial ischemia. Finally, ventricular tachycardia, supraventricular tachycardia, or other arrhythmias should be evaluated if the palpitations are accompanied by lightheadedness or syncope.

    Unfortunately, when a health care practitioner checks a patient, he or she seldom notices palpitations. A thorough physical examination should be conducted, including vital signs (including orthostatic vital signs), heart auscultation, lung auscultation, and extremity examination. If a patient is not currently experiencing the symptoms, they can tap out the beat to assist show what they felt before.

    Positive orthostatic vital signs might suggest dehydration or an electrolyte imbalance. Mitral valve prolapse may be indicated by a midsystolic click and murmur. A loud holosystolic murmur that rises with Valsalva and is best heard near the left sternal border may suggest hypertrophic obstructive cardiomyopathy.

    The atrial septal defect is distinguished clinically by a fixed splitting of the S2 throughout the cardiac cycle and a right ventricular heave. Atrial fibrillation or atrial flutter is indicated by an abnormal beat. Cardiomegaly and peripheral edema may be signs of heart failure, ischemia, or a valvular defect.

    Palpitations, which are feelings of a fast or irregular heartbeat, are most commonly produced by cardiac arrhythmias or anxiety. The majority of people with arrhythmias do not experience palpitations. Palpitations can be caused by any arrhythmia, including sinus tachycardia, atrial fibrillation, premature ventricular contractions, or ventricular tachycardia.

     

    Diagnosis

    Every patient who complains of palpitations should get a 12-lead ECG. The presence of ventricular pre-excitation is indicated by a short PR interval and a delta wave (Wolff-Parkinson-White syndrome). Significant left ventricular hypertrophy accompanied by deep septal Q waves in I, L, and V4–V6 may suggest hypertrophic obstructive cardiomyopathy. The existence of Q waves may suggest the presence of a previous myocardial infarction as the cause of the palpitations, and a prolonged QT interval may indicate the presence of the long QT syndrome.

    Initially, laboratory investigations should be kept to a minimum. Anemia and infection can be detected with a complete blood count. Serum urea, creatinine, and electrolytes are measured to check for electrolyte abnormalities and renal failure. Thyroid function testing may reveal hyperthyroidism.

    The majority of patients' palpitations are caused by benign diseases. The objective of additional testing is to identify people who are at high risk of developing an arrhythmia. Anemia, hyperthyroidism, and electrolyte disorders are all recommended laboratory tests. Echocardiograms are recommended for individuals who have structural heart disease.

    Additional diagnostic testing is advised for three types of patients. Those whose first diagnostic evaluation (history, physical examination, and EKG) indicate an arrhythmia, those who are at high risk for an arrhythmia, and those who are still anxious to have a precise explanation for their symptoms.

    Patients with organic heart disease or any cardiac abnormalities that may develop to severe arrhythmias are regarded to be at high risk for an arrhythmia. Scars from myocardial infarction, idiopathic dilated cardiomyopathy, clinically significant valvular regurgitant or stenotic lesions, and hypertrophic cardiomyopathies are examples of these diseases.

    For high-risk individuals, an aggressive diagnostic strategy is advised, which may involve ambulatory monitoring or electrophysiologic tests. Ambulatory EKG monitoring devices are classified into three types: Holter monitors, continuous-loop event recorders, and implanted loop recorders.

    The Holter monitor is a 24-hour monitoring system that the patient wears and captures and stores data continually. Holter monitors are worn for a short period of time. The patient also wears continuous-loop event recorders, which continually capture data, but the data is stored only when the patient voluntarily activates the monitor.

    Because continuous-loop recorders may be worn for longer periods of time than Holter monitors, they have been shown to be more cost-effective and efficacious. Furthermore, because the patient activates the device when they experience symptoms, they are more likely to collect data during palpitations.

    An implanted loop recorder is a subcutaneous device that constantly monitors for cardiac arrhythmias. These are most commonly utilized in individuals who have unexplained syncope and may be used for longer periods of time than continuous loop event recorders. An implantable loop recorder is a device that is subcutaneously implanted and constantly monitors for cardiac arrhythmias. 

    These are utilized for longer lengths of time than continuous loop event recorders and are most commonly employed in individuals with unexplained syncope. Electrophysiology testing allows for a thorough examination of the underlying mechanism of the cardiac arrhythmia as well as its location of origin. 

     

    Palpitations in Athletes

    Palpitations in athletes

    The prevalence of palpitations in an athletic population ranges from 0.3 percent to as high as 70%, depending on age and activity type. Palpitations, or an awareness of an elevated or irregular heart rate, are uncommon in school-age athletes but far more prevalent in older endurance athletes.

    The vast majority are thought to be benign, with prognosis based on the type of particular rhythm abnormality and the presence or absence of underlying cardiac disease. Atrial fibrillation can account for up to 9% of rhythm abnormalities in top athletes and up to 40% in individuals who have had symptoms for a long time. Athletes with a high burden of premature ventricular beats (PVCs) are more likely to have underlying heart disease.

    The monitoring device selected is critical in obtaining an accurate diagnosis of the specific rhythm problem. Simple Holter monitoring is sufficient to obtain a diagnosis for symptoms that occur during a 24-hour period. However, if symptoms occur seldom, physicians must use one of the various monitoring devices offered.

    Most significantly, the equipment should be chosen based on the gadget that is most likely to detect the rhythm disruption. Echocardiography, stress testing, endomyocardial biopsies, genetic testing, electrophysiologic testing, or cardiac magnetic resonance imaging may also be recommended. The majority of palpitations in athletes are discovered during a screening check or by a complaint from the athlete.

    The third and most recent pre-participation assessment monograph suggests asking the athlete if he or she has palpitations when exercising. The assumption has been made that palpitations in athletes at rest are harmless, however this idea has yet to be confirmed prospectively in a large cohort of the athletic population.

    Specific arrhythmias may frequently be corrected by radiofrequency ablation, allowing for a return to sports as long as there is no substantial high risk underlying heart disease present. Athletes with known malignant ventricular rhythm disturbances, or an underlying substrate for such, who have had an automatic implanted cardioverter-defibrillator implanted are not recommended to return to sport because there is no data on the safety and efficacy of defibrillators in this clinical setting, and certain athletic activities may result in device damage.

     

    Heart palpitations after eating

    Some people have palpitations after consuming large amounts of carbs, sugar, or fat. Eating meals high in monosodium glutamate (MSG), nitrates, or sodium might also trigger them. Food sensitivity may be the cause of heart palpitations after eating specific meals.

     

    Heart palpitations pregnancy

    Increased blood volume during pregnancy is one such unnoticed alteration, but it can result in a higher resting heart rate since the heart needs to work more to pump the additional blood. This additional strain on the heart can occasionally result in heart palpitations during pregnancy.

     

    Management

    If you have unexplained palpitations, start with the simple things first:

    • Don't smoke.
    • Reduce your alcohol consumption or abstain entirely.
    • Make sure you eat on a regular basis (low blood sugar can cause heart palpitations).
    • Consume lots of fluids.
    • Get adequate rest.
    • Check with your doctor or pharmacist to ensure that none of your drugs or supplements are causing palpitations. Decongestants containing pseudoephedrine or phenylephrine, for example, might cause palpitations.

     

    The underlying source of the symptoms determines how palpitations are managed. Most kinds of supraventricular and many types of ventricular tachycardias can be treated with radiofrequency ablation.

    Palpitations caused by supraventricular or premature ventricular contractions (PVCs) or coupled with normal sinus rhythm are the most difficult instances to treat.

    These disorders are believed to be harmless, and treatment consists of assuring the patient that the arrhythmias are not life-threatening. PVC-induced cardiomyopathy and progressive left ventricular failure affect up to one-third of individuals who have frequent PVCs.

    B-blockers or calcium channel blockers are first-line treatments for symptomatic or frequent PVCs. Patients who are resistant to medicinal treatment or develop left ventricular failure should have their PVCs catheterized. Catheter ablation cures PVC-induced cardiomyopathy in the majority of patients.

     

    Asymptomatic patients with unremarkable physical examinations, non-diagnostic EKGs, and normal laboratory tests who report to the emergency department can be safely discharged home and told to follow up with their primary care provider or cardiologist.

    Palpitations in patients with syncope, uncontrolled arrhythmias, hemodynamic compromise, or angina should be hospitalized for further assessment. PVCs are widespread and, in most cases, harmless.

     

    When you should seek emergency medical treatment?

    Medical treatment

    If you have heart palpitations and a documented heart issue, get medical care immediately once. Seek medical care if your palpitations are accompanied by additional symptoms such as:

    • dizziness
    • weakness
    • lightheadedness
    • fainting
    • loss of consciousness
    • confusion
    • difficulty breathing
    • excessive sweating
    • pain, pressure, or tightening in your chest
    • pain in your arms, neck, chest, jaw, or upper back
    • a resting pulse rate of more than 100 beats per minute
    • shortness of breath

     

    Differential Diagnosis

    • Arrhythmias
    • Atrial fibrillation/flutter
    • Bradycardia caused by advanced atriovenous block or sinus node dysfunction
    • Bradycardia-tachycardia syndrome
    • Multifocal atrial tachycardia
    • Premature supraventricular or ventricular contractions
    • Sinus tachycardia or arrhythmia
    • Supraventricular tachycardia
    • Ventricular tachycardia
    • Wolff-Parkinson-white syndrome

     

    Heart palpitations anxiety

    Anxiety symptoms include anxiousness and tension, as well as perspiration and an upset stomach. An unusually fast heart rate, commonly known as heart palpitations, is another typical sign of worry. Heart palpitations can make your heart feel like it's racing, beating, or fluttering.

     

    Heart palpitations after vaccine

    People who have received the vaccine should seek immediate medical treatment if they have the following symptoms of myocarditis and pericarditis after vaccination: (acute and persistent) chest discomfort, palpitations, or shortness of breath.

     

    Complications

    Many episodes of heart palpitations are not dangerous. However, if they are the result of an underlying cardiac disease, they might lead to significant consequences. Among these complications are:

    • Fainting as a result of a racing heart, in which blood pressure concurrently decreases to a very low-level stroke, which can result in neurological damage
    • Supraventricular tachycardia, in which a rapid heart rate typically begins and ends abruptly atrial fibrillation, which can indicate ischemic stroke or underlying heart disease ventricular tachycardia (VT), in which the heart rate exceeds 100 beats per minute and is out of sync with the atria (upper heart chambers) ventricular fibrillation, which can occur if VT is left untreated and is fatal
    • Heart palpitations are a sign of heart failure and may precede cardiac arrest.

     

    Conclusion  

    Palpitations can be a frightening sign for the patient. The majority of patients' palpitations have a benign cause. As a result, extensive workups are not advised. However, adequate follow-up with the primary care physician can allow you to track your symptoms over time and determine if you need to see a cardiologist.

    Patients who are confirmed to be at high risk for serious or life-threatening etiologies of palpitations require a more thorough workup and intensive care. The degree of evidence for evaluation procedures is dependent on expert consensus.

    However, if a cause is identified, the intensity of therapy recommendations is fairly strong, with moderate to high quality treatments evaluated. Partnership with the patient through a shared decision-making approach and the involvement of an interprofessional team consisting of a nurse, nurse practitioner, physician assistant, and physician can help best direct therapy and offer appropriate follow-up.

    While catheter ablation is presently the most frequent treatment method, advancements in stereotactic radioablation for specific arrhythmias have been made. This method is frequently employed in the treatment of solid tumors and has been utilized successfully in the management of difficult to treat Ventricular Tachycardia and Atrial Fibrillation.

    Direct-to-consumer alternatives for measuring heart rate and heart rate variability have become increasingly common, thanks to the proliferation of smart phones and smart watches.

    These monitoring devices are becoming more verified and may aid in the early detection of people at risk of severe arrhythmias such as atrial fibrillation.