PALPITATIONS

Aetiology

Patients complain of an unusually erratic or fast pulse, slow or forceful heartbeat, and can
even complain of chest pains and shortness of breath. Initial evaluation should determine
the likely cause of the symptoms, and whether or not there is any underlying heart
disease.

Ready Reckoner

ANXIETY SINUS ATRIAL VENTRICULA SVT

TACHYCARDIA ECTOPICS R ECTOPICS

Sudden Possible No Possible Possible Yes

onset?

‘Heart Yes Yes NO No Yes

Racing?

‘Heart Possible NO Yes Yes No

misses a
beat’

Underlying No No No Possible Possible

heart
disease

Rate/rhythm No Yes Yes Yes Yes

abnormal
during
episode

Overview

Palpitations are a symptom that is presented fairly frequently to a Doctor. Sometimes the
symptoms are isolated, or they are found mixed in with other symptoms. Patients tend to
use the word ‘palpitation’ to describe a wide variety of sensations, so it is extremely
important to establish what they mean. Cardiac causes are rare; however, fear of a cardiac

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condition and the subsequent anxiety that manifests itself within the patient, often leads
to palpitations occurring.
It is essential that a clear medical history is taken, to ascertain the patient’s perception of
a ‘palpitation’. Anxiety will exacerbate symptoms, offer reassurance to resolve this
whenever possible!

Differential Diagnosis

COMMON OCCASIONAL RARE

Anxiety (Increased Thyrotoxicosis Heart Block (especially with

awareness of heartbeat)
Sinus tachycardia (e.g.
stress, fever, exercise)
Atrial ectopics
Ventricular ectopics
Supraventricular
tachycardia (SVT)
(combination of sinus changes in block)
tachycardia and increased
awareness)
Menopause (due to sudden Sick sinus syndrome
vasodilatation)
Atrial fibrillation(various Drug abuse
causes e.g. mitral valve
disease, alcohol)
Iatrogenic ( e.g. digoxin, Ventricular tachycardia (VT)
nifedipine)
Atrial flutter

Possible Investigations

 ECG: May show arrhythmia itself or evidence of ischaemic heart disease or Wolf-
Parkinson-White syndrome. (Very Rapid heart beat ≥160 bpm)
 Thyroid Function Test (TFT): Thyrotoxicosis can cause palpations or exacerbate
other causes.
 Urea & Electrolytes (U&E): Electrolyte disturbance can precipitate or aggravate
some arrhythmias.
 24 hour ECG: ECG evidence of arrhythmia.
 Further investigation of underlying cause. E.g. Cardiac stress test,
electrocardiography for valve disease.

RED FLAGS

Multiple or multifocal, ventricular ectopics, suggest significant ischaemic heart disease,

and may herald ventricular fibrillation if they follow a Myocardial Infarction.

Remember that Digoxin can aggravate as well as resolve arrythmias.