Palpitations Diagnosis and Management

Definition and Characteristics

Palpitations are defined as an unpleasant awareness of abnormal or irregular heartbeats, which may be described as pauses followed by strong beats or irregularities in heart rhythm, according to the American College of Cardiology 1
Patients may describe palpitations as regular or irregular, with sudden onset and termination (paroxysmal) or gradual onset and offset (non-paroxysmal), as noted by the American College of Cardiology and Circulation 2, 1

Premature ventricular contractions (PVCs) can be benign or pathological depending on frequency and underlying heart condition, as reported by Circulation and the American College of Cardiology 3, 4
Atrioventricular nodal reentrant tachycardia (AVNRT) is characterized by sudden onset/offset, according to Circulation and the American College of Cardiology 2, 1
Atrial fibrillation (AF) typically causes irregular palpitations, as noted by the American College of Cardiology 1
Multifocal atrial tachycardia (MAT) is commonly associated with pulmonary disease, as reported by Circulation and the American College of Cardiology 2, 1
Ventricular tachycardia (VT) is more concerning, especially in patients with structural heart disease, according to Circulation and the American College of Cardiology 3, 4

Automaticity is enhanced or abnormal pacemaker activity in cardiac cells, as reported by Circulation 2
Triggered activity is disturbances in repolarization causing afterdepolarizations, according to Circulation and the American College of Cardiology 2, 1
Re-entry is the most common arrhythmia mechanism, as noted by Circulation and the American College of Cardiology 2, 1

Palpitations accompanied by syncope or pre-syncope (dizziness) are a warning sign, as reported by the American College of Cardiology 1
Palpitations with chest pain are a warning sign, according to the American College of Cardiology 1
Palpitations during exercise are a warning sign, as noted by the American College of Cardiology 4

Very frequent PVCs (>10,000-20,000/day) can lead to PVC-induced cardiomyopathy, which is reversible with control of the PVCs, as reported by Circulation and the American College of Cardiology 3, 4
Palpitations with sudden onset and termination are more likely to be due to reentrant tachycardias like AVNRT or AVRT, according to Circulation and the American College of Cardiology 2, 1
Termination of palpitations with vagal maneuvers suggests involvement of AV nodal tissue, as noted by the American College of Cardiology 1