Palpitations Evaluation and Management

Introduction to Palpitations

The American Heart Association recommends that sharp, sudden awareness of heartbeats occurring 10 times per hour be evaluated to exclude underlying structural heart disease, arrhythmias, or reversible triggers 1, 2

Premature ventricular contractions (PVCs) and premature atrial contractions (PACs) are the most frequent cause of intermittent palpitations, described as "skipped" or extra beats followed by a strong heartbeat, according to the American College of Cardiology 1, 2, 3
PVCs can occur in patterns of bigeminy or trigeminy, creating regular patterns of premature beats, as noted by the American College of Cardiology 1, 5

Nonsustained ventricular tachycardia can present as brief episodes of rapid, regular palpitations, as reported by the American Heart Association 1, 2
Ventricular arrhythmias may be triggered by exercise or emotional stress, particularly in patients with underlying structural heart disease, according to the American College of Cardiology 1, 5

Paroxysmal supraventricular tachycardia (PSVT) presents with sudden onset and termination of regular, rapid palpitations, as described by the American Heart Association 4, 7
Atrial fibrillation causes irregular palpitations and occurs frequently, though typically at higher rates than 10 episodes per hour, as noted by the American College of Cardiology 7

Ischemic heart disease is a critical cause of ventricular arrhythmias and must be excluded, according to the American Heart Association 1, 5, 2
Mitral valve prolapse is commonly associated with palpitations and can trigger ventricular arrhythmias, as reported by the American College of Cardiology 1, 5

QT-prolonging medications can cause torsades de pointes and ventricular arrhythmias, as warned by the American Heart Association 1, 5, 3
Stimulants, including cocaine, amphetamines, and over-the-counter supplements, can provoke arrhythmias, according to the American College of Cardiology 5
Electrolyte abnormalities, particularly potassium, magnesium, and calcium, are critical reversible causes, as noted by the American Heart Association 1, 5, 3

A 12-lead ECG is mandatory to assess for structural abnormalities, pre-excitation, QT interval, and baseline rhythm, as recommended by the American College of Cardiology 1, 5, 4, 7
Complete medication history, including over-the-counter medications, supplements, and illicit drugs, is essential, according to the American Heart Association 1, 5
Physical examination focused on detecting structural heart disease is crucial, as noted by the American College of Cardiology 1, 5

Syncope or near-syncope associated with palpitations suggests hemodynamically significant arrhythmia, as warned by the American Heart Association 1, 2, 4, 6
Chest pain or dyspnea during palpitations may indicate myocardial ischemia or heart failure, according to the American College of Cardiology 1, 2, 3
Family history of sudden cardiac death in first-degree relatives is a critical red flag, as noted by the American Heart Association 1, 5, 2