Differentiating Cardiac from Gastrointestinal Causes of Palpitations

Critical Red Flags Indicating Cardiac Origin

The European Society of Cardiology recommends immediate cardiac evaluation if syncope or presyncope accompanies palpitations, as this may indicate a cardiac origin 1, 2, 3
The American Heart Association suggests that chest pain or dyspnea during episodes of palpitations may indicate a cardiac origin, and recommends further evaluation 1, 2
Palpitations occurring during exercise may indicate a cardiac origin, and should be evaluated further 2
A family history of sudden cardiac death or inheritable heart disease may indicate a cardiac origin, and should be considered in the evaluation of palpitations 1
Sudden onset and sudden termination of palpitations may suggest reentrant tachycardia, and should be evaluated further 1, 2, 3

The European Heart Journal notes that cardiac palpitations typically have a sudden onset/offset pattern, rather than gradual, and may occur with syncope, chest pain, or exertion 1, 2, 3
Cardiac palpitations may have a regular or irregular rhythm that is independent of meals or position, and may be terminated with vagal maneuvers 3
Approximately 15% of supraventricular tachycardia (SVT) cases are associated with polyuria, which may be a distinguishing feature of cardiac palpitations 3
Cardiac palpitations may occur in the supine position or while sitting, not just upright 1

The American Gastroenterological Association notes that GI-related palpitations may be associated with reflux symptoms, bloating, or flatulence, and may improve with treatment of underlying GI pathology 4
Gradual onset rather than paroxysmal may suggest a GI-related etiology, rather than cardiac 3

The American College of Cardiology recommends obtaining a 12-lead ECG immediately to identify rhythm, look for pre-excitation, and assess QT interval 2, 3
Documenting vital signs, including orthostatic measurements, is crucial in the evaluation of palpitations 5, 4
A focused physical examination should be performed to look for irregular cannon A waves and variable S1 intensity, which may suggest ventricular origin 3

The European Society of Cardiology recommends documenting the frequency and duration of episodes, mode of onset, triggers, response to vagal maneuvers, and associated symptoms to characterize the pattern of palpitations 2, 3

The American Heart Association recommends referring patients with documented SVT to cardiac electrophysiology, especially in young patients with normal structural hearts 3
Beta-blocker therapy may be prescribed empirically after excluding bradycardia <50 bpm, and catheter ablation has a high success rate for reentrant tachycardias 3

The American Gastroenterological Association recommends treating underlying GI pathology, such as hiatal hernia repair or aggressive reflux management, to resolve GI-related palpitations 2
Dietary modifications to reduce gastric distension may also be beneficial in managing GI-related palpitations 2