Palpitations

Abstract

Palpitations are a symptom characterized by awareness of an abnormal heartbeat, often described as a sensation of unpleasant rapid pulsations in the chest area or skipped beats. Mitral valve prolapse is the leading structural heart disease responsible for palpitations, affecting 1–3% of the population. Common valvular causes of palpitations include mitral valve prolapse, mechanical prosthetic valves, and severe mitral or aortic regurgitation. Hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and atrial myxomas should be considered as structural defects predisposing patients to arrhythmias and potential sudden cardiac death. The first step in evaluating a patient with palpitations includes a detailed history, physical examination, 12-lead ECG, and basic labs to rule out systemic etiologies (such as hyperthyroidism and anemia). If the physical exam or history is suggestive of underlying structural heart disease, a transthoracic echocardiogram is also warranted. If the patient is having symptoms triggered by exertion, an exercise stress test should also be considered. Frequent, unexplained palpitations warrant a 24–72 hour Holter monitor as part of an in-depth workup. Infrequent palpitations are better investigated with a longer event monitor. Management of palpitations is based on the underlying etiology of palpitations, how symptomatic the patient is, and the presence or absence of structural heart disease.