Palpitations

What is the definition of palpitations?

Palpitations are defined as an abnormal increased awareness of the heartbeat. Patients may describe palpitations as a more forceful heartbeat, a rapid heartbeat, an irregular heartbeat or a combination of these abnormalities. The duration of palpitations may also vary from a few seconds to many hours.

What are the causes of palpitations?

There are a range of different causes of palpitations. Broadly speaking, palpitations may arise as a consequence of an abnormality of the heart rhythm (arrhythmia) or an increased awareness of the normal heart rhythm (known as sinus rhythm).

Causes of palpitations

Heart rhythm abnormalities:

Psychological causes:

  • Anxiety
  • Panic attacks

Medications or stimulants:

  • Alcohol
  • Caffeine
  • Medications and drugs

Other causes:

  • Anaemia
  • Fever
  • Hormone imbalances e.g. overactive thyroid

Amongst patients with palpitations due to heart rhythm abnormalities (arrhythmia), the pattern of palpitations may point to the underlying cause of the arrhythmia. For instance, patients with ectopic beats may experience a sensation of ‘skipped’ beats or individual forceful beats that occur intermittently. Patients with atrial fibrillation may experience a continuous fast and irregular heart rhythm. Patients with supraventricular tachycardia or atrial flutter may experience rapid regular palpitations. It is important to note however that patterns of palpitations are often non-specific and the diagnosis cannot be made based on the pattern of symptoms alone.

How can the cause of palpitations be diagnosed?

Your physician will take a detailed history with particular emphasis on the pattern of the palpitations, the frequency of symptoms and any triggers of your palpitation. Symptoms associated with palpitations (including breathing difficulties and fainting) and a previous diagnosis of heart disease may also provide important clues as to the diagnosis.

Potential investigations are outlined below. It is important to note that not all the investigations listed below are necessary in every patient. The diagnostic tests will be selected based a patients specific symptom profile and frequency of palpitations.

Electrocardiogram

A simple electrocardiographic (ECG) heart tracing is recommended in all patients with palpitations. The cause of the palpitations may be confirmed on the ECG. However, if the patient is not experiencing palpitations at the point in time when the ECG is performed, the diagnosis may not be possible with an ECG alone. The ECG only provides a snapshot of the heart rhythm over a few seconds.

Ambulatory ECG monitoring

More advanced tests to monitor the heart rhythm over a prolonged period of time (typically one day to one week) are may be performed to capture the heart rhythm abnormality in patients who have less frequent palpitations. Examples of such tests include Holter monitors and event recorders.

Ambulatory ECG monitoring involves wearing an ECG monitoring device which can record the ECG either continuously over a period of time (typically 24 hours) or intermittently when the patient manually activates the device (when symptoms occur) or when the device automatically records an abnormal heart rhythm.

ECG exercise stress testing

Amongst patients who experience palpitations during physical exercise, an exercise treadmill test (test involving ECG heart rhythm monitoring while a patient exercises on a treadmill) may be recommended. The exercise test may allow the physician to capture the heart rhythm by reproducing the circumstances that cause palpitations.

Heart imaging

In addition to trying to capturing the heart rhythm abnormality on a heart tracing (ECG or ambulatory monitoring), additional diagnostic tests may be necessary to determine the heart structure and function taking images of the heart. Heart imaging is commonly performed using an echocardiogram (ultrasound scan of the heart). In certain circumstances, more advanced imaging with an MRI scan of the heart or imaging scans to look at the heart arteries may be necessary.

Electrophysiology study

In certain specific circumstances, a specialised test, referred to as an electrophysiological study, maybe necessary to reach a diagnosis. Electrophysiological studies are minimally invasive procedures designed to map the electrical pathways of the heart in detail (discussed in more detail in the section on catheter ablation procedures. Electrophysiology studies are more commonly performed as part of a procedure aimed at curing the heart rhythm abnormality.

What are the treatment options in patients with palpitations?

Treatment may range from simply providing reassurance, to treatment with medications or performing a procedure with the aim of curing the heart rhythm abnormality. The treatment strategy depends on the cause of palpitations. In a patient who has palpitations due to heart rhythm abnormalities (arrhythmia), the treatment options are discussed in more detail under the relevant sections on atrial fibrillation, atrial flutter, supraventricular tachycardia, and ectopic beats.

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