Palpitation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]Cafer Zorkun, M.D., Ph.D. [3]

Palpitations are a nonspecific symptom that are often defined as a rapid disagreeable sensation/pulsation that may be momentary or sustained and regular or irregular.Patient often present with a flip flopping,fluttering,pounding or thud like sensation in one particular area or all over the precordium. It may or may not be associated with symptoms such as chest pain, dyspnea, presyncope, syncope or haemodynamic compromise. A detailed history, physical examination and 12 lead ECG constitute the initial evaluation necessary. Based on this, a decision regarding investigative modalities such as ambulatory ECG monitoring, laboratory investigations, echocardiography and electrophysiology study may be made. Treatment is directed at treating the underlying cause.

There is limited information about the historical perspective of palpitations.

Palpitations may be classified based on cause, duration, rhythm and clinical presentation.

Palpitations are a nonspecific symptom that are often defined as a rapid disagreeable sensation/pulsation that may be momentary or sustained and regular or irregular. It is one thing to understand the pathophysiology of palpitations as a symptom and another to understand the pathophysiology of conditions that cause palpitations. Palpitations are hypothesized to be due to neural–afferent sensory pathways located at both cardiac and extracardiac levels.It may be caused due to abnormal adjustments in the rate, rhythm and contractility of the heart.

There are a vast number of causes of palpitations, including namely any condition that causes the heart to be rapidly, forcefully, or irregularly. In general, palpitations may be caused by primary abnormalities in the heart (tachycardia or forceful heart beating), reductions in oxygen carrying capacity (anemia), reductions in the volume of blood circulating (dehydration), sympathetic nervous system stimulation (fever, exertion, panic attacks, drugs), excess hormone production (hyperthyroidism). Pharmacological causes should also be taken into consideration.

When coming up with a differential diagnoses, it would be useful to link positive history,physical examination and ECG findings to cardiac (arrhythmia Related), cardiac (not related to arrhythmia), systemic causes (Non Cardiac), pharmacological causes and psychiatric causes.

Scarce data is available regarding the epidemiology of palpitations.

Common risk factors in the development of palpitations include a past history of cardiac disease, atherosclerotic risk factors, caffeine intake, substance abuse and a family history of sudden cardiac death or psychiatric disease.

There is insufficient evidence to recommend routine screening for palpitations.

Patient often present with a flip flopping,fluttering,pounding or thud like sensation in one particular area or all over the precordium. It may or may not be associated with symptoms such as chest pain, dyspnea, presyncope, syncope or haemodynamic compromise. Complications include impairment of quality of life, hypotension, ventricular fibrillation and sudden cardiac death. Prognosis depends on the underlying cause but is generally good.

There is no single diagnostic study of choice for palpitations.

Many times, the person experiencing palpitations may not be aware of anything apart from the abnormal heart rhythm itself. But palpitations can be associated with other things such as tightness in the chest, shortness of breath, dizziness or lightheadedness. Depending on the type of rhythm problem, these symptoms may be just momentary or more prolonged. Actual blackouts or near blackouts, associated with palpitations, should be taken seriously because they often indicate the presence of important underlying heart disease. There are certain key questions that need to be asked while taking a patient’s history.

Palpitations are typically a transient symptoms. Patients may or may not be in physical distress and may even present with altered mental status secondary to substance abuse. During a physical examination one must look for signs and symptoms of hyperthyroidism, hypothyroidism, congestive heart failure, rhythm disturbances and structural heart disease.

Laboratory investigations are often performed when a systemic/pharmacological cause of palpitations is suspected. These would be directed towards diagnosing kidney problems, pheochromocytoma, thyroid dysfunction and substance abuse.

A 12 lead ECG is an important diagnostic tool used in the initial evaluation of patients presenting with palpitations. Based on the presence or absence of positive ECG findings physicians can determine the need for ambulatory ECG monitoring, echocardiography, lab investigations or electrophysiology study.

A x-ray may be employed in the diagnosis of patients presenting with palpitations when there is an increased suspicion of structural heart disease.

An echocardiography is a second line investigation that is employed in the diagnosis of patients presenting with palpitations when there is an increased suspicion of structural heart disease.

A CT may be employed in the diagnosis of patients presenting with palpitations when there is an increased suspicion of structural heart disease.

A MRI may be employed in the diagnosis of patients presenting with palpitations when there is an increased suspicion of structural heart disease.

There are no other imaging findings associated with palpitations.

An electrophysiology study (EPS) is used as a diagnostic tool in patients presenting with palpitations associated with serious symptoms such as syncope or presyncope. It is often used when other studies have proven to be non-diagnostic.

The treatment strategy for patients presenting with palpitations is directed towards treating the underlying cause. A physician needs to follow a standardized approach (which varies from institution to institution) in order to decide which patients can be discharged with the advice to follow up with a cardiologist and which patients require further work up.

There are no recommended interventions that are specifically used for patients presenting with palpitations.

The mainstay of treatment for palpitations is directed at treating the underlying cause. Surgery is usually reserved for patients with structural heart diseases.

There are no established measures for the primary prevention of palpitations.

There are no established measures for the secondary prevention of palpitations.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

There is limited information about the historical perspective of palpitations.

There is limited information about the historical perspective of palpitations.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

Palpitations may be classified based on cause, duration, rhythm and clinical presentation.

• Based on cause, palpitations may be classified as : ^[1]
  1. Cardiac –Arrhythmia related
  2. Cardiac – Not Related to Arrhythmia
  3. Pharmacological
  4. Psychiatric
  5. Systemic Causes
• Based on clinical presentation, palpitations may be classified as:
  1. Extrasystolic
  2. Tachycardic
  3. Anxiety-related
  4. Intense^[2]
• Based on duration, palpitation may be classified as :
  1. Persistent or sustained
  2. Poorly sustained/ short lasting
• Based on rhythm, palpitation may be classified as :
  1. Regular
  2. Irregular
• Extrasystolic palpitation is often described as missed beats which are sudden in onset and occur at rest.
• Tachycardiac palpitation are often described as a fluttering sensation in the chest which is sudden in onset.
  • Tachycardic palpitation include ventricular tachycardias, AV re-entry tachycardia, AN Nodal re-entry tachycardia, atrial fibrillation, atrial tachycardias and atrial flutter.
  • It is associated with a regular or irregular increase in heart rate and symptoms such as syncope, chest pain, breathlessness and neck pulsations.
• Anxiety related palpitation as the name suggest are mostly seen in individuals with generalized anxiety disorder and are gradual in onset.
  • It is associated with an increase in heart rate and symptoms such as a ‘lump-like’ sensation in the throat and tingling sensations in the hands and face.
• Patients experiencing a pulsation type of palpitation often feel like their heart is pounding.
  • This sensation is gradual in onset, triggered by exertion and may be associated with asthenia.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

Palpitations are a nonspecific symptom that are often defined as a rapid disagreeable sensation/pulsation that may be momentary or sustained and regular or irregular. It is one thing to understand the pathophysiology of palpitations as a symptom and another to understand the pathophysiology of conditions that cause palpitations. Palpitations are hypothesized to be due to neural-afferent sensory pathways located at both cardiac and extracardiac levels. It may be caused due to abnormal adjustments in the rate, rhythm and contractility of the heart.

• Palpitations are a nonspecific symptom that are often defined as a rapid disagreeable sensation/pulsation that may be momentary or sustained and regular or irregular. In other words, it is an abnormal awareness of one’s own heartbeat which may or may not be associated with symptoms such as chest pain, breathlessness, presyncope/syncope, pedal edema or lightheadedness. ^[1]
• It is one thing to understand the pathophysiology of palpitations as a symptom and another to understand the pathophysiology of conditions that cause palpitations.
• Palpitations are hypothesized to be due to neural-afferent sensory pathways located at both cardiac and extracardiac levels. ^[2]
  • Subcortical areas (thalamus, amygdala) and the base of the frontal lobes are the brain centers that possibly receive information from peripheral mechanoreceptors/baroreceptors and receptors located on the pericardium and myocardium.
  • It may be caused due to abnormal adjustments in the rate, rhythm and contractility of the heart.
  • This may be due to anomalous movements of the heart (caused by structural heart diseases) or contractions of a normal heart which may be too rapid/slow, irregular or strong. ^[3]
  • Arrythmias are due to a disturbance of the normal conduction system of the heart (spontaneous depolarization cause impulses to travel from the SA node to the ventricles via the AV Node, Bundle of His and Purkinje fibres). ^[2]
  • Aging may also cause an increased risk of arrythmia development by causing the following changes; ^[4]
    1. Decreased number of pacemaker cells in the sinoatrial node.
    2. Decreased compliance of arteries
    3. Increased afterload
    4. Impaired filling of the left ventricle
    5. Prolonged availability of intracellular calcium
    6. Decreased responsiveness of beta adrenergic receptors
    7. Increased atrial dilation.
  • Systemic conditions such as hyperthyroidism may cause an increase in myocardial oxygen demand or alter cardiac pliability. Pheochromocytomas cause an excessive release of catecholamines.
  • Psychiatric conditions such as panic disorder and generalized anxiety disorder cause an activation of the autonomic nervous system. In these cases, a ‘fight or flight’ reaction may stimulate a series of responses that causes a patient to perceive their own heartbeat. This may be viewed as a pro-arrhythmogenic effect.
  • In the case of premature ventricular contractions, an ectopic beat is followed by a compensatory pause which causes an increase in end diastolic volume. As a result, the following sinus beat is associated with an increased stroke volume.^[5]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Mugilan Poongkunran M.B.B.S [3] Akash Daswaney, M.B.B.S[4]

There are a vast number of causes of palpitations, including namely any condition that causes the heart to be rapidly, forcefully, or irregularly. In general, palpitations may be caused by primary abnormalities in the heart (tachycardia or forceful heart beating), reductions in oxygen carrying capacity (anemia), reductions in the volume of blood circulating (dehydration), sympathetic nervous system stiumlation (fever, exertion, panic attacks, drugs), excess hormone production (hyperthyroidism). Pharmacological causes should also be taken into consideration.

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Acute coronary syndrome
• Malignant hypertension
• Myocardial infarction
• Third degree AV block
• Ventricular arrhythmia

• Amiodarone “Palpitations | Circulation”. “Redirecting”. [+https://doi.org/10.1002/joa3.12358 “Isolated palpitations and ventricular pre‐excitation – Arias – 2020 – Journal of Arrhythmia – Wiley Online Library”] Check |url= value (help). ^{[1] [2] [3] [4] [4] [5]}
• Anemia
• Atrial fibrillation
• Atropine
• Cardiac glycosides
• Diseases of the valvular structures
• Flurazepam
• Heart block
• Heart failure
• Hypercapnia
• Hypoglycemia
• Hypoxia
• Insulin
• Nitrates
• Panic disorders
• Pregnancy
• Pyrexia
• Supraventricular tachycardia
• Sympathomimetics
• Thyrotoxicosis
• Ventricular tachycardia

Cardiovascular	Acute coronary syndrome, alcoholic cardiomyopathy, Andersen cardiodysrhythmic periodic paralysis, angina, aortic aneurysm, aortic regurgitation, aortic stenosis, arrhythmia, arrhythmogenic right ventricular dysplasia, arteriovenous fistula, atrial fibrillation, atrial flutter, atrial myxoma, atrial septal defect, atrioventricular heart blocks, atypical angina, AV block, AV nodal re-entry tachycardia, bradyarrhythmias, cardiac syndrome X, cardiomegaly, cardiomyopathy, catecholaminergic polymorphic ventricular tachycardia, congenital heart disease, congestive heart failure, cor pulmonale, coronary artery disease, defibrillation, endomyocardial eosinophilic fibrosis, extrasystoles,fosaprepitant, heart attack, heart block, heart failure, hemochromatosis, holiday heart syndrome, hyperkinetic heart syndrome, hypertension, hypertensive cardiomyopathy, hypertrophic cardiomyopathy, hypotension, ischaemic heart disease, Jervell and Lange-Nielsen syndrome, junctional tachycardia, left bundle branch block, long QT syndrome, Lown Ganong Levine syndrome, malignant hypertension, Meprobamate, mitral regurgitation, mitral stenosis, mitral valve prolapse, myocardial contusion, myocardial infarction, myocardial ischemia, myocarditis, NSTEMI, paroxysmal atrial tachycardia, paroxysmal supraventricular tachycardia, patent ductus arteriosus, pericardial tamponade, postpartum cardiomyopathy, premature atrial contractions, premature ventricular contractions, Prinzmetal’s angina, prosthetic heart valve, pulmonary embolism, pulmonary hypertension, restrictive cardiomyopathy, rheumatic fever, right bundle branch block, right heart catheterization, right ventricular outflow tract tachycardia, Romano-Ward syndrome, second degree heart block, short QT syndrome, short QT syndrome type 1, short QT syndrome type 2, short QT syndrome type 3, short QT syndrome type 4, short QT syndrome type 5, sick sinus syndrome, sinus tachycardia, STEMI, tachyarrhythmia, Terbutaline, third degree heart block, Timothy syndrome, torsade de pointes, tricuspid insufficiency, unstable angina, valvular heart disease, vasovagal syncope, ventricular aneurysm, ventricular arrhythmia, ventricular septal defect, ventricular tachycardia, Wolff Parkinson White Syndrome
Chemical / poisoning	Arsenic trioxide, arsenicals, betel nut, carbon monoxide, insecticide, scorpion sting, senna
Dermatologic	Dermatomyositis
Drug Side Effect	Alimemazine, almokalant, aminophylline, amiodarone, amitriptyline, amphetamines, anagrelide, antiarrythmics, antidepressants, asenapine, astemizole, atropine, azimilide, azithromycin, bepridil, Benzphetamine, beta blockers, bretylium, budipine, Butorphanol, cardiac glycosides, chloroquine, cibenzoline, cisapride, citalopram, Clemastine, Clomifene, clomipramine, clozapine, cocaine, crizotinib, cyanide, desipramine, Desmopressin, Diethylpropion, digitalis, digoxin, diphenhydramine, disopyramide, disulfiram, dofetilide, dolasetron, doxepin, dronedarone, droperidol, Efavirenz, Epinephrine (aerosol), eribulin mesylate, febuxostat,Felbamate, formoterol, Flavoxate, fluconazole, Flurazepam hydrochloride, gingko biloba, glatiramer acetate, grepafloxacin, halofantrine, haloperidol, hyoscyamine, ibutilide, Isoproterenol (aerosol), imipramine, Imipenem-Cilastatin, indapamide, inotropes, insulin, ketanserin, ketoconazole, Lacosamide, leflunomide, Letrozole, levothyroxine, lidoflazine, lubeluzole, meclofenamate,Megestrol, Metaproterenol, methadone, methadyl acetate, methamphetamine, indomethacin, Metipranolol, midodrine, Milnacipran hydrochloride, mizolastine, moxifloxacin, Nabilone, nabumetone, naltrexone, naratriptan, neuroleptics, Niacin, nicardipine, nicotine, nilotinib, nitrates, Olsalazine, ondansetron, Oprelvekin, orphenadrine, Oxaprozin, Oxcarbazepine, pasireotide, pazopanib, Pentamidine Isethionate, Pergolide, Phendimetrazine, phentermine, phenothiazines, pimozide, piperaquine,Pirbuterol, Polidocanol, prenylamine, probucol, procainamide, propoxyphene, quinidine, quinine, rizatriptan, ranolazine, repaglinide, Repaglinide and Metformin hydrochloride, retigabine, riociguat, ritodrine, ritonavir, saquinavir, serotonin syndrome, sertindole, sertraline, Siltuximab, sotalol, sparfloxacin, Sulindac, sympathomimetics, tedisamil, telithromycin, terfenadine, terodiline, tetrabenazine, theophylline, thioridazine, thyroxine, Tiagabine, Trospium, Valdecoxib, vandetanib, vemurafenib, venlafaxine, vernakalant, Vilazodone, voriconazole, vorinostat, ziprasidone, zonisamide, zotepine, zuclopenthixol
Ear Nose Throat	No underlying causes
Endocrine	Aldosteronism, De Quervain’s thyroiditis, Graves’ disease, Hashimoto’s thyroiditis, hyperpituitarism, hyperthyroidism, hypoparathyroidism, hypothyroidism, lymphocytic thyroiditis, multiple endocrine neoplasia type 1, thyroiditis, adrenal tumor
Environmental	Heat exhaustion, heat illness, hypothermia
Gastroenterologic	Dumping syndrome, hemochromatosis
Genetic	Andersen cardiodysrhythmic periodic paralysis, channelopathies, Friedreich’s ataxia, glucose-6-phosphate dehydrogenase deficiency, hemochromatosis, Jervell and Lange-Nielsen syndrome, myotonic dystrophy, Romano-Ward syndrome, spherocytosis, Timothy syndrome, Von Hippel-Lindau disease
Hematologic [6][7]	Anemia, aplastic anemia, glucose-6-phosphate dehydrogenase deficiency, hemochromatosis, hemolytic anemia, iron deficient anemia, megaloblastic anemia, paroxysmal nocturnal hemoglobinuria, pernicious anemia, sickle cell anemia, spherocytosis
Iatrogenic	Cardioversion, electrophysiologic studies, heart surgery , pacemaker, pulmonary artery catheter
Infectious Disease	Chagas disease, fever, hookworm infection, lyme disease, schistosomiasis, typhus
Musculoskeletal / Ortho	Dermatomyositis, myotonic dystrophy, Timothy syndrome
Neurologic	Autonomic neuropathy, Friedreich’s ataxia, hyperpituitarism, ganglioneuroma, migraine, pituitary adenoma, vasovagal syncope
Nutritional / Metabolic	Acid-base disturbances, acidosis, acute starvation, electrolyte imbalance, hyperkalemia, hypocalcemia, hypoglycemia, hypokalemia, hypomagnesemia, metabolic acidosis
Obstetric/Gynecologic	Menopause, vaginal bleeding after delivery, vaginal bleeding after hysterectomy
Oncologic	Adrenal tumor, ganglioneuroma, pheochromocytoma, pituitary adenoma, atrial myxoma
Opthalmologic	No underlying causes
Overdose / Toxicity	Alimemazine, almokalant, aminophylline, amiodarone, amitriptyline, amphetamines, anagrelide, antiarrythmics, antidepressants, asenapine, astemizole, atropine, azimilide, azithromycin, bepridil, beta blockers, betel nut, bretylium, budipine, cardiac glycosides, chinese restaurant syndrome, chloroquine, cibenzoline, cisapride, citalopram, clomipramine, clozapine, cocaine, crizotinib, cyanide, desipramine, digitalis, digoxin, diphenhydramine, disopyramide, dofetilide, dolasetron, doxepin, dronedarone, droperidol, eribulin mesylate, fluconazole, gingko biloba, glatiramer acetate, grepafloxacin, halofantrine, haloperidol, ibutilide, imipramine, indapamide, inotropes, insulin, ketanserin, ketoconazole, lidoflazine, lubeluzole, methadone, methadyl acetate, methamphetamine, midodrine, mizolastine, moxifloxacin, naratriptan, neuroleptics, nicardipine, nicotine, nilotinib, nitrates, ondansetron, pasireotide, pazopanib, pentamidine, phenothiazines, pimozide, piperaquine, prenylamine, probucol, procainamide, propoxyphene, quinidine, quinine, ranolazine, retigabine, ritodrine, ritonavir, saquinavir, senna, serotonin syndrome, sertindole, sotalol, sparfloxacin, sympathomimetics, tedisamil, telithromycin, terfenadine, terodiline, tetrabenazine, theophylline, thioridazine, thyroxine, vandetanib, vemurafenib, venlafaxine, vernakalant, voriconazole, vorinostat, ziprasidone, zotepine, zuclopenthixol
Psychiatric	Acrophobia, anorexia nervosa, anxiety disorder, chronic fatigue syndrome, panic attack, phobias, psychiatric disorders, social phobia
Pulmonary	Cor pulmonale, hyperventilation, hypoxemia, hypoxia, obstructive sleep apnea, respiratory acidosis, sleep apnea
Renal / Electrolyte	Renal artery stenosis, renal tubular acidosis
Rheum / Immune / Allergy	Amyloidosis, pernicious anemia, rheumatic fever
Sexual	No underlying causes
Trauma	Electrical injury, myocardial contusion
Urologic	No underlying causes
Dental	No underlying causes
Miscellaneous	Alcohol, alcohol withdrawal, caffeine, exercise, holiday heart syndrome, nicotine withdrawal, zero gravity

Acid-base disturbances Acidosis Acrophobia Acute coronary syndrome Acute starvation Adrenal tumor Alcohol Alcohol withdrawal Alcoholic cardiomyopathy Aldosteronism Alimemazine Almokalant Aminophylline Amiodarone Amitriptyline Amphetamines Amyloidosis Anagrelide Andersen cardiodysrhythmic periodic paralysis Anemia Angina Anorexia nervosa Antiarrythmics Antidepressants Anxiety Anxiety disorder Aortic aneurysm Aortic regurgitation Aortic stenosis Aplastic anemia Arrhythmia Arrhythmogenic right ventricular dysplasia Arsenic trioxide Arsenicals Arteriovenous fistula Asenapine Astemizole Atrial fibrillation Atrial flutter Atrial myxoma Atrial septal defect Atrioventricular heart blocks Atropine Atypical angina Autonomic neuropathy AV block AV nodal re-entry tachycardia Azimilide Azithromycin Bepridil Beta blockers Betel nut Bradyarrhythmias Bretylium Butorphanol Buprenorphine/naloxone Budipine Caffeine Carbon monoxide Cardiac glycosides Cardiac syndrome X Cardiomegaly Cardiomyopathy Cardioversion Catecholaminergic polymorphic ventricular tachycardia Chagas disease Channelopathies Chinese restaurant syndrome Chloroquine Chronic fatigue syndrome Cibenzoline Cisapride Citalopram Clomipramine Clozapine Cocaine Congenital heart disease Congestive heart failure Cor pulmonale Coronary artery disease Crizotinib Cyanide De Quervain’s thyroiditis Defibrillation Dermatomyositis Desipramine Desmopressin Digitalis Digoxin Diphenhydramine Disopyramide Dofetilide Dolasetron Doxepin Dronedarone Droperidol Dumping syndrome Efavirenz Electrical injury Electrolyte Imbalance Electrophysiologic studies Goiter

Endomyocardial eosinophilic fibrosis Eribulin mesylate Exercise Extrasystoles Fever Fluconazole Friedreich’s ataxia Ganglioneuroma Gingko biloba Glatiramer acetate Glucose-6-phosphate dehydrogenase deficiency Graves’ disease Grepafloxacin Halofantrine Haloperidol Hashimoto’s thyroiditis Heart attack Heart block Heart failure Heart murmurs Heart surgery Heat exhaustion Heat illness Hemochromatosis Hemolytic anemia Holiday heart syndrome Hookworm infection Hyperkalemia Hyperkinetic heart syndrome Hyperpituitarism Hypertension Hypertensive cardiomyopathy Hyperthyroidism Hypertrophic cardiomyopathy Hyperventilation Hypocalcemia Hypoglycemia Hypokalemia Hypomagnesemia Hypoparathyroidism Hypotension Hypothermia Hypothyroidism Hypoxemia Hypoxia Ibutilide Imipramine Indapamide Inotropes Insecticide Insulin Iron deficient anemia Ischaemic heart disease Jervell and Lange-Nielsen syndrome Junctional tachycardia Ketanserin Ketoconazole Left bundle branch block Lidoflazine Long QT syndrome Lown Ganong Levine syndrome Lubeluzole Lyme disease Lymphocytic thyroiditis Malignant hypertension Megaloblastic anemia Menopause Metabolic acidosis Methadone Methadyl acetate Methamphetamine Midodrine Migraine Milnacipran hydrochloride Mitral regurgitation Mitral stenosis Mitral valve prolapse Mizolastine Moxifloxacin Multiple endocrine neoplasia type 1 Myocardial contusion Myocardial infarction Myocardial ischemia Myocarditis Myotonic dystrophy Nabilone Naratriptan Neuroleptics Niacin Nicardipine Nicotine Nicotine withdrawal Nilotinib Nitrates NSTEMI Obstructive sleep apnea Ondansetron Oprelvekin Oxaprozin Pacemaker Panic attack Paroxysmal atrial tachycardia Paroxysmal nocturnal hemoglobinuria Paroxysmal supraventricular tachycardia

Pasireotide Patent ductus arteriosus Pazopanib Pentamidine Pericardial tamponade Pergolide Pernicious anemia Phenothiazines Pheochromocytoma Phobias Pimozide Piperaquine Pituitary adenoma Postpartum cardiomyopathy Premature atrial contractions Premature ventricular contractions Prenylamine Prinzmetal’s angina Probucol Procainamide Propoxyphene Prosthetic heart valve Psychiatric disorders Pulmonary artery catheter Pulmonary embolism Pulmonary hypertension Quinidine Quinine Ranolazine Renal artery stenosis Renal tubular acidosis Respiratory acidosis Restrictive cardiomyopathy Retigabine Rheumatic fever Right bundle branch block Right heart catheterisation Right ventricular outflow tract tachycardia Riociguat Ritodrine Ritonavir Romano-Ward syndrome Saquinavir Schistosomiasis Scorpion sting Second degree heart block Senna Serotonin syndrome Sertindole Short QT syndrome Short QT syndrome type 1 Short QT syndrome type 2 Short QT syndrome type 3 Short QT syndrome type 4 Short QT syndrome type 5 Sick sinus syndrome Sickle cell anemia Siltuximab Sinus tachycardia Sleep apnea Social phobia Sotalol Sparfloxacin Spherocytosis STEMI Sympathomimetics Tachyarrhythmia Tedisamil Telithromycin Terbutaline Terfenadine Terodiline Tetrabenazine Theophylline Thioridazine Third degree heart block Thyroiditis Thyroxine Tiagabine Timothy syndrome Torsade de pointes Tricuspid insufficiency Typhus Unstable angina Vaginal bleeding Valvular heart disease Vandetanib Vasovagal syncope Vemurafenib Venlafaxine Ventricular aneurysm Ventricular arrhythmia Ventricular septal defect Ventricular tachycardia Vernakalant Vilazodone Von Hippel-Lindau disease Voriconazole Vorinostat Wolff Parkinson White syndrome Zero gravity Ziprasidone Zotepine Zuclopenthixol

[8] [9]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

When coming up with a differential diagnoses, it would be useful to link positive history,physical examination and ECG findings to cardiac (arrhythmia Related), cardiac (not related to arrhythmia), systemic causes (Non Cardiac), pharmacological causes and psychiatric causes.

• Palpitation in itself is not a condition but a symptom reflective of an underlying condition.
• When coming up with a differential diagnoses, it would be useful to link positive history,physical examination and ECG findings to any of the following 5 categories:^{[1][2][3][4][5]}
  1. Cardiac (arrhythmia Related)
  2. Cardiac (Not related to arrhythmia)
  3. Systemic causes (Non cardiac)
  4. Pharmacological causes
  5. Psychiatric causes

Cardiac (Arrhythmia related) Differentials	Cardiac (Not Arrhythmia related) Differentials	Systemic Non Cardiac Differentials	Pharmacological Differentials	Psychiatric Differentials
Premature ventricular contractions Premature Atrial Contractions Ventricular tachycardia Ventricular fibrillation Atrial fibrillation Atrial flutter Postural orthostatic tachycardia syndrome Brugada syndrome Sinus tachycardia Paroxysmal supraventricular tachycardia Tachycardia with variable block, Wolff-Parkinson-White syndrome Long QT syndrome Polymorphic Ventricular Tachycardia Bradycardia caused by advanced arteriovenous block Bradycardia-tachycardia syndrome (sick sinus syndrome) Multifocal atrial tachycardia Pacemaker-mediated tachycardia Catecholamine Sensitive Arrythmia AV Re-entry tachycardia AV Nodal Re-entry Tachycardia	Congenital heart disease Cardiomegaly Aortic aneurysm Myocardial Ischemia Mitral Valve Prolapse Hypertrophic Obstructive Cardiomyopathy Atrial Septal Defect Congestive Heart Failure Stenotic/ Regurgitant Valvular Heart Diseases Cardiomyopathy Pericarditis Ventricular Septal Defect Atrial Myxoma Anemia AV fistula Paget’s disease Pregnancy	Thyrotoxicosis Mastocytosis Exercise Electrolyte imbalance Hypoglycemia Hypovolemia Pheochromocytoma Pulmonary disease Vasovagal syndrome Obstructive Sleep Apnea Food poisoning	Caffeine Cocaine Amphetamine Digitalis, Phenothiazine Theophylline Beta agonists Alcohol Tobacco	Stress Anxiety disorder Panic disorder Somatization Disorder Express Hypochondria type behavior Depression

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

Scarce data is available regarding the epidemiology of palpitations.

• There is an increased incidence of palpitations in individuals with risk factors for atherosclerotic heart disease, thyroid dysfunctions, psychosomatic disorders and pre-existing structural or conduction defects.

• There is an increased prevalence of palpitations in individuals with risk factors for atherosclerotic heart disease, thyroid dysfunctions, psychosomatic disorders and pre-existing structural or conduction defects.

• Patients of all age groups may develop palpitations.

• There is no racial predilection to palpitations.

• Palpitations affects men and women equally.

• Scarce data is available regarding the epidemiology of palpitations.
• In some areas, studies have shown that it accounts for 16% of the symptoms in the outpatient department. ^[1]
• Some others have suggested that it was the second most common complaint following chest pain amongst patients who were referred to a cardiologist.
• Another study found that palpitations were seen more in patients with an increased number of minor daily irritants and who have an increased sensitivity to bodily sensation.
  • The same study found an increased prevalence of panic disorder (and therefore palpitations) in women of child bearing age. This was due to their increased tendency to somatize excess hypochondrial concerns they had regarding their health. ^[2]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

Common risk factors in the development of palpitations include a past history of cardiac disease, atherosclerotic risk factors, caffeine intake, substance abuse and a family history of sudden cardiac death or psychiatric disease.

• Common risk factors in the development of palpitations include:
  • History of cardiac disease
  • Atherosclerotic risk factors such as obesity,lack of exercise, high sodium diet and diet rich in saturated fatty acids.
  • Caffeine intake
  • Substance abuse
  • Family history of sudden cardiac death or psychiatric diseases.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

There is insufficient evidence to recommend routine screening for palpitations.

There is insufficient evidence to recommend routine screening for palpitations.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

Patient often present with a flip-flopping, fluttering, pounding or thud like sensation in one particular area or all over the precordium. It may or may not be associated with symptoms such as chest pain, dyspnea, presyncope, syncope or haemodynamic compromise. Complications include impairment of quality of life, hypotension, ventricular fibrillation and sudden cardiac death. Prognosis depends on the underlying cause but is generally good.

• Palpitations may present during one’s childhood or in the elderly as a flip-flopping, fluttering, pounding or thud like sensation in one particular area of the chest or all over the precordium.
• It may be regular or irregular, sustained or momentary and may be associated with symptoms such as chest pain, breathlessness, pedal edema, polyuria or signs of haemodynamic instability.

• Patients presenting with palpitations generally have a good prognosis (especially in the absence of a cardiac condition), but data regarding this is scarce. ^[1]
• However, associated symptoms play a major role in whether one should ‘worry’ or not.
  • Positive ECG findings, frequent or persistent palpitations, positive family history (sudden cardiac death, myopathy or cardiac condition) and symptoms such as presyncope, syncope, dyspnea and chest pain would require specialist referral.^[2]
• In a study conducted by Weber and Kapoor, a one year mortality rate of 1.6% was noted despite a high incidence of cardiac conditions. ^[3]
  • In the same study, a large number of patients experienced a significant impact on their quality of life in terms of their work capacity, and ability to perform household chores
• Barsky et al. confirmed these findings when they noted a low one year mortality rate but increased incidence of anxiety in individuals with palpitations, increased frequency of visits to the emergency department and therefore a decrease in the patient’s quality of life.• ^[4]
• Other complications that arise due to the underlying arrhythmia include hypotension, ventricular fibrillation,congestive heart failure ,acute pulmonary edema and sudden cardiac death.

• Prognosis depends on the underlying cause but is generally good.