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Monday, August 18, 2025

Palpitations


Introduction

Palpitations are the subjective awareness of the heartbeat. Patients may describe them as fluttering, racing, pounding, irregular, or skipping beats in the chest, throat, or neck.

While often benign, palpitations may also signal serious arrhythmias, structural heart disease, or systemic conditions. They are a frequent reason for medical consultation, accounting for ~16% of referrals to cardiology clinics.

Epidemiology

  • Occur in both healthy individuals and those with cardiovascular disease.

  • Prevalence: ~16% in the general population.

  • Common in young adults due to anxiety, stress, and stimulants.

  • More clinically significant in older adults with cardiac comorbidities.

Pathophysiology

Palpitations result from altered cardiac rhythm, contractility, or perception of heartbeat:

  1. Arrhythmogenic mechanisms:

    • Increased automaticity (sinus tachycardia).

    • Triggered activity (premature atrial/ventricular contractions).

    • Reentry circuits (supraventricular tachycardia, atrial flutter, ventricular tachycardia).

  2. Non-arrhythmic causes:

    • Increased stroke volume (e.g., mitral regurgitation).

    • Hyperdynamic circulation (thyrotoxicosis, anemia, pregnancy).

    • Heightened sensitivity of the autonomic nervous system.

  3. Psychological and perceptual factors:

    • Anxiety and panic attacks heighten cardiac awareness.

Causes of Palpitations

1. Cardiac Causes

  • Arrhythmias:

    • Premature atrial contractions (PACs).

    • Premature ventricular contractions (PVCs).

    • Supraventricular tachycardia (SVT).

    • Atrial fibrillation (AF).

    • Atrial flutter.

    • Ventricular tachycardia (VT).

    • Sinus tachycardia or bradycardia.

  • Structural heart disease:

    • Mitral valve prolapse.

    • Hypertrophic cardiomyopathy.

    • Heart failure.

  • Ischemic heart disease.

2. Systemic and Metabolic Causes

  • Thyrotoxicosis.

  • Anemia.

  • Fever and sepsis.

  • Hypoglycemia.

  • Electrolyte imbalances (hypokalemia, hypomagnesemia).

3. Medications and Substances

  • Stimulants: caffeine, nicotine, cocaine, amphetamines.

  • Medications:

    • β-agonists (salbutamol, terbutaline).

    • Theophylline.

    • Digoxin toxicity.

    • Decongestants (pseudoephedrine).

    • Antidepressants (tricyclics, SSRIs, SNRIs).

4. Psychological and Functional Causes

  • Anxiety, panic disorder.

  • Somatization.

  • Often in young, otherwise healthy individuals.

5. Physiological Causes

  • Exercise.

  • Pregnancy.

  • Menopause and hormonal changes.

Clinical Presentation

  • Patient’s description:

    • Fast, pounding, irregular, skipped, fluttering.

  • Associated symptoms:

    • Chest pain (consider angina).

    • Dizziness, syncope (arrhythmia, VT).

    • Dyspnea, orthopnea (heart failure).

    • Sweating, tremor, weight loss (thyrotoxicosis).

    • Anxiety, hyperventilation.

Red flag symptoms suggesting serious arrhythmia:

  • Syncope or presyncope.

  • Severe chest pain.

  • Dyspnea or hypoxia.

  • Family history of sudden cardiac death.

Diagnostic Evaluation

1. History

  • Onset, duration, frequency, triggers.

  • Regular vs irregular rhythm.

  • Relation to exertion, stress, caffeine, or drugs.

  • Past medical history (heart disease, thyroid disease, anemia).

  • Family history (sudden death, cardiomyopathy).

2. Examination

  • Vital signs: heart rate, rhythm, blood pressure, oxygen saturation.

  • Cardiac exam: murmurs (valve disease), irregular pulse (AF).

  • Thyroid exam: goiter, tremor.

  • Signs of anemia, heart failure.

3. Investigations

  • Electrocardiogram (ECG): essential. May show arrhythmia or conduction abnormalities.

  • Holter monitoring (24–48 hours): for intermittent symptoms.

  • Event recorders / implantable loop recorders: for infrequent but concerning palpitations.

  • Echocardiogram: assess structural heart disease.

  • Exercise stress test: if symptoms occur with exertion.

  • Laboratory tests:

    • Thyroid function tests (TSH, free T4).

    • Full blood count (anemia).

    • Serum electrolytes, glucose.

    • Cardiac biomarkers (if chest pain).

Management

1. General Measures

  • Identify and eliminate triggers: caffeine, alcohol, nicotine, stimulants.

  • Manage stress and anxiety: breathing exercises, CBT.

  • Correct underlying systemic disorders (thyroid, anemia, electrolyte imbalance).

2. Pharmacological Treatment

a) Supraventricular Tachycardia (SVT)

  • Acute management:

    • Adenosine: 6 mg rapid IV bolus, may repeat with 12 mg if ineffective.

    • Alternatives: Verapamil hydrochloride 5–10 mg IV over 2 minutes.

  • Chronic prevention:

    • Beta-blockers: Metoprolol tartrate 25–100 mg orally twice daily.

    • Calcium channel blockers: Verapamil 120–240 mg orally daily in divided doses.

b) Atrial Fibrillation (AF)

  • Rate control:

    • Bisoprolol fumarate: 2.5–10 mg orally once daily.

    • Diltiazem hydrochloride: 120–360 mg orally daily in divided doses.

  • Rhythm control (selected cases):

    • Flecainide acetate: 50–100 mg orally twice daily.

    • Amiodarone hydrochloride: 200 mg orally daily (after loading).

  • Anticoagulation: if CHA₂DS₂-VASc score ≥2.

    • Warfarin sodium: adjusted to INR 2–3.

    • DOACs: Apixaban 5 mg orally twice daily, Rivaroxaban 20 mg orally once daily.

c) Ventricular Tachycardia (VT)

  • Acute management (stable):

    • Amiodarone: 150 mg IV over 10 min, then 1 mg/min infusion for 6 hrs, followed by 0.5 mg/min for 18 hrs.

  • Chronic prevention:

    • Beta-blockers (e.g., Metoprolol, Bisoprolol).

    • Implantable cardioverter-defibrillator (ICD) if high risk.

d) Anxiety-related Palpitations

  • Beta-blockers:

    • Propranolol hydrochloride: 10–40 mg orally three times daily as needed for symptomatic relief.

  • Anxiolytics (short-term use):

    • Diazepam: 2–5 mg orally once or twice daily.

  • SSRIs: for long-term management of panic disorder (e.g., Sertraline 50–200 mg orally once daily).

e) Hyperthyroidism-related Palpitations

  • Beta-blockers: propranolol 20–40 mg orally three times daily.

  • Antithyroid drugs:

    • Carbimazole: 10–40 mg orally daily.

    • Propylthiouracil: 100–150 mg orally every 8 hours.

3. Non-Pharmacological Treatment

  • Vagal maneuvers (for SVT): carotid sinus massage, Valsalva maneuver.

  • Catheter ablation: for recurrent SVT, AF, or VT.

  • Lifestyle interventions: reduce caffeine, alcohol, stress.

Complications

  • Arrhythmia-related: stroke, heart failure, sudden cardiac death.

  • Psychological: anxiety, panic attacks.

  • Medication side effects: hypotension, bradycardia, bleeding (anticoagulants).

  • Procedural risks: catheter ablation complications, pacemaker/ICD infections.

Prognosis

  • Benign causes: excellent prognosis, reassurance sufficient.

  • Arrhythmic causes: prognosis depends on arrhythmia type and presence of structural heart disease.

  • Systemic causes: outcome depends on underlying condition (e.g., anemia, thyroid disease).

  • With proper treatment, most patients achieve good symptom control.

Preventive Strategies

  • Control cardiovascular risk factors: hypertension, diabetes, hyperlipidemia.

  • Avoid stimulant use (caffeine, cocaine, amphetamines).

  • Manage stress and anxiety with relaxation techniques.

  • Regular follow-up for known arrhythmias or structural heart disease.

  • Early detection and treatment of thyroid and metabolic disorders.

Pharmacological Quick Reference

  • Adenosine: 6 mg IV bolus, then 12 mg if needed.

  • Verapamil: 5–10 mg IV (acute), 120–240 mg/day orally (chronic).

  • Metoprolol: 25–100 mg orally BD.

  • Bisoprolol: 2.5–10 mg orally OD.

  • Flecainide: 50–100 mg orally BD.

  • Amiodarone: 150 mg IV over 10 min → infusion; maintenance 200 mg orally daily.

  • Propranolol: 10–40 mg orally TDS.

  • Sertraline: 50–200 mg orally OD.

  • Carbimazole: 10–40 mg orally daily.

  • Warfarin: dose-adjusted for INR 2–3.

  • Apixaban: 5 mg orally BD.

  • Rivaroxaban: 20 mg orally OD.



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