Internal Medicine/Palpitations

Palpitations are a common complaint among patients when they visit their internists. These are often described as sensations of "thumping," "pounding," or "fluttering" in the chest. Palpitations can vary in frequency and regularity, and many patients become concerned when they feel their heartbeats skip or miss a beat. These sensations are often noticed during moments of rest when external stimuli are minimal. When palpitations are positional, they may be linked to structural issues within or near the heart, such as atrial myxoma or mediastinal masses.

The causes of palpitations can be broadly categorized into cardiac (43%), psychiatric (31%), miscellaneous (10%), and unknown (16%) factors. Cardiovascular causes include premature contractions of the atria and ventricles, various arrhythmias, mitral valve prolapse, aortic insufficiency, atrial myxoma, myocarditis, and pulmonary embolism. Intermittent palpitations are frequently associated with premature contractions of the atria or ventricles, where the post-extrasystolic beat is felt due to changes in the heart's rhythm. Regular, sustained palpitations can result from consistent supraventricular and ventricular tachycardias, while irregular, sustained palpitations may be caused by atrial fibrillation. It's important to note that most arrhythmias do not lead to palpitations, but when they do, patients can help by tapping out the rhythm or checking their pulse during episodes.

Certain factors, such as exercise, stress, or substances like tobacco, caffeine, and drugs, can lead to hyperdynamic cardiovascular states and palpitations. Athletes and individuals with conditions like aortic regurgitation may also experience palpitations due to increased myocardial contraction strength. Psychiatric causes, such as panic attacks, anxiety, and somatization, can lead to palpitations, often with longer durations and accompanying symptoms.

When assessing patients with palpitations, the primary goal is to determine if a life-threatening arrhythmia is the cause. Patients with coronary artery disease (CAD) or CAD risk factors are at higher risk for ventricular arrhythmias. Additional symptoms like syncope or lightheadedness can support this diagnosis. A thorough physical examination, measurement of vital signs, assessment of jugular venous pressure, pulse evaluation, and chest auscultation can help confirm or rule out an arrhythmia. Resting electrocardiograms are useful for documenting arrhythmias, while exercise electrocardiography can help if arrhythmias are exercise-induced. For infrequent arrhythmias, various monitoring methods like Holter monitoring, telephonic monitoring, loop recordings, and mobile cardiac outpatient telemetry can be employed.

Most patients with palpitations do not have serious arrhythmias or structural heart issues. Benign atrial or ventricular premature contractions can often be managed with beta-blocker therapy if necessary. Palpitations triggered by alcohol, tobacco, or illicit drugs require abstinence, and those caused by medications should be addressed by considering alternative treatments. Psychiatric causes of palpitations may benefit from cognitive therapy or medication. It's important for physicians to recognize that palpitations can be distressing to patients, but once serious causes are ruled out, patients should be reassured that their prognosis is not adversely affected by palpitations.