Palpitations are an unpleasant sensation that one’s heart is beating abnormally.
Pertinent H&P findings are ____
DDx of palpitations in this pt is ___
Risk Factors in this patient are___
Distinguish cardiac vs. non-cardiac cause.
Rule out an ischemic cause.
Diagnostic testing
Labs1: CBC, CMP, TSH, Mg. Consider serum/urine catecholamines/metanephrines
ECG in everybody.
TTE if structural heart disease is suspected.
Holter monitor/Event monitor/Loop Recorder if an arrhythmia is suspected.
Stress Test (e.g. ETT) if ischemic heart disease is suspected.
Tilt-table test if unexplained syncope suspected.
Orthostatic vitals if indicated.
Treatment
Decide who to send to the ED, who to refer to cards/EP, and who to treat w/o a referral.
Send to ED: pts w/ A-fib w/ RVR, A-fib w/ slow ventricular response; symptomatic bradycardia; v-tach; high-risk ECG findings; syncope/presyncope w/ high-risk ECG findings; pts w/ sustained or hemodynamically significant arrhythmias; pts w/ high-risk heart disease.
Refer to cardiology/electrophysiology: pts w/ 1) sustained or poorly tolerated palpitations, 2) persistent SVTs or PVCs that are not controlled w/ β-blockers, 3) high probability of structural heart disease, and 4) those with an unclear diagnosis,3 5) long QT syndrome, 6) syncope/presyncope, 7) other serious symptoms and other high-risk patients.
Reassure pts w/ Premature atrial contractions and d/c triggers like caffeine, alcohol, nicotine, etc.3
Treat medical, psychiatric, and medication-induced (Rx and illicit) causes.
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Key Points
Notes
1 CBC, CMP (for glucose, electrolytes, BUN/creatinine), TSH, and Mg to r/o anemia, kidney disease, and electrolyte or thyroid disorders.
References/Further Reading
https://www.health.harvard.edu/heart-disease-overview/skipping-a-beat–the-surprise-of-palpitations
Am Fam Physician. 2017 Dec 15;96(12):784-789. Palpitations: Evaluation in the Primary Care Setting. https://www.aafp.org/afp/2017/1215/p784.html
Am Fam Physician. 2015 Nov 1;92(9):793-802. Diagnosis and Management of Common Types of Supraventricular Tachycardia. https://www.aafp.org/afp/2015/1101/p793.html
Am Fam Physician. 2011 Jul 1;84(1):63-69. Outpatient Approach to Palpitations. https://www.aafp.org/afp/2011/0701/p63.html
Am Fam Physician. 2005 Feb 15;71(4):743-750. Diagnostic Approach to Palpitations. https://www.aafp.org/afp/2005/0215/p743.html
The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med. 1990 Aug;150(8):1685-9. https://www.ncbi.nlm.nih.gov/pubmed/2383163
Dr. Sanjay Gupta, Cardiologist from York, UK, Youtube video. GERD triggers heart palpitations.
Pocket Primary Care, edited by Meghan M. Kiefer, MD