Causes of palpitations can be divided into four main categories: 1) Psychiatric, 2) cardiac, 3) Medication, and 4) Systemic medical causes.
Psychiatric/Psychosomatic causes
Anxiety disorder; Stress
Panic attacks/Panic disorder
Depression
Somatization disorder
Cardiac Causes
Arrhythmias
Premature atrial contractions (PACs) / Premature supraventricular contractions.
Premature ventricular contractions (PVCs)
Atrial fibrillation
Atrial flutter
Sinus tachycardia or arrhythmia
Ventricular tachycardia (VT), nonsustained.
Pacemaker-mediated tachycardia
Supraventricular tachycardia
Bradycardia-tachycardia syndrome (Sick sinus syndrome)
Bradycardia caused by advanced arteriovenous block or sinus node dysfunction
Atrial tachycardia (AT) / Multifocal atrial tachycardia
Atrioventricular reentry
Wolff-Parkinson-White syndrome
Atrioventricular tachycardia
Autonomic dysfunction
Long QT syndrome
Structural heart disease
Valvular heart disease e.g. Mitral valve prolapse, aortic insufficiency, stenosis.
Atrial myxoma
Atrial or ventricular septal defect
Cardiomyopathy
Congestive heart failure
Congenital heart disease
Pericarditis
Ischemic heart disease (IHD)
Angina pectoris,
Silent myocardial ischemia,
Myocardial infarction.
Sudden cardiac arrest
Vasospastic Angina / Prinzmetal’s angina
Coronary microvascular disease.
Rx meds / illicit drugs
Alcohol
Medication side effects: Digoxin, Beta-blockers, CCB, hydralazines, diuretics, minoxidil, digoxin, phenothiazine, theophylline, beta-agonists.
Stimulant drugs/sympathomimetics: Caffeine, Nicotine/tobacco, cocaine, amphetamines/methamphetamines, NMDA
Marijuana use (can cause arrhythmias)
Beta-blocker withdrawal; alcohol withdrawal; Anticholinergics
Systemic/medical Causes
Hypoglycemia
Anemia
Hyperthyroidism; thyrotoxicosis
Pheochromocytoma
Gastroesophageal reflux disease (GERD) – GERD triggers palpitations. Treating it reduces them.
Paget disease of bone
Pregnancy
Electrolyte imbalance (hypokalemia, hypomagnesemia)
Hypovolemia; Dehydration; orthostasis
Postural tachycardia syndrome.
Pulmonary disease
Vasovagal syndrome
Exercise
Fever
Menopause
Thinking through the differential diagnosis
Palpitations make up 16% outpatient visits. (
It helps to divide the differential diagnosis into cardiac causes (arrhythmia, structural, and ischemic heart disease) and non-cardiac causes (psychosomatic, drugs, and systemic conditions). Cardiac causes are the most concerning.
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.
https://www.nhlbi.nih.gov/health-topics/ischemic-heart-disease