Can palpitations lead to death?

Can Palpitations Lead to Death?

Yes, palpitations can lead to death when they are manifestations of serious underlying cardiac arrhythmias, particularly ventricular arrhythmias such as ventricular tachycardia or ventricular fibrillation, which can cause sudden cardiac death. 1

Understanding Palpitations and Their Significance

Palpitations themselves are simply the sensation of an abnormal heartbeat - described as pounding, racing, skipped beats, or pauses. While often benign, they can sometimes indicate potentially life-threatening conditions.

Classification of Palpitations by Severity

Palpitations can be categorized based on their hemodynamic impact:

• Hemodynamically stable palpitations:

  • Minimal symptoms (awareness of heartbeat, pounding/racing sensations)
  • Generally not immediately life-threatening

• Hemodynamically unstable palpitations:

  • Associated with presyncope (dizziness, lightheadedness)
  • Associated with syncope (loss of consciousness)
  • Can progress to sudden cardiac death or cardiac arrest 1

Dangerous Arrhythmias That Can Present as Palpitations

Several potentially fatal arrhythmias may initially present as palpitations:

• Ventricular tachycardia (VT): Can lead to hemodynamic compromise and sudden death
• Ventricular fibrillation (VF): Rapid, grossly irregular ventricular rhythm that causes cardiac arrest
• Torsades de pointes: Associated with long QT syndrome, can deteriorate to VF
• Atrial fibrillation with WPW syndrome: Can conduct extremely rapidly to ventricles 1

Risk Factors for Life-Threatening Palpitations

Certain conditions increase the risk that palpitations represent a dangerous arrhythmia:

• Structural heart disease: Coronary artery disease, cardiomyopathy, valvular disease
• History of myocardial infarction: Particularly within 2 years
• Reduced ejection fraction: Especially <35%
• Diabetes mellitus: Increases risk of sudden cardiac death 1
• Congenital heart conditions: Long QT syndrome, Brugada syndrome

Warning Signs That Palpitations May Be Life-Threatening

Immediate medical attention is needed when palpitations are accompanied by:

• Syncope or presyncope (fainting or near-fainting)
• Severe shortness of breath
• Chest pain
• Persistent symptoms despite rest
• Family history of sudden cardiac death

Diagnostic Approach for Concerning Palpitations

1. 12-lead ECG: Essential initial test to identify arrhythmias or structural abnormalities
2. Cardiac imaging: Echocardiogram to assess for structural heart disease
3. Ambulatory monitoring: Event monitors or Holter monitors to capture intermittent arrhythmias
4. Electrophysiology studies: For high-risk patients or when diagnosis remains unclear

Medication-Related Considerations

Some medications used to treat arrhythmias can paradoxically increase risk of death:

• Flecainide: Can cause proarrhythmic effects including VT and VF, particularly in patients with structural heart disease or prior myocardial infarction 2
• Other antiarrhythmics: May have similar proarrhythmic potential

Clinical Pitfalls to Avoid

1. Assuming palpitations are benign: Even in patients with anxiety disorders, cardiac causes must be excluded
2. Missing intermittent arrhythmias: Appropriate monitoring duration is essential
3. Overlooking structural heart disease: Echocardiography should be performed when cardiac origin is suspected
4. Failing to recognize red flags: Syncope with palpitations warrants urgent evaluation

When to Refer to a Cardiologist

Immediate cardiology referral is indicated for patients with:

• Palpitations with syncope
• Sustained ventricular arrhythmias
• Palpitations in patients with known structural heart disease
• Supraventricular tachycardia
• Evidence of pre-excitation (WPW syndrome)
• Long QT syndrome 3

In conclusion, while many palpitations are benign, they can represent the first symptom of a potentially fatal arrhythmia. Proper evaluation and risk stratification are essential to identify patients at risk of sudden cardiac death.