What triggers palpitations?

Triggers of Palpitations

The most common triggers of palpitations include cardiac arrhythmias, stimulant substances, emotional stress, and physiological factors, which should be systematically evaluated to guide appropriate management. 1

Cardiac Causes

Arrhythmias

• Primary cardiac arrhythmias are the most common cardiac cause of palpitations 1:
  • Premature beats (atrial or ventricular)
  • Supraventricular tachycardias
  • Atrial fibrillation
  • Sinus tachycardia
  • Ventricular tachycardia

Structural Heart Conditions

• Mitral valve prolapse 2
• Pericarditis
• Congestive heart failure
• Hypertrophic cardiomyopathy 2
• Ischemic heart disease 2

Non-Cardiac Physiological Triggers

Endocrine Factors

• Hyperthyroidism
• Hypoglycemia
• Hormonal fluctuations:
  • Menstrual cycle variations 3
  • Pregnancy 3
  • Perimenopause 3

Autonomic Nervous System Triggers

• Orthostatic changes (postural hypotension) 2
• Vasovagal reactions 2

Substance-Related Triggers

Stimulants

• Caffeine 2, 4
• Nicotine 2, 4
• Alcohol 2
• Recreational drugs

Medications

• Adrenergic medications
• Anticholinergic drugs 4
• Psychotropic medications 2
• Diuretics (through electrolyte disturbances) 2
• Beta-blockers (paradoxically can cause palpitation awareness as a side effect) 5

Psychological Triggers

• Anxiety and panic disorders 2
  • 45% of patients with panic disorder have MVP 2
• Stress 4
• Depression 2

Environmental and Lifestyle Factors

• Physical exertion/exercise 4
• Dehydration 2
• Fever
• Sleep deprivation
• Physical inactivity 2

Warning Signs of Serious Palpitations

Palpitations should be considered potentially more serious when associated with:

• Syncope or pre-syncope 1
• Chest pain
• Dyspnea
• Family history of sudden cardiac death
• Known structural heart disease

Management Approach

1. Identify and address modifiable triggers:

   • Reduce or eliminate caffeine, alcohol, and nicotine 2
   • Manage stress and anxiety
   • Treat underlying medical conditions

2. For benign palpitations:

   • Reassurance
   • Lifestyle modifications
   • Avoidance of triggers

3. For arrhythmia-related palpitations:

   • Beta-blockers for symptomatic patients 2
   • Specific anti-arrhythmic therapy based on the type of arrhythmia
   • Catheter ablation for certain arrhythmias 6

4. For palpitations due to orthostatic changes:

   • Volume expansion
   • Liberalizing fluid and salt intake
   • Support stockings 2

Diagnostic Evaluation

When palpitations occur:

• Document timing, duration, and associated symptoms
• 12-lead ECG during symptoms if possible
• Consider ambulatory monitoring:
  • 48-hour ambulatory ECG for frequent palpitations 2
  • Event monitors for less frequent episodes
  • Implantable loop recorders for very infrequent but concerning episodes 2

Key Pitfalls to Avoid

1. Dismissing palpitations as purely anxiety-related without appropriate cardiac evaluation
2. Missing underlying structural heart disease that may predispose to dangerous arrhythmias
3. Overlooking medication side effects as potential causes
4. Failing to recognize warning signs that suggest potentially dangerous arrhythmias
5. Not addressing modifiable lifestyle factors that can significantly reduce symptoms

Understanding the specific triggers of a patient's palpitations is essential for effective management and determining whether further cardiac evaluation is necessary.