What causes a patient to hear their heartbeat?

Causes of Hearing One's Heartbeat

Pulsatile tinnitus (hearing one's heartbeat) can be caused by various conditions including vascular abnormalities, increased cardiac output states, hypertension, and anxiety-related conditions, with the most common causes being vascular disorders and anxiety. 1

Common Causes

Vascular Causes

• Vascular abnormalities: Arteriovenous malformations, carotid artery stenosis, or venous hums
• Increased intracranial pressure: Can transmit pulsations more prominently
• Vascular tumors: Such as glomus tumors or paragangliomas

Cardiac-Related Causes

• Increased cardiac output states: Including:
  • Anemia
  • Hyperthyroidism
  • Pregnancy
  • High-output heart failure
• Valvular heart disease: Particularly aortic stenosis or regurgitation 2
• Hypertension: Can increase the force of blood flow, making pulsations more audible

Ear-Related Causes

• Middle ear effusion: Fluid in the middle ear can transmit pulsations
• Eustachian tube dysfunction: Can alter the perception of internal sounds
• Conductive hearing loss: May amplify internal body sounds while external sounds are dampened

Neurological/Psychological Causes

• Anxiety and stress: Can increase awareness of normal physiological sounds 1, 3
• Increased sympathetic tone: Causes heightened awareness of normal bodily functions
• Psychological stress: Can accentuate perception of heartbeat, especially in patients with mitral valve prolapse 3, 4

Diagnostic Approach

Initial Assessment

1. 12-lead ECG: Essential to identify any underlying cardiac abnormalities (Class I, Level B-NR) 1
2. Blood pressure measurement: To identify hypertension
3. Auscultation: To detect murmurs, bruits, or other abnormal sounds

Further Evaluation

• Ambulatory ECG monitoring: For patients with intermittent symptoms to correlate with cardiac rhythm 1
• Echocardiography: To exclude structural heart disease (Class I) 1
• Vascular imaging: CT angiography or MRA if vascular cause is suspected
• Audiological evaluation: To assess for hearing loss or other ear pathologies

Management Based on Etiology

For Vascular Causes

• Treatment of underlying vascular abnormality
• Management of hypertension with appropriate medications
• Surgical intervention for vascular tumors if indicated

For Cardiac Causes

• Beta-blockers: First-line treatment for tachycardia-related palpitations 1
• Management of underlying cardiac conditions (valvular disease, arrhythmias)
• Treatment of conditions causing high cardiac output (anemia, hyperthyroidism)

For Anxiety-Related Causes

• Beta-blockers: Can help reduce physical symptoms of anxiety including palpitations 1
• Lifestyle modifications:
  • Reduction of stimulants (caffeine, alcohol, nicotine) 1
  • Stress management techniques
  • Regular exercise

For Ear-Related Causes

• Treatment of middle ear effusion or infection
• Management of Eustachian tube dysfunction
• Addressing hearing loss if present

Special Considerations

High-Risk Features Requiring Urgent Evaluation

• Syncope or near-syncope with palpitations
• Family history of sudden cardiac death
• Known structural heart disease
• New-onset irregular heartbeat in patients with risk factors for stroke 1

Referral Guidelines

Immediate cardiology referral is necessary for:

• Wide complex tachycardia of unknown origin
• Severe symptoms during palpitations
• Irregular palpitations suggesting atrial fibrillation in high-risk patients 1

Follow-up

• Follow-up in 2 weeks to assess response to treatment
• Adjustment of medication doses based on symptom response
• Consider extended monitoring with event monitor or implantable loop recorder if symptoms persist despite treatment 1

Remember that while pulsatile tinnitus is often benign, it can sometimes be the first sign of a serious underlying condition, so thorough evaluation is warranted, particularly in patients with risk factors for cardiovascular disease.