Are palpitations with normal vital signs, normal blood pressure, and no rhythm problems considered cardiac in origin?

Palpitations with Normal Vital Signs: Cardiac or Non-Cardiac Origin?

Palpitations with normal vital signs, normal blood pressure, and no rhythm problems are often non-cardiac in origin, though a thorough evaluation is still necessary to definitively rule out cardiac causes. 1, 2

Diagnostic Approach

• Long-term ambulatory recording is the most useful procedure for documenting cardiac rhythm associated with palpitations, especially when the cause is unclear 3
• For patients with frequent or sustained palpitations, 48-hour ambulatory ECG monitoring is recommended as the first-line diagnostic test 3
• If palpitations are infrequent, a loop or event recording may be more appropriate to capture episodes 3
• Electrophysiological studies have low sensitivity in patients with unexplained palpitations and should only be used if recording attempts fail to provide an answer 3

Classification of Palpitations

Non-Cardiac Causes (More Likely with Normal Vitals)

• Anxiety or panic disorders 4
• Hyperthyroidism 3
• Stimulant medications or substances (caffeine, nicotine) 1, 5
• Vasovagal reactions 4
• Hypoglycemia 4
• Hormonal fluctuations, especially in women 6

Cardiac Causes (Less Likely with Normal Vitals)

• Premature ventricular or atrial contractions 1, 4
• Supraventricular tachycardias with brief episodes 1, 2
• Atrial fibrillation with controlled ventricular response 1, 4
• Structural heart abnormalities (e.g., mitral valve prolapse) 4, 6

Risk Stratification

Low-Risk Features

• Normal vital signs and ECG 3, 2
• No associated symptoms like syncope or pre-syncope 1, 7
• No structural heart disease 2, 4
• Palpitations that are brief and terminate spontaneously 1, 5

Warning Signs (Requiring More Urgent Evaluation)

• Palpitations accompanied by syncope or pre-syncope 1, 7
• Palpitations with chest pain 1, 7
• Palpitations during exercise 1
• Family history of sudden cardiac death 2

Management Algorithm

1. Initial Evaluation:

   • 12-lead ECG (even if normal vitals) 2, 4
   • Basic laboratory tests to rule out metabolic causes 7

2. For Patients with Normal Vitals and No Concerning Features:

   • Reassurance that palpitations are likely benign 8, 5
   • Lifestyle modifications (reduce caffeine, alcohol, stress) 1, 5
   • Monitor symptoms with diary 2

3. For Persistent or Concerning Palpitations:

   • 48-hour ambulatory ECG monitoring for frequent episodes 3
   • Event or loop recorder for infrequent episodes 3
   • Echocardiography to exclude structural heart disease 2

4. If Diagnosis Remains Unclear:

   • Consider implantable loop recorder for long-term monitoring 3
   • Electrophysiological studies only if recording attempts fail and symptoms are significant 3

Clinical Pearls

• The vast majority of palpitations with normal vital signs and no rhythm disturbances are benign 8, 5
• Class III recommendation: Electrophysiological studies are not recommended in patients with normal ECG, no heart disease, and no palpitations 3
• Palpitations documented to be due to extracardiac causes (e.g., hyperthyroidism) do not warrant electrophysiological studies 3
• Even with normal vital signs, palpitations preceding syncope require thorough evaluation 3

When to Refer to Cardiology

• Palpitations with syncope or pre-syncope 2, 7
• Palpitations with family history of sudden cardiac death 2
• Palpitations that significantly impact quality of life despite normal evaluation 2
• When ambulatory monitoring captures concerning arrhythmias 2, 7