What are the causes and treatments of palpitations that stop with coughing?

Palpitations That Stop With Coughing

Direct Answer

Palpitations that terminate with coughing are most likely caused by ventricular premature contractions (VPCs) or supraventricular tachycardia (SVT), where the mechanical act of coughing functions as a vagal maneuver to interrupt the arrhythmia. 1, 2

Understanding the Mechanism

The relationship between coughing and palpitation cessation works through two distinct pathways:

• Vagal stimulation: Forceful coughing increases intrathoracic pressure and stimulates the vagus nerve, which can terminate reentrant arrhythmias like SVT by slowing AV nodal conduction 3, 2

• Hemodynamic interruption: In cases of VPCs, coughing may alter the hemodynamic conditions that trigger the premature beats, particularly affecting pulmonary artery blood flow patterns 1

Primary Causes to Consider

Ventricular Premature Contractions (VPCs)

• VPCs can directly trigger cough reflexes through VPC-induced hemodynamic changes in the pulmonary circulation, and the cough itself may then interrupt the pattern of premature beats 1
• Each cough may be preceded by a premature beat, creating a self-perpetuating cycle that breaks when the arrhythmia pattern is disrupted 1

Supraventricular Tachycardia (SVT)

• Coughing acts as a vagal maneuver similar to the Valsalva maneuver, potentially terminating reentrant SVT by increasing vagal tone and slowing AV nodal conduction 2
• This is analogous to "cough CPR" described in cardiac catheterization laboratories, where forceful coughing can maintain consciousness during brief arrhythmic episodes 3

Diagnostic Approach

Initial Evaluation

• Obtain a 12-lead ECG immediately during the initial visit to identify baseline abnormalities or capture the arrhythmia if present 2
• Focus history on the exact nature of palpitations, their onset pattern, duration, and the specific relationship to coughing (does coughing always terminate them?) 2, 4
• Assess for associated symptoms including dizziness, syncope, near-syncope, dyspnea, or chest pain, which suggest more serious underlying conditions requiring urgent evaluation 2, 5

Ambulatory Monitoring Strategy

• For frequent symptoms (daily or near-daily): Use 48-hour ambulatory ECG (Holter) monitoring as first-line diagnostic test 2
• For less frequent episodes: Event recorder or wearable loop recorder is more appropriate and cost-effective than Holter monitoring 2, 5
• The goal is to capture the arrhythmia during symptoms and document the termination with coughing 4, 5

Additional Testing

• Echocardiography should be performed to exclude structural heart disease, especially if palpitations are sustained or associated with concerning symptoms 2
• Consider stress testing only if palpitations occur primarily during or immediately after physical exertion 2

Treatment Based on Etiology

For VPC-Induced Palpitations

• Antiarrhythmic therapy with agents like disopyramide has been shown to successfully eliminate both VPCs and associated coughing 1
• Beta-blockers may also be effective for suppressing premature ventricular contractions 2

For SVT

• Teach vagal maneuvers (Valsalva, carotid massage) as first-line acute management, since the patient has already demonstrated response to vagal stimulation via coughing 2
• Consider beta-blockers or catheter ablation for definitive management of recurrent SVT 2
• Patients with documented SVT require guideline-directed medical therapy 2

Red Flags Requiring Urgent Evaluation

Immediate referral to cardiology/electrophysiology is indicated for: 2

• Palpitations associated with syncope or near-syncope
• Evidence of structural heart disease on echocardiography
• Documented complex ventricular arrhythmias
• Palpitations with severe dyspnea or chest pain

Common Pitfalls to Avoid

• Do not dismiss the symptom as benign without ECG documentation, even if palpitations terminate with coughing—this pattern suggests a specific arrhythmic mechanism that requires identification 1, 4
• Do not rely solely on resting ECG if it is normal; ambulatory monitoring is essential when the etiology cannot be determined from initial evaluation 2, 5
• Do not assume all self-terminating palpitations are benign—ventricular tachycardia can occasionally terminate spontaneously and requires different management than SVT 2

When No Arrhythmia is Found

If extensive monitoring fails to capture an arrhythmia despite clear symptoms:

• Consider non-cardiac causes including hyperthyroidism, hypoglycemia, or anxiety 5
• Review all medications and over-the-counter stimulants 5
• Up to 16% of patients with palpitations have no identifiable cause after complete evaluation 5