Can You Get Palpitations on PrEP?
Palpitations are not a recognized or documented side effect of PrEP medications (tenofovir disoproxil fumarate/emtricitabine or tenofovir alafenamide/emtricitabine) based on current guidelines and clinical evidence. 1
PrEP Medications and Cardiac Effects
- TDF/emtricitabine and TAF/emtricitabine do not appear on comprehensive lists of medications known to cause palpitations or cardiac arrhythmias 2
- The major guidelines for PrEP use from the International Antiviral Society-USA and CDC do not list palpitations as a known adverse effect of these medications 1
- Clinical trials evaluating PrEP efficacy (iPrEx, Partners PrEP, TDF2, FEM-PrEP) did not report palpitations as a significant adverse event 1
Known Side Effects of PrEP
The documented adverse effects of TDF-based PrEP include:
- Renal dysfunction (particularly glomerular dysfunction in individuals over 50 years, usually reversible) 1
- Bone density changes (reduced bone mineral density with TDF) 1
- Gastrointestinal symptoms (nausea, diarrhea) 1
- Headache 1
Cardiovascular Considerations with TAF
- Recent evidence suggests TAF may be associated with increased risk of hypertension and dyslipidemia compared to TDF, particularly in patients 40 years and older 3
- TAF users showed elevated risk of incident hypertension (OR 1.64) and statin initiation (OR 2.33) in matched cohort analysis 3
- However, hypertension itself does not typically cause palpitations unless severe or associated with arrhythmias 1
Evaluating Palpitations in PrEP Users
If a patient on PrEP reports palpitations, consider alternative etiologies:
Cardiac Causes to Evaluate:
- Arrhythmias (atrial fibrillation, premature ventricular contractions, supraventricular tachycardia, ventricular tachycardia) 1, 4
- Structural heart disease (mitral valve prolapse, cardiomyopathy, valvular disease) 1
- Ischemic heart disease (particularly if patient has cardiovascular risk factors) 1
Non-Cardiac Causes:
- Anxiety or panic disorder (one of the most common causes of palpitations) 4, 5
- Hyperthyroidism 1, 4
- Medications or substances: stimulants (caffeine, cocaine, amphetamines), decongestants (pseudoephedrine), anticholinergic drugs, anabolic steroids 1, 6
- Electrolyte abnormalities (hypokalemia, hypomagnesemia) 1, 2
- Hypoglycemia 4
Red Flag Symptoms Requiring Urgent Evaluation:
- Palpitations with syncope or near-syncope 1, 6
- Palpitations with chest pain 1, 6
- Palpitations during exercise 6
- Palpitations with dyspnea or signs of heart failure 1
Diagnostic Approach
For PrEP users with palpitations:
Obtain detailed symptom characterization: frequency, duration, associated symptoms (dizziness, chest pain, dyspnea), triggers (exercise, stress, substances) 1, 4
Assess cardiovascular risk factors: hypertension, diabetes, dyslipidemia, smoking, family history of sudden cardiac death or arrhythmias 1
Review all medications and substances: including over-the-counter medications, supplements, stimulants, and recreational drugs 1
Physical examination: heart rate and rhythm, blood pressure, cardiac auscultation for murmurs, signs of heart failure 1
12-lead ECG: essential initial test to identify arrhythmias, conduction abnormalities, or structural heart disease 4, 5
Ambulatory ECG monitoring if etiology unclear:
Laboratory testing: thyroid function, electrolytes (potassium, magnesium), complete blood count 1, 2
Echocardiography if structural heart disease suspected based on history, exam, or ECG findings 1
Clinical Pitfall
Do not attribute palpitations to PrEP medications without thorough evaluation for other causes, as this may delay diagnosis of potentially serious cardiac arrhythmias or other treatable conditions 1, 4. Palpitations warrant systematic investigation regardless of medication history, particularly when accompanied by concerning symptoms or in patients with cardiovascular risk factors 1.