Can Angina Pectoris Present as Palpitations?
No, palpitations are not a typical presentation of angina pectoris, but they can occur as an associated symptom in specific cardiac conditions that may coexist with coronary artery disease, particularly mitral valve prolapse and arrhythmias triggered by myocardial ischemia.
Classic Angina Presentation
The European Society of Cardiology defines typical angina as meeting all three characteristics: substernal chest discomfort of characteristic quality and duration, provoked by exertion or emotional stress, and relieved by rest and/or nitrates within minutes 1. Palpitations are notably absent from this definition and from the standard clinical classification of angina pectoris 1.
When Palpitations May Occur with Cardiac Ischemia
Arrhythmias During Ischemic Episodes
- Ventricular arrhythmias can occur during episodes of unstable angina, with serious ventricular arrhythmias documented in 57% of patients during spontaneous angina attacks at rest 2.
- In unstable angina, arrhythmias appear in 22% of ECGs recorded during chest pain episodes, with ventricular premature contractions in 9% and ventricular tachycardia in 4% 3.
- These arrhythmias may be perceived as palpitations by the patient, but they are a complication of ischemia rather than a primary presentation of angina 3, 2.
Mitral Valve Prolapse Syndrome
- The ACC/AHA guidelines specifically note that patients with mitral valve prolapse commonly present with palpitations, often reported when continuous ambulatory ECG recordings show no arrhythmias 1.
- Critically, these guidelines state that chest pain in MVP patients "rarely resembles classic angina pectoris" 1.
- Palpitations in MVP are associated with mild tachyarrhythmias or increased adrenergic symptoms, and predictors include depression, poor self-rated health, alcohol intoxication in women, and heavy coffee drinking and physical inactivity in men 1.
Distinguishing Angina from Other Causes of Palpitations
Panic Disorder Considerations
- In patients with cardiovascular risk factors and gastric issues, panic disorder with agoraphobia can present with palpitations, chest discomfort, and fear of medical emergencies 4, 5.
- 45% of patients with panic disorder have mitral valve prolapse, creating diagnostic overlap 1.
- Panic attacks are characterized by sudden onset building to a peak, with associated symptoms including trembling, dizziness, derealization, paresthesias, and chills or hot flushes 1.
Acute Coronary Syndrome Presentations
- The ACC/AHA guidelines list palpitations as one of several possible presenting symptoms when evaluating suspected acute coronary syndrome, but only when accompanied by other symptoms suggestive of acute ischemia 1.
- In a study of 10,689 patients evaluated for suspected ACS, palpitations alone (without chest pain or anginal equivalents) was insufficient for diagnosis, and 75% of patients were ultimately deemed not to have acute ischemia 1.
Clinical Approach to This Patient
Given the context of gastric issues and cardiovascular risk factors:
- First, evaluate for typical anginal symptoms: substernal chest discomfort with exertional trigger relieved by rest, rather than focusing on palpitations as the primary cardiac symptom 1.
- Obtain ECG during symptoms: if palpitations occur with chest discomfort, ECG may reveal ST-segment changes (depression ≥1 mm indicating ischemia) or arrhythmias 6, 3.
- Consider gastroesophageal reflux disease: gastrointestinal disorders commonly present with chest pain that mimics angina and can occur with palpitations, particularly in patients with known gastric issues 7.
- Assess for panic disorder: if palpitations occur with fear, avoidance behaviors, and multiple somatic symptoms without clear cardiac triggers, panic disorder is more likely than angina 4, 5.
Critical Pitfall to Avoid
Do not diagnose angina pectoris based on palpitations alone 1. The absence of classic anginal chest discomfort (substernal pressure/tightness provoked by exertion and relieved by rest) makes angina unlikely as the primary diagnosis 1. If palpitations are the predominant symptom, consider arrhythmias (which may be ischemia-induced), mitral valve prolapse, panic disorder, or other non-ischemic cardiac conditions before attributing them to angina pectoris 1.