Are palpitations and paroxysmal supraventricular tachycardia (PSVT) the same?

Are Palpitations and PSVT the Same?

No, palpitations and PSVT are not the same—palpitations are a symptom (the subjective sensation of an abnormal heartbeat), while PSVT is a specific cardiac arrhythmia that can cause palpitations. 1

Understanding the Distinction

Palpitations represent a symptom, not a diagnosis. They describe the patient's subjective awareness of their heartbeat, which may feel like skipped beats, racing, pounding, or irregular rhythm. 1 Palpitations have numerous potential causes including:

• Premature beats (PACs, PVCs) - commonly described as pauses or strong beats 1
• Atrial fibrillation - irregular palpitations 1, 2
• Sinus tachycardia - gradual onset/offset, triggered by stressors 1
• PSVT - regular, sudden onset/termination 1
• Ventricular tachycardia - potentially life-threatening 2
• Non-cardiac causes - hyperthyroidism, caffeine, anxiety, medications 3, 2

PSVT is a specific electrophysiologic diagnosis characterized by a regular rapid heart rate (150-250 bpm) with abrupt onset and termination, most commonly caused by reentry mechanisms involving either AV nodal reentry (AVNRT) or AV reentry via an accessory pathway (AVRT). 1, 4

Critical Clinical Features That Distinguish PSVT from Other Causes of Palpitations

The pattern of onset and termination is the most important distinguishing feature. PSVT episodes have sudden, paroxysmal onset and abrupt termination, whereas sinus tachycardia accelerates and decelerates gradually. 1

Regular versus irregular rhythm separates PSVT from other arrhythmias:

• Regular palpitations with sudden onset/offset strongly suggest AVNRT or AVRT 1
• Irregular palpitations point toward premature beats, atrial fibrillation, or multifocal atrial tachycardia 1

Response to vagal maneuvers confirms the diagnosis. Termination of tachycardia with Valsalva maneuver or carotid massage indicates reentrant tachycardia involving AV nodal tissue (AVNRT or AVRT). 1, 4

Polyuria occurs in approximately 15% of PSVT patients due to atrial natriuretic peptide release from atrial contraction against a closed AV valve—this symptom is highly specific for sustained supraventricular arrhythmia. 1

Diagnostic Approach to Palpitations

Obtain a 12-lead ECG immediately in every patient presenting with palpitations to identify baseline rhythm, look for pre-excitation patterns (delta waves suggesting Wolff-Parkinson-White syndrome), and determine if documented tachycardia is narrow or wide complex. 2

Pattern characterization must include:

• Frequency and duration of episodes 3, 2
• Mode of onset - sudden versus gradual 1
• Triggers - exercise, caffeine, alcohol, emotional stress 3, 2
• Associated symptoms - syncope, presyncope, chest pain, dyspnea, polyuria 1, 2
• Response to vagal maneuvers during episodes 1, 2

Ambulatory monitoring strategy depends on symptom frequency:

• Daily palpitations - 24-48 hour Holter monitoring 2
• Weekly episodes - event recorder (superior diagnostic yield and cost-effectiveness) 2
• Less than twice monthly with severe symptoms - implantable loop recorder 2

Management Implications

The distinction between palpitations as a symptom and PSVT as a diagnosis fundamentally changes management. Palpitations require diagnostic evaluation to identify the underlying cause, whereas documented PSVT warrants specific treatment decisions. 2

For documented PSVT, catheter ablation is first-line therapy for recurrent symptomatic episodes, with >95% acute success rate, <5% recurrence, and <1% risk of complete heart block. 2, 5

Beta-blockers may be prescribed empirically for suspected PSVT while awaiting rhythm documentation, but only after excluding significant bradycardia (<50 bpm). 2 However, Class I or III antiarrhythmic drugs should never be started without documented arrhythmia due to proarrhythmic risk. 2

Common Pitfalls

Do not assume all palpitations represent PSVT. The differential diagnosis is broad, and treatment differs dramatically depending on the underlying rhythm disturbance. 1, 2

Pre-excitation on ECG with a history of regular paroxysmal palpitations mandates immediate electrophysiology referral due to risk of sudden death from atrial fibrillation with rapid conduction over the accessory pathway. 2

Syncope or presyncope with palpitations occurs in approximately 15% of PSVT patients but may also indicate ventricular tachycardia or structural heart disease requiring urgent evaluation. 1, 2

Wide complex tachycardia documented on any rhythm strip requires immediate cardiology referral, as this may represent ventricular tachycardia rather than PSVT with aberrancy. 2, 4