From the Guidelines
Palpitations are most commonly caused by cardiac issues, such as arrhythmias, including supraventricular tachycardia (SVT) and premature ventricular contractions (PVCs), as well as psychological factors like anxiety and stress, and lifestyle factors including stimulant use. According to the most recent guidelines, specifically the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1, palpitations can be a symptom of various conditions, including ventricular arrhythmias. The guideline highlights that nondihydropyridines calcium channel blockers and some antiarrhythmic medications may relieve symptoms of palpitations.
Common Causes of Palpitations
- Cardiac causes:
- Arrhythmias (e.g., atrial fibrillation, supraventricular tachycardia, premature ventricular contractions)
- Heart valve problems
- Heart failure
- Structural heart abnormalities
- Psychological factors:
- Anxiety
- Panic attacks
- Stress
- Lifestyle contributors:
- Stimulants (caffeine, nicotine, alcohol, certain medications or recreational drugs)
- Medical conditions:
- Thyroid disorders (particularly hyperthyroidism)
- Anemia
- Fever
- Dehydration
- Electrolyte imbalances
- Hormonal changes:
- Pregnancy
- Menstruation
- Menopause
Importance of Medical Evaluation
If palpitations are persistent or concerning, especially when accompanied by symptoms like chest pain, shortness of breath, dizziness, or fainting, it is crucial to seek medical attention promptly, as these could indicate a serious underlying condition requiring treatment. The evaluation may involve a clinical history, physical examination, and possibly an electrophysiological study to assess the arrhythmogenic risk, as suggested by the guidelines 1. Management typically involves addressing the underlying cause, which might include medication adjustments, lifestyle modifications, or specific treatments for cardiac conditions.
Recent Guidelines and Recommendations
The 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1 provides valuable insights into the management of palpitations, especially in the context of ventricular arrhythmias. It emphasizes the importance of identifying and treating the underlying cause of palpitations to prevent complications such as sudden cardiac death. The guideline also discusses the role of implantable cardioverter-defibrillators (ICDs) in primary and secondary prevention of sudden cardiac death.
Given the complexity and potential severity of palpitations, it is essential to approach each case with a thorough evaluation and management plan tailored to the individual's specific condition and risk factors, prioritizing morbidity, mortality, and quality of life outcomes. This approach ensures that patients receive appropriate care to mitigate risks and improve their quality of life.
From the Research
Causes of Palpitations
- Palpitations can be caused by various factors, including arrhythmias, structural heart disease, psychiatric disease, systemic noncardiac disease, and drug or illicit substance assumption 2
- Cardiac causes of palpitations are the most concerning etiology, and distinguishing cardiac from noncardiac causes is important due to the risk of sudden death in those with an underlying cardiac etiology 3
- Noncardiac disorders, such as psychiatric illness, adverse effects of prescription and over-the-counter medications, and substance use, can also cause palpitations 3
- Primary cardiac arrhythmias are the most common cause of palpitations, but other cardiac disorders, such as cardiomyopathy, valvular heart disease, and coronary artery disease, can also contribute to this symptom 4
- Palpitations can also be caused by noncardiac disorders, such as anxiety-induced sinus tachycardia, and careful history is invaluable in deciding appropriate investigations and management 5
Specific Causes of Palpitations
- Premature atrial contractions (PACs) and premature ventricular contractions (PVCs) are common causes of palpitations, and can be associated with underlying heart disease 6
- Supraventricular tachycardia is another common cause of palpitations, and can be treated with cardioversion, catheter ablation, or medical antiarrhythmics 6
- Sinus node dysfunction can also cause palpitations, and can be treated with atropine, discontinuation of bradycardia-causing drugs, or pacemaker implantation 6
- Hormonal changes, such as those that occur during the menstrual cycle, pregnancy, and menopause, can also contribute to palpitations 4
Risk Factors for Cardiac Causes of Palpitations
- A history of cardiovascular disease, palpitations at work, or palpitations that affect sleep can increase the risk of a cardiac cause of palpitations 3
- A family history concerning for cardiac dysrhythmias, or abnormal physical examination or electrocardiography findings, can also prompt a more in-depth evaluation for heart disease 3