Palpitations and Monitoring

Case 2. PA is a 20-year-old college student who presents with a concern about palpitations. They report moderate stress, have no significant medical history, take no medications, use alcohol and marijuana occasionally, drink caffeinated energy drinks when studying for examinations, and walk around campus for exercise. On presentation, PA does not appear anxious and vital signs are within normal limits. Their cardiac examination reveals an irregular heartbeat.

Palpitations are defined as an unpleasant or alarming awareness of regular or irregular heartbeats. Various symptoms described by patients include heart skipping, pounding, fluttering, and racing, typically localized to the precordium, neck, or throat. Palpitations are a common concern encountered by primary care physicians and cardiologists.¹ They are the second leading cause of referrals to cardiologists after chest discomfort.^2,3 Primary care clinicians are faced with the task of differentiating benign etiologies of palpitations from those that are potentially life-threatening, such as ventricular arrhythmias and structural heart disease. Accurate distinction between cardiac and noncardiac causes is essential to guide appropriate diagnostic evaluation and management. In the primary care setting, about one-half of patients presenting with palpitations are found to have no clinical arrhythmias.^4,5 Although most cases of palpitations are benign, they remain a significant source of patient anxiety and distress and health care use.⁶

Given the broad definition and varying etiologies of palpitations, epidemiologic data are limited. Palpitations account for 16% of all primary care visits.^3,7 The prevalence is thought to be greater in women than in men.^7,8 Women presenting with palpitations have better prognosis than men, with lower rates of diagnosed arrhythmias, hospitalizations, and death at 1 year.^8,9

Palpitations can have arrhythmic or nonarrhythmic causes. Arrhythmic palpitations are more likely to be diagnosed in patients who have preexisting cardiac disease (coronary artery disease, cardiomyopathy, significant valvular disease), are male, and are older than 60 years.^8–10 Negative predictors for arrhythmic palpitations include smoking, anxiety disorders, a family history of palpitations, alcohol use, and panic disorder.⁴ Patients with anxiety disorders experience a high prevalence of palpitations yet have a low incidence of documented cardiac arrhythmias.¹¹ Certain arrhythmogenic conditions such as supraventricular tachycardia (SVT) may present with autonomic symptoms mimicking anxiety. Therefore, the presence of a psychiatric diagnosis should not exclude a cardiac evaluation when it is clinically indicated.⁴