Palpitations and Monitoring

Palpitations are a common symptom, characterized by the unpleasant or alarming awareness of heartbeats. Patients may describe sensations of rapid heart rate, fluttering, pounding, or skipped beats, typically localized to the precordium, neck, or throat. Palpitations may be associated with regular or irregular heartbeats. Palpitations are responsible for 16% of all primary care visits and are the second leading cause of referral to cardiologists. The differential diagnosis for palpitations is broad and includes arrhythmic and nonarrhythmic causes. Although most cases of palpitations are benign, the challenge for primary care physicians is to differentiate between benign etiologies and those requiring urgent management. Taking a detailed family and personal history is essential for evaluation. All patients presenting with palpitations should have 12-lead electrocardiography performed. Ambulatory electrocardiographic monitoring remains the mainstay of evaluation. Echocardiography may be appropriate in adult patients presenting with palpitations to evaluate for structural heart disease that may contribute to arrhythmias. Consumer-available wearable devices with ambulatory heart rhythm–monitoring capabilities have demonstrated diagnostic accuracy for detection of atrial fibrillation and promote greater patient engagement in care. The management of palpitations depends on the underlying etiology and can include conservative measures and reassurance, pharmacologic interventions, and invasive procedures.