Heart Palpitations

What Causes Them and How Should They Be Treated?

Nurse Adjusts the ECG Pads on a Male Hospital Patient's Chest
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Heart palpitations refers to an unusual awareness of the heartbeat. It is an extremely common symptom, and affects most people at some time in their lives.

People who experience palpitations most often describe them either as "skips" in the heartbeat (that is, a pause, often followed by a particularly strong beat), or as periods of rapid and/or irregular heartbeats.

While many people who have palpitations can simply ignore them, others find them extremely disturbing or frightening, and often worry that they are about to die at any moment.

Fortunately, however, the vast majority of palpitations are not caused by dangerous or life-threatening heart rhythm disturbances.

When you tell your doctor you are having palpitations, it becomes his or her obligation to do two things: a) identify the underlying cause of your palpitations, and b) provide you with the best advice for treating that cause.

What Kinds of Arrhythmias Produce Palpitations?

Most people with palpitations have some type of cardiac arrhythmia. Virtually any arrhythmia can cause palpitations, but the most common causes are premature atrial complexes (PACs), premature ventricular complexes (PVCs), episodes of atrial fibrillation and episodes of supraventricular tachycardia (SVT).

However, in some cases palpitations can be caused by more dangerous arrhythmias, such as ventricular tachycardia. Life-threatening arrhythmias are usually seen in patients who have some type of significant heart disease, so it is especially important to identify the cause of palpitations in people with heart disease, or who have significant risk factors for heart disease (such as family history, smoking history, high cholesterol, overweight, sedentary lifestyle).

Not all people who report palpitations have heart arrhythmias, however. The same sorts of symptoms can be caused by musculoskeletal problems or gastrointestinal disturbances, such as gas.

How Palpitations Should Be Evaluated

If you have palpitations, your doctor's first order of business is to find out whether the palpitations are caused by a heart rhythm disturbance, and to identify the particular arrhythmia that is producing the problem.

This should be relatively straightforward to do, so it's surprising how often doctors seem to have trouble with it. The “trick” in making the diagnosis is simply to record an electrocardiogram (ECG) at the time the patient is having symptoms. That’s it - it’s not exactly rocket science.

Don't Let These Mistakes Happen to You

Doctors commonly make two mistakes in their attempt to determine the cause of palpitations:

  • 1) They often fail to record the arrhythmia that is causing the symptoms.
  • 2) They often attribute the palpitations to an arrhythmia that is actually not causing them.

Mistake 1: The doctor will order an ECG (which records the heart rhythm for only 12 seconds) or a Holter monitor study (which records the heart rhythm for only 24 hours), and during this time of monitoring the patient will not experience either their palpitations or an arrhythmia. All too often, the doctor will then inappropriately conclude that the palpitations are not related to an arrhythmia. Worse, the doctor may tell the patient that the symptoms are "all in your head." Actually, the doctor’s workup was just inadequate.

To make a correct diagnosis, the palpitations and ECG recording must occur at the same time. If the palpitations occur only intermittently, and especially if they do not occur every single day, instead of doing an ECG or a 24-hour Holter study, the doctor should order an event recorder study. The event recorder study can continuously record the heart rhythm for weeks at a time – however long it takes to "capture" an episode of palpitations. It’s really quite simple – record the ECG for as long as it takes for the patient to have at least one episode of their palpitations, then look to see what the heart rhythm is during the palpitations.

Mistake 2: The doctor will see an arrhythmia during the monitoring period that is not associated with palpitations, and blame the palpitations on that arrhythmia. This is wrong. To say an arrhythmia is causing palpitations, the arrhythmia and the palpitations must occur at the same time.

Once again, monitoring must continue until palpitations occur, so that the heart rhythm can be examined at the time of the palpitations.

Since doctors frequently make these two mistakes, it is important for you to keep in mind this simple rule if you have palpitations: To make a correct diagnosis, an ECG must be recorded at the very time the palpitations are taking place. If your doctor thinks the workup is complete before this has been accomplished, then you must redirect his or her efforts through gentle reminders, guile, appeals to reason, righteous indignation or whatever it takes.

Treating Palpitations

Appropriately treating palpitations depends entirely on which arrhythmia is causing them. Different cardiac arrhythmias often require quite different treatment approaches.

Sources

Zimetbaum, P, Josephson, ME. Evaluation of patients with palpitations. N Engl J Med 1998; 338:1369.

Crawford MH, Bernstein SJ, Deedwania PC, et al. ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the guidelines for ambulatory electrocardiography). Circulation 1999; 100:886.

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