Palpitations

Defined as a conscious awareness of one’s heartbeat, palpitations are usually felt over the precordium or in the throat or neck. The patient may describe them as pounding, jumping, turning, fluttering, or flopping, or as missing or skipping beats. Palpitations may be regular or irregular, fast or slow, paroxysmal or sustained.

Although usually insignificant, palpitations may result from a cardiac or metabolic disorder and from the effects of certain drugs. Nonpathologic palpitations may occur with a newly implanted prosthetic valve because the valve’s clicking sound heightens the patient’s awareness of his heartbeat. Transient palpitations may accompany emotional stress (such as fright, anger, or anxiety) or physical stress (such as exercise and fever). They can also accompany use of stimulants, such as tobacco and caffeine.

To help characterize the palpitations, ask the patient to simulate their rhythm by tapping his finger on a hard surface. An irregular “skipped beat” rhythm points to premature ventricular contractions, whereas an episodic racing rhythm that ends abruptly suggests paroxysmal atrial tachycardia.

Emergency Interventions

History and physical examination

If the patient isn’t in distress, perform a complete cardiac history and physical examination. Ask if he has a cardiovascular or pulmonary disorder, which may produce arrhythmias. Does the patient have a history of hypertension or hypoglycemia? Be sure to obtain a drug history. Has the patient recently started cardiac glycoside therapy? Ask about caffeine, tobacco, and alcohol consumption.

Explore associated symptoms, such as weakness, fatigue, and angina. Auscultate for gallops, murmurs, and abnormal breath sounds.

Medical causes

Anemia

Palpitations may occur with anemia, especially on exertion. Pallor, fatigue, and dyspnea are also common. Associated signs include a systolic ejection murmur, bounding pulse, tachycardia, crackles, an atrial gallop, and a systolic bruit over the carotid arteries.

Anxiety attack (acute)

Anxiety is the most common cause of palpitations in children and adults. With this disorder, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, the patient hyperventilates, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.

Cardiac arrhythmias

Paroxysmal or sustained palpitations may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate; decreased blood pressure; confusion; pallor; oliguria; and diaphoresis.

Hypertension

With this disorder, the patient may be asymptomatic or may complain of sustained palpitations alone or with headache, dizziness, tinnitus, and fatigue. His blood pressure typically exceeds 140/90 mm Hg. He may also experience nausea and vomiting, seizures, and decreased level of consciousness (LOC).

Hypocalcemia

Typically, this disorder produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek’s and Trousseau’s signs.

Hypoglycemia

When blood glucose levels drop significantly, the sympathetic nervous system triggers adrenaline production. This may cause sustained palpitations, which may be accompanied by fatigue, irritability, hunger, cold sweats, tremors, tachycardia, anxiety, and headache. Eventually the patient may develop central nervous system reactions. These include blurred or double vision, muscle weakness, hemiplegia, and altered LOC.

Mitral prolapse

This valvular disorder may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.

Mitral stenosis

Early features of this valvular disorder typically include sustained palpitations accompanied by exertional dyspnea and fatigue. Auscultation also reveals a loud S₁ or opening snap, and a rumbling diastolic murmur at the apex. Patients may also experience related signs and symptoms, such as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, paroxysmal nocturnal dyspnea, peripheral edema, jugular vein distention, ascites, hepatomegaly, and atrial fibrillations.

Pheochromocytoma

This rare adrenal medulla tumor causes episodic hypermetabolism, commonly associated with paroxysmal palpitations. The cardinal sign of pheochromocytoma is dramatically elevated blood pressure, which may be sustained or paroxysmal. Associated signs and symptoms include tachycardia, headache, chest or abdominal pain, diaphoresis, warm and pale or flushed skin, paresthesia, tremors, insomnia, nausea and vomiting, and anxiety.

Sick sinus syndrome

A patient with this disorder may experience palpitations, as well as bradycardia, tachycardia, chest pain, syncope, and heart failure.

Thyrotoxicosis

A characteristic symptom of this disorder, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or ventricular gallop.

Wolff-Parkinson-White syndrome

Seen in children and adolescents, this disorder results in recurrent palpitations and frequent episodes of paroxysmal tachycardia.

Other causes

Drugs

Palpitations may result from drugs that precipitate cardiac arrhythmias or increase cardiac output, such as cardiac glycosides; sympathomimetics such as cocaine; ganglionic blockers; beta-adrenergic blockers; calcium channel blockers; atropine; and minoxidil.

Exercise

Exercise can normally cause palpitations, as well as in patients with coronary heart disease, hypertension, mitral valve prolapse, and cardiomegaly.

herb alert  Herbal remedies, such as ginseng and ephedra (ma huang), may cause adverse reactions, including palpitations and an irregular heartbeat. (Note: The FDA has banned the sale of dietary supplements containing ephedra because they pose an unreasonable risk of injury or illness).

Special considerations

Prepare the patient for diagnostic tests, such as an electrocardiogram and Holter monitoring. Remember that even mild palpitations can cause the patient much concern. Maintain a quiet, comfortable environment to minimize anxiety and perhaps decrease palpitations.

Pediatric pointers

Palpitations in children commonly result from fever and congenital heart defects, such as patent ductus arteriosus and septal defects. Because many children can’t describe this complaint, focus your attention on objective measurements, such as cardiac monitoring, physical examination, and laboratory tests.

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

Other Book Chapters Related to Arrhythmia

Read excerpts from these other book chapters related to Arrhythmia:

Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

More About Causes of Arrhythmia

• Back to symptom: Arrhythmia: Introduction (review 234 causes)
• Next Book Extract About Arrhythmia: Pulse rhythm abnormality (Professional Guide to Signs & Symptoms (Fifth Edition))
• All Book Extracts: All Online Book Extracts for Arrhythmia

More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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