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 the 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
If the patient complains of palpitations, ask him about dizziness and shortness of breath. Then inspect for pale, cool, clammy skin. Take the patient’s vital signs, noting hypotension and an irregular or abnormal pulse. If these signs are present, suspect cardiac arrhythmia. Prepare to begin cardiac monitoring and, if necessary, to deliver electroshock therapy. Start an I.V. line to administer an antiarrhythmic, if needed.
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? Make sure to obtain a drug history. Has the patient recently started cardiac glycoside therapy? Also, ask about caffeine, tobacco, and alcohol consumption.
Then explore associated symptoms, such as weakness, fatigue, and angina. Finally, auscultate for gallops, murmurs, and abnormal breath sounds.
Medical causes
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, patients hyperventilate, 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 hypertension, the patient may be asymptomatic or may complain of sustained palpitations alone or with a headache, dizziness, tinnitus, and fatigue. His blood pressure typically exceeds 140/90 mm Hg. He may also experience nausea and vomiting, seizures, and a decreased level of consciousness.
Hypocalcemia
Typically, hypocalcemia 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.
Mitral prolapse
Mitral prolapse is a valvular disorder that may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder, however, is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, a migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.
Mitral stenosis
Early features of mitral stenosis 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 fibrillation.
Thyrotoxicosis
A characteristic symptom of thyrotoxicosis, 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 a ventricular gallop.
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.
Herb Alert
Herbal remedies, such as ginseng, may cause adverse reactions, including palpitations and an irregular heartbeat.
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 a 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: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Palpitations
Read excerpts from these other book chapters related to Palpitations:
Medical Books Excerpts
- MURMURS
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
- Murmurs
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Murmurs
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Tachycardia
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Palpitations
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Tachycardia
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Palpitations
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Murmurs
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Tachycardia
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Palpitations
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Murmurs
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Tachycardia
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Murmurs
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
- MURMURS
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Palpitations
» Next page: Palpitation* (A Pocket Manual of Differential Diagnosis)
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