Palpitations Causes and Treatment

Palpitations are defined as abnormal perception of the heartbeat and are described by patients as a disagreeable sensation of pulsation or movement in the chest and/or adjacent areas.

Causes of palpitations

Normally, the activity of the heart is not perceived by the individual in resting condition. During or immediately after intense physical activity or emotional stress, one may feel the heartbeat for brief periods. These sensations are regarded as physiological palpitations.

Outside of such situations, instead, palpitations are perceived as abnormal.

The palpitations are a very frequent symptom in the general population and, in particular, in patients suffering from hypertension or heart disease

Major causes of palpitations are arrhythmias and psychosomatic disorders (panic and anxiety disorders.

In spite of many theories put forward, not much is known about the events responsible for heartbeat sensation.

Palpitations may be either short-lasting that terminates spontaneously within a brief period of time, or persistent where the palpitations are ongoing and terminate only after adequate medical treatment.

Palpitations may occur daily, weekly, monthly, or yearly.

Causes of Palpitations

Cardiac arrhythmias

Supraventricular/ventricular extrasystoles
Supraventricular/ventricular tachycardias
Bradyarrhythmias
- Severe sinus bradycardia
- Sinus pauses
- Second- and third-degree atrioventricular block
Anomalies of pacemakers

Structural heart diseases

Mitral valve prolapse
Severe mitral regurgitation
Severe aortic regurgitation
Congenital heart diseases with significant shunt
Cardiomegaly and/or heart failure of various aetiologies
Hyperthrophic cardiomyopathy
Mechanical prosthetic valves

Psychosomatic disorders

Anxiety, panic attacks
Depression
Somatization disorders

Systemic causes

Hyperthyroidism
Hypoglycaemia
Postmenopausal syndrome
Fever
Anemia
Pregnancy
Hypovolaemia
Orthostatic hypotension
Postural orthostatic tachycardia syndrome
Pheochromocytoma
Arteriovenous fistula

Drugs

Sympathicomimetic agents in pump inhalers
Vasodilators
Anticholinergics
Hydralazine
Recent withdrawal of β-blockers
Alcohol
Cocaine
Heroin
Amphetamines
Caffeine
Nicotine
Cannabis

Types of Palpitations

Extrasystolic

This are due to due to ectopic beats and produces feelings of ‘missing a beat’ and/or ‘sinking of the heart’ interspersed with periods during which the heart beats normally. Patients feel the heart to stop and then start again, causing an unpleasant, almost painful, sensation of a blow to the chest.

This type is linked to the presence of atrial or ventricular extrasystolic beats.

This kind of palpitation is often seen in the absence of heart disease. It generally has a benign prognosis.

Tachycardiac

There is rapid fluctuation like ‘beating wings’ in the chest with an associated rapid heartbeat and are generally linked to supraventricular or ventricular tachyarrhythmias,

It may be regular [atrioventricular reentrant tachycardia, atrial flutter, or ventricular tachycardia], or irregular or arrhythmic[atrial fibrillation or post-atrial fibrillation-ablation atypical atrial flutter.]

Anxiety-related

The heartbeat is slightly elevated. The palpitations begin and end gradually, and are associated with unspecific symptoms, such as tingling in the hands and face, a lump in the throat, mental confusion, agitation, atypical chest pains, and sighing dyspnoea etc. These symptoms normally precede the palpitations.

Pulsation

These are felt as strong, regular and not particularly rapid, heartbeats. They tend to be persistent and are generally linked to structural heart diseases, such as aortic regurgitation, or to systemic causes involving a high stroke volume, such as fever and anaemia.

Diagnosis

The diagnosis is made by clinical history, physical examination, and a standard 12-lead ECG. The aim is to

Distinguish the mechanism of the palpitations
Otaining an electrocardiographic recording during symptoms
Evaluating the underlying heart disease.

Stress testing is indicated if the palpitations are associated with physical exertion, in athletes [Exercise-induced palpitations should raise suspicion for heart disease] and when coronary heart disease is suspected.

Echocardiography is used to evaluate the presence of structural heart disease.

Depending on the basis of the clinical presentation, in case of a systemic or pharmacological cause of palpitations, specific laboratory tests should be performed.

When required, mental health of the patient must be assessed.

Certain symptoms and circumstances associated may be very helpful in making differential diagnoses.

Arising after sudden changes in posture
- Intolerance to orthostatis
- Atrioventricular nodal reentrant tachycardia.
Polyuria
- Due to hypersecretion of natriuretic hormone
- Typical of atrial tachyarrhythmias, particularly atrial fibrillation.
The sensation of a rapid, regular pulse in the neck
- Suspcion of supraventricular tachycardia, particularly atrioventricular nodal reentrant tachycardia.

A patient may or may not have symptoms during physical examination

If the examination is done during palpitations, idea about frequency and regularity of heart rhythm may be taken by listening to the patient’s chest or by palpation of the arterial pulse. Carotid sinus massage causing interruption of the tachycardia is highly suggestive of a tachycardia involving the atrioventricular junction. A temporary reduction of the frequency is suggestive of atrial fibrillation, flutter, or atrial tachycardia.

Detailed examination of cardiovascular system should be carried. In case of a sinus rhythm or sinus tachycardia presence of systemic diseases potentially responsible for palpitations should be looked for.

In the absence of palpitations, the aim is to find signs of structural heart disease that could explain the occurrence of palpitations. It is also important to search for signs of systemic diseases.

Standard Electrocardiogram

If the patient is examined during palpitations, 12-lead ECG represents the diagnostic gold standard.

Even when the ECG is recorded in the absence of palpitations it provides important data that can suggest the arrhythmic origin.

Ambulatory ECG monitoring serves to document the cardiac rhythm during an episode of palpitations if this cannot be done by means of standard ECG

The devices currently used for ambulatory ECG monitoring can be external and implantable.

External devices comprise Holter recorders, hospital telemetry external loop recorders, and mobile cardiac outpatient telemetry.

Implantable devices comprise pacemakers and and implantable loop recorders (ILRs).

Electrophysiological Study

Electrophysiological study, as an invasive procedure, is usually considered at the end of the diagnostic work-up. However, EPS is able to correctly identify the type of arrhythmia responsible for the palpitations.

Treatment

Treatment for palpitations is directed towards the cause whenever it can be determined.

When a clear-cut cause is established and a low-risk curative therapy is available (e.g. ablation for supraventricular arrhythmias), it is the treatment of choice.

Moreover, in many benign arrhythmia, changes in lifestyle like restraining adrenergic substances such as caffeine or alcohol-containing beverages or non-cardiologic therapies (e.g. anxiolytic drugs or psychiatric counselling) may be useful to control symptoms and should be considered.

Patients with palpitations alsobenefit from [ scientific evidence is lacking] intensified reduction of cardiovascular risk factors. These could be

Smoking cessation
Treatment of dyslipidemia,
Management of hypertension, heart failure, and diabetes mellitus,
Moderate exercise

Patients with cardiac arrhythmias and/or structural heart disease need emergency hospitalization when they palpitations are associated with hemodynamic compromise, chest pain, or syncope.