Palpitations - Differential Diagnosis Framework What? • It is an unpleasant awareness or sensation that the heart is pounding, racing, rapid fluttering or flip-flopping in the chest or neck. Palpitations Diagnosis: • Focused medical history • Physical exam • 12-lead ECG • Limited laboratory testing Heart Rate and Rhythm Regularity: Have the patient tap out their feeling of palpitations • Rapid and regular rhythms: PSVT or VT • Rapid and irregular rhythms: Paroxysmal AF, atrial flutter, or atrial tachycardia with variable block Mimics: • Esophageal spasm • Reflux • Hiatal hernia • Stomach rumbling • Intercostal muscle twitching CARDIAC CAUSES OF PALPITATIONS: Arrhythmias: • Atrial fibrillation/flutter • Bradycardia caused by advanced atrioventricular block or sinus node dysfunction • Bradycardia-tachycardia syndrome (sick sinus syndrome) • Multifocal atrial tachycardia • Premature supraventricular or ventricular contractions • Sinus tachycardia or arrhythmia • Supraventricular tachycardia • Ventricular tachycardia • Wolff-Parkinson-White syndrome Nonarrhythmic Cardiac Causes: • Cardiomyopathy • Congenital heart disease • Congestive heart failure • Mitral valve prolapse • Pacemaker-mediated tachycardia • Pericarditis or myocarditis • Valvular disease (e.g., aortic insufficiency, stenosis) • Severe mitral regurgitation • Severe aortic regurgitation • Congenital heart diseases with significant shunt • Cardiomegaly • Heart failure of various etiologies • Hypertrophic cardiomyopathy • Mechanical prosthetic valve NON-CARDIAC CAUSES OF PALPITATIONS: Medications/Toxins: • ETOH • Caffeine • Energy drinks • Methamphetamines • Cocaine • Tobacco • Recent withdrawal of β-blockers • Serotonergic drugs • Anticholinergics Systemic: • Electrolyte imbalance • Fever • Hypoglycemia • Hypovolemia • Pheochromocytoma • Pulmonary disease • Vasovagal syndrome • Hyperthyroidism • Anemia Psychiatric: • Panic disorder/Anxiety • Somatization Arrhythmias: • SVT will have an abrupt onset and offset • Sensation of palpitations associated with anxiety may build and relieve more gradually • Random palpitations: PVC • Gradual onset & resolution: sinus tachycardia • Abrupt in onset & termination: SVT or VT • Terminates with carotid sinus massage or other vagal maneuvers: SVT-AVNRT or AVRT • Standing up straight after bending over: AVNRT Red Flag Symptoms: • Chest pain: Underlying congenital or acquired heart disease • Lightheadedness/dizziness: Possible severe tachycardia due to decreased brain flow (VT/Vfib/Afib/WPW) • Loss of consciousness • Near-syncope, or syncope: Hemodynamically significant arrhythmia? • Family history of premature SCD • Structural heart disease • Severe bradycardia #Palpitations #Cardiology #Differential #Diagnosis
