Life-threatening causes of palpitations:

• Arrhythmias (e.g., Wolff-Parkinson-White Syndrome, ventricular tachycardia, ventricular fibrillation, long QT syndrome – Torsades).
• Sepsis.
• Metabolic abnormalities.
• Structural or ischemic heart diseases.

• 1/3^rd of emergency department visits due to palpitations are estimated to be due to a cardiac cause.
• Palpitations are associated with a high admission rate to the hospital.

Table 1. Differential Diagnosis for Palpitations

A 12-lead ECG should be obtained immediately for patients presenting with palpitations.

• Assess hemodynamic stability and address arrhythmia / underlying cause.
• For patients that don’t have diagnosis from ECG or cardiac exam, proceed to more comprehensive work-up.

ECG findings:

• Short PR interval & delta waves (supraventricular tachyarrhythmias, WPW syndrome).
  • Pre-excitation syndromes (Lown-Ganong-Levine Syndrome or WPW syndrome).
• Deep Q waves in leads I, aVL, and V4, V5, V6 (left ventricular hypertrophy).
• QT prolongation and abnormal T waves (long QT syndrome).
• Polymorphic VT (Torsade de pointes).
• Bradycardias (heart blocks).
• Q waves characteristic of prior MI.
• Pseudo RBBB and persistent ST elevations in V1-V2 (Brugada syndrome).

Arrhythmogenic right ventricular dysplasia cardiomyopathy.

History:

• Inquire about: lightheadedness, syncope, and presence of pacemaker.
• Inquire about co-existing ischemic, structural, metabolic, drug induced, psychiatric, pregnancy, or related conditions.
• Family Hx of sudden death.

Physical Exam

• Cardiac exam.
• Signs of hyperthyroidism.

Lab work: anemia and metabolic abnormalities.

Consider urine drug screening for patients that are suspected of substance use.

If concerns for heart disease, consider referral to cardiology for an echocardiogram.

For unexplained palpitations, ambulatory ECG monitoring should be considered.

If palpitations are sustained or poorly tolerated, consider referral to cardiology.

Specific treatment depends on the underlying cause of palpitations.

Some general treatments to consider include:

• Correction of metabolic imbalances (e.g., hypoglycemia, hypokalemia, hyperthyroidism).
• Discontinue offending medication or substance.
• Refer to psychiatry if underlying mental health condition suspected.
• For patients with palpitations that have an otherwise normal evaluation and normal sinus rhythm, consider holter monitor and to return during palpitations to evaluate.
• Manage arrhythmia depending on specific type (see in-depth resources).

1. https://www.uptodate.com/contents/ambulatory-ecg-monitoring?search=palpitations&topicRef=6835&source=see_link

   
   

2. https://www.uptodate.com/contents/arrhythmia-management-for-the-primary-care-clinician?search=palpitations&topicRef=6835&source=see_link

   
   

3. https://www.uptodate.com/contents/arrhythmia-management-for-the-primary-care-clinician?search=palpitations&topicRef=6835&source=see_link#H19b

   
   

4. https://www1.racgp.org.au/ajgp/2019/april/approach-to-palpitations

   
   

5. https://pubmed.ncbi.nlm.nih.gov/23177608/

   
   

1. Abbott AV. Diagnostic Approach to Palpitations. American Family Physician. 2005 Feb 15;71(4):743–50.

   
   

2. Wexler RK, Pleister A, Raman SV. Palpitations: Evaluation in the Primary Care Setting. American Family Physician. 2017 Dec 15;96(12):784–9.

   
   

3. Govender I, Nashed KK, Rangiah S, Okeke S, Maphasha OM. Palpitations: Evaluation and management by Primary Care Practitioners. South African Family Practice. 2022 Feb 24;64(1). doi:10.4102/safp.v64i1.5449

   
   

4. Zimetbaum PJ. Evaluation of palpitations in adults [Internet]. 2024 [cited 2024 Apr 16]. Available from: https://www.uptodate.com/contents/evaluation-of-palpitations-in-adults?search=palpitations&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H4272713002

   
   

5. Probst MA, Mower WR, Kanzaria HK, Hoffman JR, Buch EF, Sun BC. Analysis of emergency department visits for palpitations (from the National Hospital Ambulatory Medical Care Survey). The American Journal of Cardiology. 2014 May 15;113(10):1685–90. doi:10.1016/j.amjcard.2014.02.020