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



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