Evaluation of palpitations

history often vague; palpitations that just seem to fade away; hyperthyroidism-associated symptoms such as decreased weight despite increased appetite, emotional lability, oligomenorrhea; associated breathlessness and fatigue due to anemia; can be experienced in the setting of intense emotional episodes; associated headaches and flushing might be due to a pheochromocytoma

regular pulse >100 bpm; normal cardiac exam; signs and symptoms of hyperthyroidism (e.g., fine tremor, tachycardia, lid lag), anemia (e.g., pallor) or pheochromocytoma (episodic hypertension)

history of structural heart disease; association with acute illness; palpitations are often paroxysmal; fast and regular palpitations with sudden onset and termination; less specific symptoms such as fatigue and breathlessness can be present if atrial tachycardia is incessant

often normal; can see signs and symptoms of heart failure or pulmonary disease such as COPD or pneumonia

fast and regular palpitations; seen in patients with normal hearts but is more often seen in patients with left ventricular dysfunction or rheumatic heart disease; commonly seen in conjunction with atrial fibrillation

fluttering of the venous jugular pulse may be seen; arterial pulse typically normal in intensity but ventricular rate is variable depending on the degree of AV block; signs of congestive heart failure and left ventricular dysfunction may be present

history of congestive heart failure, valvular heart disease, hypertrophic/dilated cardiomyopathy, pericarditis, thyroid disease, pulmonary disease (including asthma), obstructive sleep apnea, or atrial flutter; paroxysmal or persistent palpitations; often associated with other symptoms such as dyspnea or fatigue; or can occur after binge drinking (holiday heart); common in older people; use of omega-3-acid ethyl esters in patients treated for hypertriglyceridemia; may be a history of athletic training

irregularly irregular pulse; often rapid; if the patient is in a normal rhythm at the time of examination signs of congestive heart failure, rheumatic heart disease, or thyroid disease should be sought

can occur at any age; symptom onset most common in the late 20s or early 30s; more common in women; palpitations typically have an abrupt initiation and termination, are fast and regular, described as being machine-like, and can be accompanied by a fullness in the throat due to right atrial contractions against a closed tricuspid valve; often terminated with Valsalva maneuvers and sometimes associated with presyncope

typically normal; during arrhythmia, the pulse is rapid and regular with a rapid fluttering of the jugular venous wave pulse

rapid and regular palpitations that can be terminated with Valsalva maneuvers; typically present in the teenage years; more frequently seen in males; associated with a slight increase in incidence of sudden cardiac death

typically normal at baseline; during palpitations there is a rapid pulse that is regular, except in the case of atrial fibrillation in the setting of WPW, in which case the pulse is irregular

usually seen in normal hearts; palpitations are described as an early beat with a pause followed by an unusually strong or "pounding" beat, or simply as a "flip-flop"; may be associated with caffeine intake

typically normal; peripheral arterial pulse is regular except for occasional premature beats, often with a brief pause afterward

usually seen in normal hearts; palpitations described as a skipped beat often with a pause afterward or a brief flip-flop, may be associated with caffeine intake; symptoms are usually not as intense as premature ventricular beats

typically normal; peripheral arterial pulse is regular except for occasional premature beats, often with a brief pause afterward

palpitations may be preceded by a stressful event; tingling, paresthesia, breathlessness may accompany the palpitations

physical exam is nonspecific

sweating, flushing, underlying illness, for example, influenza

elevated temperature

decreased weight despite increased appetite, emotional lability, oligomenorrhea, heat intolerance

weight loss, hyperreflexia, tachycardia, atrial fibrillation, fine tremor, may be goiter

significant alcohol intake, especially history of binge drinking

atrial fibrillation may be evident, signs of alcohol intoxication

history of large caffeine consumption or direct correlation between caffeine intake and palpitations

physical examination is nonspecific

use of stimulants or medications that prolong the QT interval such as fluoroquinolone antibiotics or certain antipsychotics

physical examination is nonspecific

usually young women age 15 to 25 years, may be recent viral infection; symptoms related to orthostatic intolerance (palpitations, lightheadedness, blurred vision, exercise intolerance, presyncope and syncope, tremor, generalized weakness, fatigue); may also present with nonorthostatic symptoms including dyspnea, gastrointestinal symptoms (e.g., bloating, nausea, diarrhea, constipation, abdominal pain), exercise intolerance, fatigue, headache, sleep disturbance, cognitive impairment, chest pain, bladder disturbance; may present with symptoms of associated comorbidities, such as Ehlers-Danlos syndrome and autoimmune diseases, particularly Hashimotos thyroiditis and celiac disease

orthostatic tachycardia, orthostatic palpitations; signs of associated comorbidities (e.g., joint hypermobility, small nontender goiter, diarrhea)

exaggerated heart response to exercise, without an identifiable etiology for the tachycardia such as pregnancy, anemia, or hyperthyroidism; commonly seen in young women

normal except for a fast and regular pulse >100 bpm

paroxysmal palpitations; often seen in the setting of catecholamine excess such as vigorous exercise; can be associated with near-syncope; typically no family history of arrhythmia

typically normal except during palpitations when the patient may have salvos of nonsustained VT that manifest as a rapid regular pulse

palpitations, often associated with syncope, can be triggered by exercise, fever, or emotional stress; drug history includes QT-prolonging drugs such as fluoroquinolone antibiotics or certain antipsychotics

typically normal

patients can present between ages 22 and 65 years with palpitations due to episodes of nonsustained VT or ventricular fibrillation (VF); often associated with syncope

typically normal

family history of hypertrophic cardiomyopathy or sudden cardiac death; symptoms are associated with dyspnea on exertion, near-syncope, and syncope, most often due to atrial fibrillation, but also VT

harsh crescendo-decrescendo murmur heard best in the right upper sternal border that gets louder with Valsalva maneuver, going from squatting to standing, or after a premature ventricular contraction; signs and symptoms of heart failure can be present, but typically not until later in the disease course

history of coronary heart disease with myocardial infarction, repaired congenital heart disease, mitral valve prolapse and/or regurgitation

signs of cardiomyopathy and/or congestive heart failure; diffuse and/or laterally displaced apical impulse consistent with left ventricular enlargement; gallop rhythm (S3); signs of atherosclerosis such as arterial bruits

headaches, flushing, diaphoresis, resistant hypertension, family history of panic attack-like symptoms (but episodic rather than situational)

hypertension, sinus tachycardia