This is a UKMLA-centred history guide about palpitations.
Introduction
Palpitations are an abnormal awareness of one’s own heartbeat. This can include the sensation of the heart racing, beating irregularly, or an unusual pounding sensation.
Presenting Complaint
Site
Most palpitations are felt in the chest.
You should additionally ask if they are also felt in the neck.
Palpitations are felt in the neck if the atria contract against closed atrioventricular valves. For example, premature ventricular beats or AV nodal tachycardias.
Quality/Character
Fast – tachycardias
Slow – Bradycardias and ectopic beats
Irregular – Irregular would be suggestive of atrial fibrillation, atrial flutter or ectopic beats
Regular – SVT, VT, sinus tachycardia, sinus bradycardia, heart block, etc
Additional beat or thump – suggestive of missed beat (increased diastolic filling with a skipped beat makes the next beat stronger and the patient is more aware of it)
Skipped beat or fluttering – suggestive of an additional ectopic beat (patient is aware of compensatory pause following premature beat)
Onset
Sudden – can be indicative of cardiac arrhythmias, although sinus tachycardia can also be sudden onset.
Triggers – anxiety, pain, caffeine and stress are all triggers for physiological palpitations. (this is normal)
Associated Symptoms
Pulmonary Embolism:
Chest pain, syncope, calf swelling/pain, shortness of breath
Dehydration:
Fevers, vomiting, diarrhoea, reduced urine output, poor oral intake.
Thyroid:
Heat intolerance, tremor, weight loss, diarrhoea, anxiety, dry skin, and hair loss
Anaemia:
Chest pain, dizziness, shortness of breath, pallor, bleeding.
Differentials
There is a large amount of overlap between the symptoms seen in the differential diagnoses for palpitations. This is summarised below.
| Differential | Features |
|---|---|
| Atrial Fibrillation | Irregularity is the main feature of AF. Can be paroxysmal (comes and goes) or continuous. |
| Pulmonary Embolism | Chest pain, dizziness, shortness of breath, syncope, calf pain and unilateral calf swelling. |
| Anaemia | Syncope, dizziness, chest pain, fatigue, breathlessness, symptoms of bleeding. |
| Dehydration | Precipitants: Fevers, vomiting, diarrhoea. Features: Reduced urine output, poor oral intake, fatigue. |
| Infection | Coryzal symptoms, cough, fever, dysuria, D&V, rash etc |
| Hyperthyroidism | Weight loss, tremor, heat intolerance, diarrhoea, anxiety, dry skin and hair loss. |
| Tachyarrhythmias such as SVT, VT, Atrial flutter. | Very fast rate, syncope, chest pain and more likely to feel unwell. |
Red Flags
There are serious causes of palpitations and it is important to demonstrate that you are considering them and asking red flag questions to screen for them:
Pulmonary embolism – As above
Unstable arrythmias – Syncope, chest pain, often strong personal of cardiac disease, ask about heart failure, cardiomyopathy, ischaemic heart disease and family history of sudden cardiac death below the age of 40.
Background
In any history you will ask about past medical history, medications, allergies, social history, and family history. In a history about abdominal pain, you can show how much you know about the various causes by explicitly asking about the following things:
Past Medical History
Hypertension, diabetes, obesity, sleep apnoea, and thyrotoxicosis are associated with atrial fibrillation and flutter.
Risk of serious arrhythmias is increased by ischaemic heart disease, heart failure, cardiomyopathy and valvular disease.
Previous VTE increases the risk of PEs.
Drug History
Salbutamol use will acutely raise a person’s heart rate.
Thyroxine will cause hyperthyroidism if taken in excess.
Oestrogen e.g. COCP and HRT increases the risk of VTE.
Anticoagulants significantly reduce the risk of pulmonary embolism, but do not make it impossible.
Family History
A family history of sudden cardiac death under the age of 40 years increases the risk of serious arrhythmias.
Family history of VTE is a risk factor for PE, but does not contribute to a Wells score.
Family history of thyroid disease and autoimmune conditions can increase the chance of a patient having hyperthyroidism.
Social History
Caffeine use cause and/or worsen palpitations.
Nicotine / alcohol withdrawal – ask about usual intake and if they have recently stopped, ask if they did this gradually or abruptly.
Cocaine, amphetamines, MDMA and cannabis use can all cause palpitations.
Examination
When examining the patient, you should keep your differentials in mind and look for signs that confirm or refute your potential diagnoses. All patients with active palpitations should have a full set of observations and an ECG.
Author and Editor – Dr James Mackintosh
Last updated 24/01/24
