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Palpitations
Diagnosis/Definition
- Irregular or rapid heartbeats sensed by the patient.
- These are commonly described as intermittent sensations of beating, flip-flopping or pounding in the substernal region or neck.
- Can be a common symptom even with a normal heart rhythm.
Initial Diagnosis and Management
- History and physical exam.
- Symptoms such as dizziness, light-headedness, syncope, shortness of breath or chest pain.
- Assess for triggers such as exercise, smoking, caffeine, drugs, stress.
- Evaluate for diseases such as murmurs, congestive heart failure, hypertension, chronic obstructive pulmonary disease, anemia, thyrotoxicosis.
- 12 lead electrocardiogram (EKG).
- Labs-CBC, thyroid function, electrolytes, digoxin or theophylline levels, as appropriate.
- Reassure patient if exam and EKG are both normal and symptoms are brief and infrequent.
- Decrease caffeine and other stimulant use.
- Do full evaluation (graded exercise test, holter/event monitor, echocardiography) if cardiovascular disease or with worrisome symptoms. Can refer to Cardiology, Internal Medicine or Family Practice depending on patient’s primary care portal.
Ongoing Management and Objectives
- Premature atrial contractions do not necessarily need to be treated.
- For patients without cardiac disease, simple ventricular ectopy (i.e., frequent premature ventricular contractions, couplets or brief non-sustained ventricular tachycardia) reassurance or beta blockers are first line therapy.
- Paroxysmal supraventricular tachycardia (PSVT) & re-entry supraventricular tachycardia rhythms may respond to vagal maneuvers.
- Beta-blockers, digoxin and calcium channels blockers can be tried for frequent episodes of PSVT.
- Avoid beta-blockers, verapamil, and digoxin in Wolfe-Parkinson-White syndrome.
Indications for Specialty Care Referral
See referral guideline for ventricular arrhythmias. – Ischemia, syncope, and/or frequent symptoms.
Atrial fibrillation (see referral guideline), conduction disturbances or benign (documented) arrhythmia not responding to conservative therapy.
Criteria for Return to Primary Care
Stable therapy regimens with control of arrhythmia.
Evaluation completed if no treatable abnormalities are found.
