Palpitations
From benign ectopy to dangerous arrhythmia — characterize, choose the right monitor, and catch the red flags.
Learning Objectives
- 1.Categorize palpitations by likely mechanism.
- 2.Select the right rhythm-monitoring strategy for the symptom frequency.
- 3.Recognize the high-risk features that change urgency.
Overview
Most palpitations are benign, but the job is to identify the minority that aren’t. Characterization plus the right monitor (matched to frequency) answers most cases; the red flags tell you who can’t wait.
Why this matters
Palpitations can be the only warning of a dangerous arrhythmia (VT, pre-excited AFib) or of structural heart disease. The company the palpitations keep — syncope, chest pain — drives urgency.
Mechanism categories
- •Ectopy (PACs/PVCs): "skips" — usually benign in structurally normal hearts.
- •SVT: abrupt-onset/offset regular tachycardia.
- •Atrial fibrillation/flutter: irregular (AFib) or regular ~150 (flutter).
- •Ventricular tachycardia: dangerous, often with structural disease.
Focused history
- •Fast/slow, regular/irregular; abrupt vs gradual onset and offset.
- •Associated syncope/near-syncope, chest pain, dyspnea.
- •Triggers, frequency, and duration; family history of sudden death.
- •Structural heart disease or prior cardiac history.
Exam and workup
- •EKG (ideally during symptoms); resting EKG for pre-excitation/QT/structural clues.
- •Ambulatory monitoring matched to frequency: Holter (daily), event/patch (weekly), implantable loop (rare/serious).
- •Echo if structural disease suspected; labs/TSH (thyroid, anemia, electrolytes).
Red flags / escalation
- •Palpitations with syncope/near-syncope, chest pain, or severe dyspnea.
- •Documented or suspected VT / wide-complex tachycardia.
- •Structural heart disease or family history of sudden cardiac death.
- •Pre-excitation (WPW) with AFib.
Escalate
Palpitations plus syncope, chest pain, or a dangerous rhythm are urgent/emergent — escalate rather than ordering a routine monitor and waiting.
Management basics
- •Benign ectopy with normal heart: reassurance, trigger reduction.
- •SVT/AFib: rate/rhythm and anticoagulation considerations belong to the management modules and physician.
- •Dangerous rhythms: escalate; do not manage alone.
Common beginner mistakes
- •Ordering a 24-hour Holter for monthly symptoms (will miss them).
- •Dismissing palpitations with red-flag features as anxiety.
- •Ignoring structural disease / family history of sudden death.
Nurse / MA workflow connection
- •MAs acquire EKGs and place monitors; nurses triage red-flag rhythm calls to you.
Mini cases
Healthy 30-year-old, occasional "skipped beats," no syncope, normal EKG and exam.
Next step?
Show answer
Likely benign ectopy. If reassurance isn’t enough or to document, use an ambulatory monitor sized to symptom frequency — not an urgent workup. No red flags here.
Patient with prior MI, palpitations with near-syncope, EKG capture shows wide-complex tachycardia.
Action?
Show answer
Wide-complex tachycardia with structural disease = assume VT — escalate emergently and manage per the VT pathway. This is not an outpatient monitor situation.