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Palpitations Hub

Palpitations are a common cardiology complaint ranging from benign PVCs to life-threatening arrhythmias. This module covers the differential, red flags, triage, appropriate workup including ambulatory monitoring, and effective patient communication.

Cardiology APPsCardiology NursesMAsPA/NP Students

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💗Palpitations

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Pre-Test — Palpitations

~2 min

Answer a few quick questions before starting to measure your learning gain.

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Overview

Learning Objectives

1.Define palpitations and understand the patient experience
2.Build a focused differential from benign to life-threatening causes
3.Identify red flag features requiring urgent evaluation
4.Choose appropriate ambulatory monitoring: Holter vs event monitor vs loop recorder
5.Recognize when PVCs require further workup
6.Understand the SVT pattern of history
7.Identify common medication, dietary, and metabolic triggers
8.Know when to escalate to electrophysiology
9.Communicate effectively with Spanish-speaking patients

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APP Lesson: Palpitation Evaluation

Audience: Cardiology clinic nurses and APPs triaging palpitation complaints.

What Are Palpitations?

›Palpitations are the subjective awareness of the heartbeat — a sensation of the heart racing, pounding, fluttering, skipping, or stopping. Most patients find them uncomfortable or alarming even when benign.
›The challenge in evaluating palpitations is that they are symptom-based — the patient may be perfectly well when you see them, with a normal ECG and exam. The key is obtaining a detailed history, identifying red flags, and selecting the right monitoring strategy to capture the heart rhythm during symptoms.
›The vast majority of palpitations have a benign cause. However, a subset reflect dangerous arrhythmias requiring urgent evaluation or treatment.

The Differential: Benign vs Concerning

›BENIGN (most common):
› Premature ventricular contractions (PVCs) — single extra beats followed by a pause; felt as a "thump" or "skipped beat"
› Premature atrial contractions (PACs) — similar to PVCs but originating in the atria; often less symptomatic
› Sinus tachycardia — fast but regular rhythm; driven by fever, dehydration, anxiety, caffeine, pain, anemia, thyroid disease
› Anxiety and panic disorder — can cause or worsen palpitations; diagnosis of exclusion after cardiac causes ruled out
›CONCERNING (must not miss):
› SVT (supraventricular tachycardia) — paroxysmal, abrupt onset and termination; AVNRT most common type
› Atrial fibrillation / atrial flutter — irregular rhythm; can cause stroke, hemodynamic compromise
› Ventricular tachycardia (VT) — potentially life-threatening; especially in structural heart disease
› WPW (Wolff-Parkinson-White) — accessory pathway; delta waves on ECG; risk of rapid conduction in AFib → VF
› Long QT syndrome — congenital or acquired; risk of torsades de pointes → syncope and SCD
› Sinus node dysfunction — sick sinus syndrome; bradyarrhythmias alternating with tachyarrhythmias

History: What to Ask

›Onset: When did palpitations start? First episode vs recurrent? Duration of each episode?
›Character: Racing, pounding, fluttering, skipping, stopping? Regular or irregular?
›Onset/offset: Abrupt or gradual? SVT typically has sudden onset AND sudden termination.
›Frequency: How often? Daily, weekly, monthly?
›Triggers: Exercise? Rest? Caffeine? Stress? After meals? Specific positions? Alcohol?
›Associated symptoms — red flag symptoms include:
› Syncope or presyncope (lightheadedness, near-fainting) — concerning for hemodynamically significant arrhythmia
› Chest pain or pressure — possible ischemia or pericarditis
› Dyspnea — may indicate reduced cardiac output during episode
› Palpitations during exertion — red flag; associated with VT or CPVT
›Termination: Do they stop abruptly? Can the patient terminate them (e.g., bearing down, coughing, splashing cold water = vagal maneuvers suggesting SVT)?
›Medical history: Structural heart disease, prior arrhythmia, prior ablation, thyroid disease, prior MI, cardiomyopathy
›Family history: Sudden cardiac death, arrhythmia, pacemaker/ICD, long QT, hypertrophic cardiomyopathy
›Medications: Stimulants, sympathomimetics, decongestants, thyroid replacement, digoxin, antiarrhythmics, QT-prolonging drugs
›Substance use: Caffeine quantity, energy drinks, alcohol, tobacco, recreational drugs (cocaine, methamphetamine, cannabis)

Red Flags — Escalate Promptly

›Syncope with palpitations — this combination is high-risk; may indicate VT or other hemodynamically significant arrhythmia
›Palpitations during exercise — suggests exercise-induced arrhythmia (VT, CPVT, WPW); requires exercise stress testing
›Family history of sudden cardiac death, especially in young relatives
›Known structural heart disease (cardiomyopathy, prior MI, valve disease, congenital heart disease)
›Abnormal ECG findings: delta waves (WPW), prolonged QTc, wide complex tachycardia, LVH pattern
›Hemodynamic instability during palpitations: hypotension, severe dyspnea
›Wide complex tachycardia on ECG — always assume VT until proven otherwise
›Irregular tachycardia — consider new AFib, especially if fast ventricular rate

ECG Interpretation Essentials

›Always obtain an ECG when palpitations are ongoing or in any patient with palpitation complaint at first visit.
›Key findings to look for:
› PR interval: short PR + delta wave = WPW (accessory pathway)
› QTc: prolonged QTc (>450ms men, >460ms women) = long QT syndrome risk
› QRS width: wide complex tachycardia = VT until proven otherwise
› P waves: absent or chaotic = AFib; flutter waves at 300bpm = atrial flutter
› Narrow complex tachycardia, regular = SVT or sinus tachycardia
› Frequent PVCs: note morphology (unifocal vs multifocal), frequency
›Normal sinus rhythm on a resting ECG does NOT rule out a significant arrhythmia — the patient may be arrhythmia-free at the moment of the tracing.

Ambulatory Monitoring: Which to Choose?

›The choice of monitor depends on symptom frequency:
›Holter monitor (24–48 hours, up to 14 days): Best for frequent symptoms (daily or near-daily). Continuous recording. Patient keeps a diary and presses a button during symptoms. Suitable when symptoms are likely to occur during the monitoring period.
›Event monitor (30 days): Best for less frequent episodes (several times per week or month). Patient activates it during symptoms. Data transmitted to a monitoring center. More practical for outpatient use over weeks.
›Extended continuous patch monitors (e.g., Zio patch): Wearable patch worn up to 14 days; continuous recording; does not require patient button press; automatically detects arrhythmias. Growing alternative to Holter.
›Implantable loop recorder (ILR): Subcutaneous device inserted under local anesthesia; monitors continuously for up to 3 years. Best for infrequent but high-risk symptoms (monthly syncope, cryptogenic stroke workup, suspected intermittent arrhythmia). Dr. Armour implants these in clinic.
›Exercise stress test: Use when palpitations are reliably triggered by exercise — evaluates for exercise-induced arrhythmia.
›Electrophysiology (EP) study: Invasive; used to characterize arrhythmia mechanism and guide ablation.

PVCs — When to Evaluate Further

›PVCs are extremely common and usually benign in structurally normal hearts.
›PVC burden >10% of total heartbeats is associated with PVC-induced cardiomyopathy — check echocardiogram to assess EF.
›Symptomatic, high-burden PVCs (especially with reduced EF) may respond to:
› Beta-blockers (first-line for symptomatic PVCs)
› Antiarrhythmic medications (flecainide, sotalol — specialist-initiated)
› Catheter ablation — highly effective for symptomatic PVC burden, especially outflow tract PVCs
›Reassurance is appropriate for: low-burden PVCs, structurally normal heart, no red flags, tolerable symptoms.
›Further evaluation needed for: high burden (>10%), symptoms with exertion, structural heart disease, reduced EF, or significant patient concern.

SVT — Recognition and Concepts

›SVT (supraventricular tachycardia) is most commonly AVNRT (AV nodal reentrant tachycardia) — a reentrant circuit involving the AV node.
›Classic SVT history: abrupt onset, abrupt termination, regular, fast (150–250 bpm), may have neck pulsations ("frog sign" = RP wave visible in neck), may terminate with vagal maneuvers.
›Vagal maneuvers: Valsalva, carotid sinus massage, cold water immersion — can terminate SVT by slowing AV nodal conduction.
›Adenosine: IV medication that briefly blocks the AV node — can terminate SVT and also unmask atrial flutter.
›Ablation: Highly effective (>95% cure rate for AVNRT); appropriate for recurrent symptomatic SVT or patient preference.
›Beta-blockers or calcium channel blockers: Rate-control or prevention in non-ablation candidates.

Metabolic and Medication Triggers

›Thyroid disease: Hyperthyroidism causes sinus tachycardia and can precipitate AFib — check TSH in all palpitation patients without an obvious cause.
›Electrolyte abnormalities: Hypokalemia and hypomagnesemia lower the arrhythmia threshold; check BMP and magnesium.
›Anemia: Causes compensatory sinus tachycardia — check CBC.
›Caffeine and energy drinks: Common trigger, especially for PVCs and sinus tachycardia; counsel on reduction.
›Alcohol: Can trigger AFib, PVCs, and sinus tachycardia. "Holiday heart" — AFib triggered by alcohol binge.
›Stimulant decongestants: Pseudoephedrine, phenylephrine — sympathomimetic; avoid in palpitation patients.
›QT-prolonging medications: Many antibiotics (azithromycin, fluoroquinolones), antipsychotics, antifungals — check QTc and medication list.
›Thyroid replacement: Over-replacement causes tachyarrhythmias — check TSH.

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Clinical Cheat Sheet

Red Flags — Urgent Evaluation

•Syncope or presyncope with palpitations
•Palpitations during exertion
•Family history of sudden cardiac death
•Structural heart disease / prior MI / cardiomyopathy
•Abnormal ECG: delta waves, prolonged QTc, wide complex tachycardia
•Hemodynamic instability during episodes
•Irregular tachycardia suggesting new AFib

Monitor Selection

•Daily symptoms → Holter 24–48h or 14-day patch
•Weekly symptoms → 30-day event monitor
•Monthly / rare symptoms → Implantable loop recorder
•Exercise-triggered → Exercise stress test
•High-risk / syncope → Loop recorder or EP study

Common Causes by Pattern

•Abrupt onset + offset, regular = SVT
•Irregular tachycardia = AFib/flutter
•"Skip" or "thump" = PVCs or PACs
•Fast regular = sinus tachycardia or SVT
•Wide complex tachycardia = VT until proven otherwise
•With delta waves on ECG = WPW

Metabolic and Trigger Checklist

•TSH — rule out hyperthyroidism
•BMP — check potassium and sodium
•Magnesium — hypomagnesemia increases arrhythmia risk
•CBC — anemia as a driver
•Caffeine, energy drink, alcohol intake
•Stimulant medications / decongestants
•QT-prolonging drugs on medication list
•Thyroid replacement over-dosing

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Nurse Triage Checklist

Systematic nurse assessment for patients presenting with palpitation complaints.

Immediate Actions

Obtain ECG immediately if palpitations are currently ongoing
Obtain ECG at baseline even if palpitations have resolved
Vital signs including heart rate, blood pressure, SpO2
Orthostatic vital signs if presyncope or dizziness reported
Notify provider promptly if: irregular rhythm, wide complex tachycardia, syncope, or hemodynamic instability

History Checklist

How long have they had palpitations?
Describe the sensation: racing, skipping, fluttering?
Duration of each episode (seconds, minutes, hours)?
Frequency: daily, weekly, monthly?
Abrupt onset AND termination? (SVT pattern)
Any triggers: exercise, caffeine, stress, alcohol?
Did they pass out or feel like they were going to faint?
Any associated chest pain, dyspnea?
Family history of sudden cardiac death or arrhythmia?

Medication and Substance Review

Caffeine intake: cups of coffee, energy drinks per day
Stimulant decongestant use (Sudafed, phenylephrine)
Thyroid medication — dose and recent TSH
Alcohol and tobacco use
Recreational drug use (cocaine, amphetamines)
QT-prolonging medications on medication list
Recently started any new medications?

Escalate Urgently

Ongoing palpitations with hemodynamic instability
Syncope or loss of consciousness with palpitations
Wide complex tachycardia on ECG
Irregular rapid rhythm (possible new AFib)
Palpitations during exercise
Family history of SCD with current symptoms
Delta waves on ECG (WPW) — do not give AV nodal agents until reviewed

Loop Recorder Education Points (if ordered)

Explain: small device inserted under skin of chest under local anesthesia
Monitors heart rhythm continuously for up to 3 years
Patient receives a device activator — press during symptoms
Data can also be transmitted automatically
No activity restrictions after initial healing
MRI-conditional — verify before any future MRI
Follow-up schedule for device checks

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Patient Education Handout

What Are Palpitations?

Palpitations are the feeling that your heart is racing, pounding, skipping beats, or fluttering. Most people describe a sudden awareness of their heartbeat that feels unusual.
The good news: most palpitations are harmless. They are often caused by extra heartbeats (PVCs or PACs) that are very common and do not damage your heart.
However, some palpitations can be a sign of a heart rhythm problem that needs treatment. That is why it is important to tell your care team about them.

When to Go to the ER Immediately

Go to the emergency room or call 911 if palpitations are associated with:
•Fainting or loss of consciousness
•Severe chest pain or pressure
•Severe difficulty breathing
•Feeling like your heart is going very fast and will not stop
•Sudden confusion or weakness
•Blue lips or fingertips

Common Triggers to Reduce

Caffeine — coffee, tea, energy drinks, soda. Try cutting back and see if palpitations improve.
Alcohol — even small amounts can trigger palpitations in some people.
Stress and anxiety — deep breathing, exercise, and counseling can help.
Poor sleep — sleep deprivation can worsen palpitations.
Decongestant medications (cold medicines with pseudoephedrine) — can trigger fast heartbeats.
Energy supplements or weight loss pills — often contain stimulants.

What to Expect from Heart Monitoring

Since palpitations often come and go, your doctor may ask you to wear a heart monitor to catch the rhythm during an episode.
Holter monitor: A small recorder with sticky patches on your chest. You wear it 24–48 hours (or up to 14 days). Press the button when you feel palpitations. Keep a diary of when symptoms occur.
30-day event monitor: A smaller device worn for up to 30 days. You activate it when symptoms happen and it transmits the recording wirelessly.
Patch monitor (Zio): A single adhesive patch worn on your chest for up to 14 days. No wires or button needed — it records everything automatically.

What is a Loop Recorder?

A loop recorder is a very small device (about the size of a USB drive) that is inserted just under the skin of your chest during a quick procedure using local anesthesia.
It continuously monitors your heart rhythm for up to 3 years.
Your doctor may recommend one if your palpitations are infrequent but concerning — or if you have had unexplained fainting.
You will receive a small activator device to press during symptoms. The device can also transmit data automatically to your clinic.
You can do all normal activities. It does not affect your daily life.

When to Call the Clinic

•Palpitations are new or getting more frequent
•Episodes last longer than usual
•You feel lightheaded or nearly faint during an episode
•You have any questions about your heart monitor
•You are having side effects from any new medications

This handout is for education only and does not replace medical advice from your healthcare team.

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Spanish / Communication Phrases

Interpreter Notice: These phrases are for basic communication and rapport only. Use a certified medical interpreter for diagnosis, treatment decisions, medication changes, consent, discharge instructions, and all complex clinical conversations.

Are you feeling your heart racing or skipping?

¿Siente que su corazón late rápido o que se salta latidos?

How long do the episodes last?

¿Cuánto tiempo duran los episodios?

Did you pass out or feel like you were going to faint?

¿Se desmayó o sintió que se iba a desmayar?

Do you drink a lot of caffeine or energy drinks?

¿Toma mucha cafeína o bebidas energéticas?

We are going to do an EKG right now.

Le vamos a hacer un electrocardiograma ahora.

We may ask you to wear a heart monitor.

Es posible que le pidamos que use un monitor del corazón.

Do palpitations happen during exercise?

¿Le ocurren las palpitaciones durante el ejercicio?

Has anyone in your family had a sudden heart problem?

¿Alguien en su familia ha tenido un problema repentino del corazón?

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Sim Patient Case

Cardiology ClinicInteractive

Patient

[EN] 34-year-old Spanish-speaking female with no cardiac history presenting with episodic palpitations for 2 months. Episodes last 30–60 seconds, have abrupt onset and termination, occur at rest, and are associated with mild lightheadedness. No syncope. No family history of sudden cardiac death. Drinks 3 cups of coffee daily. [ES] Mujer de 34 años, hispanohablante, sin antecedentes cardíacos, que presenta palpitaciones episódicas durante 2 meses. Los episodios duran de 30 a 60 segundos, tienen inicio y terminación abruptos, ocurren en reposo y se asocian con mareo leve. Sin síncope. Sin antecedentes familiares de muerte cardíaca súbita. Toma 3 tazas de café al día.

Chief Complaint

[EN] "My heart just suddenly starts racing out of nowhere and then stops just as fast. It's happened maybe 10 times this month." [ES] "Mi corazón de repente empieza a latir muy rápido de la nada y luego se detiene igual de rápido. Me ha pasado unas 10 veces este mes."

Vitals

118/74 mmHg

72 bpm — regular sinus rhythm

SpO2

99%

Temp

98.4°F

14 breaths/min

Goal

[EN] Take a focused history in Spanish, identify the SVT-pattern of palpitations, choose appropriate workup, determine the right monitoring strategy, counsel on triggers, and decide when electrophysiology referral is appropriate. [ES] Realice una historia clínica enfocada en español, identifique el patrón de taquicardia supraventricular en las palpitaciones, elija el estudio apropiado, determine la estrategia de monitoreo correcta, oriente sobre los factores desencadenantes y decida cuándo es apropiada la derivación a electrofisiología.

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Disclaimer: This content is for educational purposes only. It is not medical advice, does not replace clinical judgment, and is not a substitute for institutional protocols or certified medical interpreters. No patient health information (PHI) should be entered into this application.