Palpitations

Heart palpitations -- an unusual awareness of the heartbeat -- is an extremely common symptom. Most people who complain of palpitations describe them either as “skips” in the heartbeat (that is, a pause, often followed by a particularly strong beat,) or as periods of rapid and irregular heartbeats.

While many people with palpitations can ignore them, others find them extremely disturbing and frightening, and often worry that they are about to die at any moment. Fortunately, the vast majority of palpitations are not associated with life threatening heart rhythm disturbances.

When a patient complains to a doctor about palpitations, it becomes the doctor’s obligation to do two things: a) identify the cause of the palpitations, and b) provide optimal treatment for that cause.

What Kinds of Arrhythmias Produce Palpitations?
Most people with palpitations have some type of cardiac arrhythmia. Virtually any arrhythmia can cause palpitations, but the most common causes of palpitations are premature atrial complexes (PACs), premature ventricular complexes (PVCs), episodes of atrial fibrillation, and episodes of supraventricular tachycardia (SVT). Click here for a quick and easy review of heart arrhythmias.

However, in some cases, palpitations can be caused by more dangerous arrhythmias, such as ventricular tachycardia. Life-threatening arrhythmias are usually seen in patients with underlying heart disease, however, so it is especially important to identify what is causing palpitations in individuals who have underlying heart disease. The same thing holds true for patients with palpitations who also have significant risk factors for heart disease (family history, smoking history, high cholesterol, overweight, sedentary lifestyle).
How Palpitations Should Be Evaluated
The first order of business when a patient complains of palpitations is to find out whether the palpitations are caused by a heart rhythm disturbance, and if so, to identify the particular arrhythmia that is causing the palpitations.

This should be relatively straightforward to do, so it always amazes me to see how much trouble doctors seem to have in accomplishing this feat. The trick is simply to record an electrocardiogram (ECG) at the time the patient is having symptoms. That’s it. Not exactly rocket science, is it?.

Don't Let These Mistakes Happen to You
Doctors commonly make two major mistakes in their attempt to determine whether an arrhythmia is causing the palpitations: They often miss the arrhythmia that is causing the palpitations, and they often attribute the palpitations to an arrhythmia that is not causing them.

Mistake 1: The doctor will order an ECG (which records the heart rhythm for 12 seconds) or a Holter monitor study (which records the heart rhythm for 24 hours), and during that time the patient will not experience palpitations. Then, not seeing an arrhythmia, the doctor will declare that there is no arrhythmia causing the palpitations. Worse, the doctor may tell the patient that the symptoms are “all in your head.” But often, the arrhythmia that is causing the palpitations just happened not to occur during the arbitrary monitoring period. The doctor’s workup was inadequate.

To make a correct diagnosis, the palpitations and ECG must occur at the same time. If the palpitations occur only intermittently, and especially if they do not occur every single day, instead of doing an ECG or a 24-hour Holter study, the doctor should order an event recorder study. The event recorder study can continuously record the heart rhythm for weeks at a time – however long it takes to “capture” an episode of palpitations. It’s really quite simple – record the ECG for as long as it takes for the patient to have an episode of palpitations, then look to see what the heart rhythm is during the palpitations.

Mistake 2
: The doctor will see an arrhythmia during monitoring that is not associated with palpitations, and blame the palpitations on that arrhythmia. This is wrong. To say an arrhythmia is causing palpitations, the arrhythmia and the palpitations must occur at the same time. Once again, monitoring must continue until palpitations occur, so that the heart rhythm can be examined at the time of the palpitations.

Since doctors frequently make these two mistakes, it is important for patients to keep in mind the simple rule: To make a correct diagnosis, the ECG must be recorded at the very time the palpitations are taking place. If this has not been accomplished, the patient must redirect the physician's efforts through gentle reminders, guile, appeals to reason, righteous indignation, or whatever it takes.