Palpitations account for 16% of outpatient clinic and 0.6% of emergency department visits.^1,2 They are one of the most common symptoms prompting referral to cardiology.³ Ten percent of patients during their lifetime will experience palpitations, a subjective awareness of the heart rhythm often described as racing, irregular, fluttering, forceful pounding, skipped beats, or pounding in the neck.^4,5 The mechanisms for palpitations are variable and include contraction rates of the heart (i.e., fast, slow, or irregular rhythms), intense contractions and anomalous movement of the heart (e.g., structural heart disease, mitral valve prolapse), and anomalies in the subjective perception of the heartbeat (e.g., minimal cardiac irregularities or normal rhythms felt by the patient during certain situations or positions).⁶

The etiology of palpitations from a retrospective study revealed cardiac causes in 43% of patients (atrial fibrillation, 10%; supraventricular tachycardia, 9.5%; premature ventricular contractions, 8%), psychiatric in 31% (i.e., anxiety, panic disorder, somatization), miscellaneous in 10% (e.g., illicit drugs or medications, anemia, thyrotoxicosis), and unknown causes in 16%.⁷

A retrospective study (N = 357,681) evaluated patients presenting to the emergency department with the chief symptom of palpitations. Overall, 34% of patients had a cardiac diagnosis, and 25% of patients were hospitalized. In those discharged from the emergency department, the most common diagnoses were palpitations (30%), atrial fibrillation (13%), and cardiac dysrhythmias (11%). Among patients who were hospitalized, the most common discharge diagnoses were atrial fibrillation (28%), cardiac dysrhythmias (13%), and palpitations (8%). This study had a significantly lower rate of psychiatric diagnoses (5%) for patients presenting with palpitations than a 1996 study, possibly a result of spectrum bias or reluctance to ascribe a psychiatric diagnosis after a single emergency department encounter.¹

Patients presenting with palpitations generally have a benign course, with a 1-year mortality rate of 1.6%; however, prognostic implications are dependent on the underlying etiology and the clinical characteristics of the patient.⁷ Those with structural heart disease, arrhythmogenic heart disease, or family history of sudden cardiac death potentially have a more unfavorable prognosis, whereas palpitations in patients without structural heart disease, associated symptoms (i.e., chest pain, presyncope, syncope, dyspnea), or palpitations occurring during heightened psychomotor states generally have an excellent prognosis.⁶ Recurrence rates for palpitations are estimated to be 75%, with recurrence significantly impairing quality of life and increasing health care use.⁷

DIAGNOSTIC EVALUATION

Palpitations are a nonspecific symptom with a broad differential diagnosis^8,9 (eTable A). A detailed history, physical examination, and directed testing can determine the etiology of palpitations in approximately 40% of patients.⁸ The challenge is to distinguish palpitations of benign etiology from those that originate from structural heart disease and potentially lethal arrhythmias. In a multivariate logistic regression, the four independent predictors for palpitations being from cardiac origin are male sex, description of an “irregular” heartbeat, history of heart disease, and palpitations lasting longer than 5 minutes.¹⁰

History

The evaluation of a patient presenting with palpitations includes characterization of palpitations, personal medical history, history of early unexplained events (i.e., drowning, falling from a height, motor vehicle collision), family history of sudden cardiac death, social history, illicit drug use, and medication use^2,9,11–13 (eTable B). The clinician should determine the onset (sudden or gradual), duration (instant, paroxysmal, sustained), quality (rapid, regular, irregular), frequency (daily, weekly, monthly), triggers (activity, position, stress), and associated symptoms (chest pain, nausea, shortness of breath, presyncope, syncope) of palpitations.⁹ Asking the patient to tap the rhythm of the palpitations can be useful in identifying the rate and regularity of symptoms.

Patients with chronic conditions such as cardiac disease (i.e., heart failure, ischemic heart disease, cardiac surgery, and congenital heart disease) that include implantable cardiac devices, pulmonary disease (i.e., chronic obstructive pulmonary disease [hypercarbia, hypoxia] and pulmonary hypertension), and thyroid disease are also at increased risk for palpitations.² Palpitations in patients with a history of cardiac disease are attributable to arrhythmias in 91% of cases.¹⁴ Some patients with structural heart diseases (i.e., valvular disease, congenital heart disease, hypertrophic cardiomyopathy, prosthetic valves) report palpitations in the absence of arrhythmias.⁶ In the wake of the COVID-19 pandemic and recognized long COVID, multiple debilitating symptoms related to autonomic dysfunction have emerged, including chest pain, orthostatic intolerance, and palpitations.¹⁵

A small 2016 case-control study revealed that a higher percentage of patients with palpitations had coexisting psychiatric disorders than those without such disorders; however, other potentially harmful causes of palpitations must be ruled out before establishing psychosomatic disorder–related palpitations.¹⁶ In many cases, the primary sensation of palpitations in this population is from sinus tachycardia or heightened perception of the heartbeat in the context of a sinus rhythm. Occasionally, adrenergic hyperactivation associated with emotional stress can predispose patients to transient ventricular or supraventricular arrhythmias.⁶

Physical Examination

The physical examination is rarely diagnostic unless it is performed while the patient is experiencing palpitations or in the context of undiagnosed structural or ischemic heart disease. However, a well-focused examination can provide clues that may narrow the differential diagnosis and guide additional testing. The initial assessment should review vital signs to ensure hemodynamic stability and measure orthostatic blood pressures. Examination should include the cardiac system, pulmonary system, and neck and also assessment for physical findings of psychiatric health^2,9,11–13 (eTable B).

Diagnostic Studies

The initial diagnostic evaluation is a baseline 12-lead electrocardiography (ECG) and laboratory assessment.¹⁷ There is no consensus on recommended laboratory studies; however, obtaining a complete blood count, comprehensive metabolic panel, thyroid function studies, magnesium level, beta human chorionic gonadotropin (women of reproductive age), and toxicology screening is a reasonable cost-efficient starting point.¹³ Cardiac biomarkers (i.e., troponin, B-type natriuretic peptide) typically are not indicated unless patients have sustained arrhythmias, concern for ischemic heart disease, or hemodynamic instability. Chest radiography can be considered to evaluate suspected cardiac disease.

ECG. Twelve-lead ECG is the initial test of choice; however, the diagnostic yield is low, ranging from 3% to 26%.¹⁸ ECG documentation of a rhythm disorder during spontaneous symptoms provides the strongest evidence of causality distinguishing between arrhythmic vs. non-arrhythmic palpitations. When ECG is performed during palpitations, 48% of patients are found to have a rhythm abnormality.¹¹ Structural heart disease, ischemic heart disease, syndromic conditions, and conduction disorders are additional findings easily identified on ECG.

Echocardiography. Transthoracic echocardiography is useful to evaluate structural heart abnormalities. It is also recommended for patients with abnormal physical examination findings (i.e., displaced point of maximal impulse, evidence of heart failure, new or concerning murmur), abnormal ECG, episodes of syncope or presyncope, or family history of hypertrophic cardiomyopathy or sudden cardiac death.^6,9

Stress Testing. Cardiac stress testing is recommended in patients who experience palpitations during or shortly after exercise and in those with suspected ischemic heart disease.^2,6,8

Ambulatory ECG Monitoring. If the initial ECG is nondiagnostic and the suspicion for an arrhythmia remains high, then ambulatory ECG monitoring is recommended.¹⁹ Additional indications include history of structural heart disease, family history of sudden cardiac death, or inherited channelopathies. Some patients may experience undue anxiety from palpitations and require reassurance with ambulatory ECG monitoring.⁹ The length and type of ECG monitoring often are based on symptom frequency; several monitoring devices are described in Table 1.^5,6,20 Holter monitors are diagnostic in only 10% to 15% of patients with palpitations; however, they are recommended in those who have daily episodes of palpitations.²¹

Patients with an episode of syncope and palpitations or infrequent palpitations require extended ECG monitoring. Continuous external monitoring for 2 weeks is the recommended duration in evaluation of palpitations of unknown etiology, with the highest diagnostic yield-to-cost ratio of 70% to 85%.^{4,5,9,12,19,20} Implantable loop recorders have an average battery life of 3 years and are recommended when external loop recorders are unable to capture events or when patients' symptoms are too infrequent. Implantable loop recorders remain superior for patients with recurrent syncope (with or without palpitations) and detection of silent atrial tachyarrhythmias in patients with cryptogenic strokes.^21,22 They have the highest diagnostic yield for palpitations at 80% to 90%; however, the implantable loop recorder is the most invasive ambulatory ECG-monitoring device.²⁰

Electrophysiologic Study. An electrophysiologic study generally is indicated if ambulatory ECG remains undiagnostic, if palpitations are associated with a tachycardic heart rate (primarily high clinical suspicion for supraventricular tachycardia), or if palpitations precede syncope.^8,23 The procedure is highly diagnostic and therapeutic (ablative therapy) for tachyarrhythmias (i.e., atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, monomorphic ventricular tachycardia).

RED FLAGS

Most patients with palpitations are stable and can be evaluated within the outpatient setting. Low-risk features that generally do not require referral include isolated palpitations not provoked by exercise and absence of cardiac symptoms (i.e., syncope, presyncope, dyspnea, chest pain), no personal history of structural heart disease or family history of sudden cardiac death, and the presence of normal ECG findings.^13,24 Hemodynamic instability in association with palpitations may indicate a potentially lethal arrhythmia or coexisting structural heart disease. Individuals who require immediate resuscitation or who have ischemic chest pain, acute hypotension, signs of heart failure, decreased level of consciousness, and ischemic ECG changes should be transferred to the emergency department with immediate cardiology referral.¹³ Additional clinical findings requiring urgent evaluation are listed in Table 2.^{6,12,17,24,25}

MANAGEMENT

Treatment of palpitations is based on etiology; acute management depends on the patient's hemodynamic status and underlying arrhythmia (Figure 1).²⁶ In general, patients who present with palpitations with structural heart disease, ischemic heart disease, or conduction disorders require referral to cardiology for further diagnostic assessment and management. Patients are encouraged to discontinue any drugs precipitating palpitations. Table 3 lists treatment options for the most identified arrhythmias resulting in palpitations.^27–39 Premature atrial and ventricular beats are usually benign and often require only reassurance. Patients who have persistent symptoms from premature ventricular contractions may benefit from atrioventricular nodal blockers such as beta blockers (i.e., atenolol, propranolol, metoprolol, carvedilol [Coreg]) or nondihydropyridine calcium channel blockers (i.e., diltiazem, verapamil).^35–37 Individuals with symptomatic premature atrial contractions can be treated with beta blockers.³²

It is appropriate to refer patients with high ectopic burden or persistent symptoms despite pharmacologic treatment. Syndromic conditions with classic ECG findings and patients with concerning echocardiogram findings should be referred immediately to cardiology ^8,9 (eTable A). Patients with palpitations and no associated arrhythmia on ECG monitoring can be reassured without medical therapy. Those with underlying psychiatric disorders should have treatment directed toward psychosomatic symptoms. General recommendations for all patients with palpitations include reassurance when the cause is determined to be benign; avoidance of adrenergic substances, illicit drugs, or alcohol; management of cardiac risk factors; and stress-reduction therapy.⁶ A systematic review that enrolled participants with arrhythmias demonstrated reduction in palpitation episodes and premature ventricular contractions for patients engaged in a structured yoga practice for 45 to 60 minutes at least 3 days per week.⁴⁰

Some patients experience persistent palpitations resulting in significant disability despite a comprehensive evaluation in which no psychosomatic or cardiac etiology is found.⁴¹ Heightened cardioception awareness and enhanced activity of adrenergic neurotransmitters in the brain are proposed factors contributing to persistent symptoms. First-line therapy for most patients is reassurance and education; however, those with debilitating symptoms may benefit from the use of central alpha-2 agonists such as clonidine and avoidance of alpha-2 antagonists.⁴¹

SMARTPHONE-BASED AMBULATORY CARDIAC-MONITORING DEVICES

Current U.S. Preventive Services Task Force recommendations conclude that there is insufficient evidence to assess the balance of benefits and harms to screen for atrial fibrillation and make no recommendation for other types of arrhythmia screening.⁴² However, many U.S. adults use smartwatches and other consumer-grade devices that record heart rates by photoplethysmography (i.e., light-based technology to detect volumetric changes in blood in peripheral circulation) or single-lead ECG to detect arrhythmias, primarily atrial fibrillation.²⁹ Several apps are available (e.g., AliveCor KardiaMobile, Apple Watch, Fitbit, Frontier X2, QARDIO MD, Samsung smartwatch) for ECG monitoring; many devices have U.S. Food and Drug Administration clearance or approval⁴³ (Table 4^44–47). These devices combined have excellent sensitivity (92% to 98%) and specificity (76% to 95%) for detection of atrial fibrillation; however, the benefit of identifying other arrhythmias in patients experiencing palpitations is less clear.^44,48

A retrospective study (n = 152) evaluated patients referred to a cardiology department for recurrent palpitations after initial assessment. Participants used a 30-second ECG smartphone-based event recorder with mean monitoring time of 17 ± 8.2 days to record when activated by the patient for subjective symptoms of palpitations. Participants in the study had a mean age of 42 years and were considered healthy (i.e., only 3% had heart history, only 7% had abnormal ECG). Diagnostic yield using a smartphone-based cardiac monitor at conclusion of the study was 75% (31 out of 152 patients [20%] had confirmed arrhythmia with palpitations and 82 out of 152 [54%] had no arrhythmias coinciding with palpitations), with the remainder of patients having no symptoms during the recording period. The most common ECG findings observed in this study, in order of frequency, were sinus rhythm, sinus tachycardia, premature ventricular contractions, supraventricular tachycardia, and premature atrial contractions.⁴⁹

Another smaller study (n = 38) in patients with palpitations who wore the AliveCor KardiaMobile device and an external loop recorder demonstrated non-inferiority of the AliveCor Kardia-Mobile in detection of arrhythmias.⁵⁰ Main disadvantages of these devices are the inability to detect asymptomatic arrhythmias (patients must activate the application before ECG recording) and arrhythmias of short duration (e.g., isolated and infrequent extrasystoles); the devices also have high false-positive arrhythmia detection rates.⁴⁹

Wearable heart rhythm monitors (i.e., smartwatches) have demonstrated high diagnostic accuracy for detection of arrhythmias, particularly atrial fibrillation.⁵¹ Studies currently are underway to determine utility of mobile health interventions in improving clinical outcomes. For example, the Heart-line study is attempting to determine whether early detection of atrial fibrillation using these devices reduces thromboembolic events and cardiovascular outcomes.⁵² The challenge is deciding how to integrate digital health technologies with established clinical medicine. Additional uncertainties are determining best practices for physician notification, documentation, reimbursement protocols, and coordination of care with arrhythmia detection from consumer-grade devices.⁵³

This article updates previous articles on this topic by Wexler, et al.,²⁶ and Abbott.⁵⁴

Data Sources: A literature search was conducted in PubMed using the key terms palpitations, ambulatory electrocardiogram monitoring, arrhythmias, atrial fibrillation, atrial flutter, epidemiology, inappropriate sinus tachycardia, atrial tachycardia, atrioventricular non reentrant tachycardia, atrioventricular reentrant tachycardia, and smartwatch. The search included meta-analyses, randomized controlled trials, reviews, and society guidelines. The Cochrane database, U.S. Preventive Services Task Force, and Essential Plus were also searched. Major organization guidelines included the European Society of Cardiology, European Heart Rhythm Association, American Heart Association, American College of Cardiology, and the Heart Rhythm Society. We critically reviewed studies that used patient categories such as race and/or gender before including them in our final review. Search dates: December 15, 2023; January 2 and August 5, 2024.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army, the U.S. Department of Defense, or the U.S. government.