Palpitations
Exam Tips
- In OSCEs, ask the patient to tap out the rhythm; a regular sudden-onset rhythm suggests SVT, while irregularly irregular suggests AF.
- Treat any broad-complex tachycardia as VT until expert review proves otherwise.
- Exertional palpitations, syncope, chest pain, breathlessness, and family history of sudden death are key red flags.
- Always look for reversible causes (thyroid disease, anaemia, fever, stimulants, QT-prolonging drugs) before labeling symptoms as anxiety.
- On ECG interpretation stations, recognise short PR + delta wave (WPW), prolonged QT, saw-tooth flutter waves, and absent P waves with irregular baseline in AF.
Definition
Palpitations are an abnormally perceived heartbeat, usually described as racing, pounding, fluttering, skipped beats, or an irregular rhythm. They are a symptom rather than a single diagnosis, and may arise from benign ectopy, systemic illness, anxiety states, or potentially life-threatening arrhythmias.
Pathophysiology
Palpitations occur when changes in cardiac impulse formation (enhanced automaticity, triggered activity) or impulse conduction (re-entry circuits) produce beats that are faster, irregular, or more forceful than normal sinus rhythm. Common mechanisms include supraventricular tachycardia re-entry pathways, atrial fibrillation/flutter, and ventricular ectopy/tachycardia. Symptom perception is amplified by increased adrenergic tone (stress, fever, thyrotoxicosis, stimulants), increased stroke volume (anaemia, pregnancy), and heightened interoceptive awareness in anxiety/panic disorders.
Risk Factors
- Previous ischaemic heart disease, heart failure, cardiomyopathy, or valvular disease
- Family history of sudden cardiac death under 40 years
- Hypertension, diabetes, obesity, and obstructive sleep apnoea (particularly for AF/flutter)
- Hyperthyroidism, anaemia, fever/sepsis, hypovolaemia, hypoglycaemia
- Alcohol excess, caffeine, nicotine, cocaine, amphetamines, ecstasy, cannabis
- Pro-arrhythmic medicines (for example macrolides, antipsychotics, tricyclics/SSRIs such as citalopram, azole antifungals), and recent beta-blocker withdrawal
- Pregnancy and menopause
- Congenital or structural abnormalities (for example pre-excitation syndromes, hypertrophic cardiomyopathy)
Clinical Features
Symptoms
- Awareness of rapid, pounding, fluttering, or irregular heartbeat
- Sudden episodic onset/offset (suggests paroxysmal tachyarrhythmia)
- Breathlessness
- Chest pain or chest tightness
- Dizziness, presyncope, or syncope
- Association with exertion (red flag), stress, caffeine, alcohol, or stimulant use
- Associated anxiety/panic symptoms
Signs
- Tachycardia or irregularly irregular pulse
- Haemodynamic instability (hypotension, altered mental state, shock features)
- Cardiac murmurs suggesting structural/valvular disease
- Signs of heart failure (raised JVP, bibasal crepitations, peripheral oedema)
- Signs of thyrotoxicosis (tremor, goitre, warm peripheries)
- Pallor or other signs of anaemia
- Fever or other infective features
Investigations
Management
Lifestyle Modifications
- Safety-net urgently for syncope, chest pain, breathlessness, or exertional onset; admit if haemodynamically unstable
- Reduce/stop triggers: caffeine excess, alcohol binges, nicotine, recreational stimulants
- Sleep optimisation, hydration, stress reduction, and management of anxiety/panic where relevant
- Review and rationalise prescribed/OTC medicines that may provoke tachycardia or QT prolongation
Pharmacological Treatment
Acute regular narrow-complex SVT
- Adenosine 6 mg rapid IV bolus, then 12 mg if needed; a further 12 mg may be given
Use after vagal manoeuvres and continuous ECG monitoring. Contraindications/cautions: severe asthma or active bronchospasm, 2nd/3rd-degree AV block (without pacemaker), sick sinus syndrome. Interactions: dipyridamole potentiates effect (lower dose), theophylline/caffeine antagonise effect.
Rate control for atrial fibrillation/flutter (stable patients)
- Bisoprolol 2.5-10 mg once daily
- Diltiazem MR 120-360 mg once daily
- Verapamil 40-120 mg three times daily (immediate-release)
- Digoxin 125-250 micrograms once daily (especially in sedentary patients or with heart failure)
Choose based on comorbidity and blood pressure. Avoid beta-blockers in uncontrolled asthma/bradycardia. Do not combine verapamil with beta-blockers due to risk of severe bradycardia/heart block.
Stroke prevention in AF when indicated by CHA2DS2-VASc
- Apixaban 5 mg twice daily (reduce to 2.5 mg twice daily if dose-reduction criteria met)
Assess bleeding risk (e. g, HAS-BLED), renal function, drug interactions, and adherence. Anticoagulation is not for isolated benign ectopy.
Symptomatic benign ectopy or adrenergic palpitations
- Propranolol 10-40 mg three times daily
Useful when symptoms are troublesome and no high-risk pathology is found. Contraindicated in asthma, significant bradycardia, or hypotension.
Surgical / Interventional
- Catheter ablation for recurrent symptomatic SVT, some atrial flutter pathways, and selected AF cases
- Electrical cardioversion for selected unstable or persistent tachyarrhythmias
- ICD implantation for patients at high risk of malignant ventricular arrhythmias
- Pacemaker revision/reprogramming when device malfunction contributes to symptoms
Complications
- Haemodynamic collapse in unstable tachyarrhythmia
- Syncope and trauma
- Stroke/systemic embolism in atrial fibrillation or flutter
- Tachycardia-induced cardiomyopathy and heart failure
- Sudden cardiac death (especially with VT/VF, inherited channelopathies, or structural disease)
Prognosis
Prognosis depends on cause: isolated ectopics and anxiety-related palpitations are usually benign, while prognosis is worse with structural heart disease, inherited arrhythmia syndromes, sustained ventricular arrhythmias, or untreated AF-related thromboembolic risk. Early identification of red flags, ECG diagnosis during symptoms, and treatment of reversible triggers significantly improve outcomes.
Sources & References
🏥BMJ Best Practice(1)
✅NICE Guidelines(1)
- Palpitations[overview]
📖Textbook References(9)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 424, 425)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 241)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 676, 677)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 235)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 33)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 99, 100)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 140)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 140)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 338, 339)[context]