As unsettling as they may be, palpitations aren’t necessarily a bad thing! Palpitation is the common term applied to that funny feeling happening in your chest. The feeling is described as racing, fluttering, pounding, or flip-flopping occurring at the center on your chest and scaring you to death. Palpitations occur any time of the day or night, at rest or with activity, and may be accompanied by any number of worrisome symptoms.
By themselves, palpitations carry a low mortality rate. However, when they occur frequently and repeatedly, they impair quality of life and cause increased use of health care resources to find their cause and to make them go away. The anxiety palpitations causes leads to all sorts of symptoms that are frequently psychogenic in origin. Today’s technological advances in testing and recording make it much easier to determine the cause of palpitations. This allows doctors to have better-informed and less anxious patients who can live more reassured lives.
To find the cause, or sometimes just the actual presence, of palpitations sometimes requires a lot of testing and a lot of patience from the physician. In the past, a patient’s complaint was met with auscultation (listening) of the heart and a 12-lead electrocardiogram. When you listen to the heart and don’t hear skipped, missing, or extra beats and do an EKG which is normal, the doctor’s frustration and doubts were heightened while the patient’s anxiety was not allayed. You wished you had some test or procedure that would give you the answer.
Today, doctors have numerous options that eventually lead to the correct diagnosis. Complex decision flow chart protocols incorporate all the available “physician-requiring” testing methods used to determine the cause. There also exist a number of “patient-initiated” recording/testing devices that allow patients to self diagnose or personally monitor their arrhythmia. A listing and a brief explanation of these devices will follow next:
Begin the evaluation with a thorough history and physical examination, a 12-lead electrocardiogram, a chest X-ray, and blood tests including thyroid testing, and tests specific to the heart (troponin, natriuretic peptide), magnesium, CBC, metabolic panel. An EKG is helpful only if it is abnormal. The diagnostic yield is low being 3% to 26%. If a palpitation does not occur during the EKG recording, you have learned nothing. The next step is to do an
Echocardiogram: This is a sonar/ultrasound of the heart. It assesses pumping function, chamber size, and integrity of the 4 valves within the heart. During an echo, if palpitations occur, the device records them giving a clue to their origin. Next
Exercise Stress Testing: If palpitations are caused by exercise, a treadmill stress test or a medication-induced stress test is done to capture and identify the cause. Next is
Ambulatory EKG-Monitoring Device Testing:
1. Holter Monitor—an electronic heart recording device worn for 24-48 hours. It records every heart beat and reports every thing that the heart does during the recording period. If palpitations don’t occur (diagnostic only 10% to 15% of the time) during the recording period, a diagnosis is not made.
2. Event Recorder—an electronic recording device that is worn or carried for up to one month. The patient activates it when palpitations occur. If the arrhythmia is brief, the time lapse between the event and device activation may cause it not be recorded.
3. Patch Monitor—a single lead EKG worn and recording up to 14 days.
4. Mobile Cardiac Telemetry—an internet-based external recorder with three leads connected to patient. It records up to 30 days.
5. Implantable Recorder—device inserted under the skin for monitoring up to 36 months. This is an invasive procedure. The last resort is an
Electrophysiologic Study: An invasive procedure done like a cardiac catheterization. The physician tries to provoke the palpitations and if successful will try to therapeutically ablate (destroy, disable) the site of origin of the arrhythmia. EP studies are highly successful diagnostically and therapeutically for rapid arrhythmias.
Each of the above-listed procedures can be used to diagnose palpitations caused by the following arrhythmias:
Atrial Fibrillation
Atrial Flutter
Inappropriate Sinus Tachycardia—resting heart rate > 100 beats/minute
Nonsustained Ventricular Tachycardia—rapid heart rate after heart attack (myocardial
infarction)
Premature Atrial Contractions—extra, early beats originating in upper chambers (atria)
Premature Ventricular Contractions—extra, early beats coming for lower chambers
Sinus Node Dysfunction—heart beats very slowly, pacemaker required to treat
Supraventricular Tachycardia—rapid rhythm coming from upper chambers (atria)
Psychosomatic Disorders—patient has heightened awareness of minor irregularities, the
heart is normal
Once the cause and origin of the palpitations are determined, they can be treated appropriately and controlled or eliminated. Patients now have portable and wearable fitness devices that accurately and quickly monitor the arrhythmia and tell patients if treatment is being effective. Those devices are the following:
KardiaMobile/AliveCor—patient places fingers on a touch pad and can see a 30-second
EKG recording. Helpful for atrial fibrillation, rapid rhythms, and slow rhythms.
HeartCheck/CardiBeat—similar to Kardia Mobile. Gives 30-second EKG.
Apple Smartwatch—wrist sensor detects heart rate, arrhythmias, O2 saturation, unable to
distinguish all arrhythmias, expensive
Frontier X2–records EKG up to 24 hours, usable during exercise, expensive, worn on chest
Withings Scan Watch—detects heart rate, 30-second EKG, identifies arrhythmia types,
expensive
The only one of these devices I have actually seen at work is the Kardia Mobile monitor. At lunch, a friend showed me his unit and how it told him he was in atrial fibrillation with a heart rate of 133! Yikes! A lot of people have Apple Watches, but only once did I see the wearer attempt to detect an arrhythmia. It was unsuccessful.
The purpose of all these technological miracles is to identify the type of palpitations a patient has, their site of origin, and how frequently they occur. The benefit of having all this information is that it helps the physician develop a plan to treat the palpitations in the hope that they will be controlled if not eliminated. The wearable devices, such as the KardiaMobile, help patients to know if their palpitations are worrisome or not, and if they need to make a trip to the ER.
Years ago, before we had many of today’s sophisticated recording devices, I took care of a frail, elderly lady, who for years was treated for what everyone, including her cardiologists and I, thought was severe anxiety. Never did it occur to any of her physicians that she might have a cardiac arrhythmia until one day she had a mild stroke and was admitted to the hospital. Heart monitoring in the hospital revealed she had frequent episodes of Atrial Fibrillation that lasted only a few seconds. Immediately, her whole therapeutic approach was altered to focus on rhythm and heart rate control. The attitude of her attending physicians changed completely, as well.
Palpitations are a common problem that should be taken seriously, and today’s technology makes detection and identification much easier and more informative.
Reference: Gauer RL, Thomas MF, McNutt RA. Palpitations: Evaluation, Management, and Wearable Smart Devices. Am Fam Phys 2024 Sept.;110(3):259-269.
