920 Full

EHRA POSITION PAPER
Europace (2011) 13, 920934

doi:10.1093/europace/eur130
Management of patients with palpitations: a

position paper from the European Heart
Rhythm Association
Antonio Raviele 1*, Franco Giada 2, Lennart Bergfeldt 3, Jean Jacques Blanc 4,
Carina Blomstrom-Lundqvist5, Lluis Mont 6, John M. Morgan 7, M.J. Pekka Raatikainen 8,
Gerhard Steinbeck 9, and Sami Viskin 10
Document reviewers: Paulus Kirchhof (review coordinator) 11, Frieder Braunschweig 12, Martin Borggrefe 13, Meleze Hocini 14, Paolo Della Bella 15, and Dipen
Chandrakant Shah 16
1
Cardiovascular Department, Arrhythmia Center & Center for Atrial Fibrillation, DellAngelo Hospital, Via Paccagnella 11, 30170 Mestre-Venice, Italy; 2Cardiovascular Department,
PF Calvi Hospital, Noale-Venice, Italy; 3Cardiology Department, Salgrenska University, Gothenburg, Sweden; 4Cardiology Department, Bretagne University, Brest, France;
5
Cardiology Department, Uppsala University Hospital, Uppsala, Sweden; 6Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain; 7Wessex Cardiac
Center, Southampton University Hospital, Southampton, UK; 8Heart Center, Tampere University Hospital, Tampere, Finland; 9Internal Medicine, Ludwig-Maximilians University,
Munich, Germany; 10Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel; 11University Hospital Muenster, Muenster, Germany; 12Karolinska
University Hospital, Stockholm, Sweden; 13Universitaetsmedizin Mannheim, Mannheim, Germany; 14Hopital du Haut Leveque, Pessac, France; 15Ospedale San Raffaele, Milan, Italy;
and 16Cantonal Hospital, Geneva, Switzerland
Aim of the document

Palpitations are among the most common symptoms that prompt
patients to consult general practitioners, cardiologists, or emergency healthcare services.1 4 Very often, however, the diagnostic
and therapeutic management of this symptom proves to be
poorly efficacious and somewhat frustrating for both the patient
and the physician. Indeed, in many cases a definitive, or at least
probable, diagnosis of the cause of palpitations is not reached
and no specific therapy is initiated.5,6 This means that many
patients continue to suffer recurrences of their symptoms, which
impair their quality of life and mental balance, lead to the potential
risk of adverse clinical events, and induce continual recourse to
healthcare facilities.
These difficulties stem from the fact that palpitations are generally a transitory symptom. Indeed, at the moment of clinical evaluation, the patient is often asymptomatic and the diagnostic
evaluation focuses on the search for pathological conditions that
may be responsible for the symptom. This gives rise to some
uncertainty in establishing a cause effect relationship between
any anomalies that may be detected and the palpitations themselves. Moreover, as palpitations may be caused by a wide range
of different physiological and pathological conditions, clinicians
tend to apply a number of instrumental investigations, laboratory
tests, and specialist examinations, which are both time-consuming
and costly. Comparable, for example, to syncope, such an
approach is warranted in selected patients, whereas other patients
with palpitations may not require such careful follow-up. The initial
clinical assessment should, therefore, include an educated estimation of the likelihood of a relevant underlying arrhythmia in a
patient with palpitations (gatekeeper function).
The current management of patients with palpitations is guided
chiefly by the clinical experience of the physician. Indeed, the literature lacks specific policy documents or recommendations
regarding the most appropriate diagnostic work-up to be
adopted in individual patients. The aim of this article is to
propose expert advice for diagnostic evaluation in order to
guide optimal management of patients with palpitations.
Definition
Palpitations are a symptom defined as awareness of the heartbeat
and are described by patients as a disagreeable sensation of pulsation
or movement in the chest and/or adjacent areas.7 Implicit in that
awareness is a sense of unpleasantness which may be associated
with discomfort, alarm, and less commonly pain. As this awareness
causes the individual to mentally focus on their heartbeat, the
nature of the heartbeat, both in terms of its perceived forcefulness and its rate, is assimilated into the term. Therefore, the
term is used to describe a patients subjective perception of abnormal cardiac activity in a way that may be associated with a symptomatic cardiac arrhythmia. However, because palpitations are a
symptom with a broad range of causes and underlying diseases,
it does not have a rigorous and definable clinical correlate.
* Corresponding author. Tel: +39 0419657201; fax: +39 0419657235, Email: araviele@tin.it
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2011. For permissions please email: journals.permissions@oup.com.
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Introduction
921
Managing patients with palpitations
In normal resting conditions, the activity of the heart is generally

not perceived by the individual. However, during or immediately
after intense physical activity or emotional stress, it may be quite
normal to become aware of ones own heartbeat for brief
periods; these sensations are regarded as physiological palpitations,
in that they represent the normal or expected response to a
certain challenge or activity leading to an increase in the frequency
and strength of the contraction of the heart. Outside of such situations, instead, palpitations are perceived as abnormal.5 9
Pathophysiology
Little is known about the events responsible for heartbeat sensation, the afferent sensory pathways that are involved, or the
higher-order cognitive processing that filters, modulates, and
amplifies these stimuli and brings some to conscious attention.10
Possible sensory receptors are myocardial, pericardial, and peripheral mechanoreceptors, and/or peripheral baroreceptors with
their afferent parasympathetic and sympathtic pathways.11,12 Possible brain centres involved in the elaboration of afferent stimuli are
the subcortical areas (thalamus, amygdala) and the base of the
frontal lobes.
Cardiac arrhythmias
Supraventricular/ventricular extrasystoles
Supraventricular/ventricular tachycardias
Bradyarrhythmias: severe sinus bradycardia, sinus pauses, secondand third-degree atrioventricular block
Anomalies in the functioning and/or programming of pacemakers
and ICDs
Structural heart diseases
Mitral valve prolapse
Severe mitral regurgitation
Severe aortic regurgitation
Congenital heart diseases with significant shunt
Cardiomegaly and/or heart failure of various aetiologies
Hyperthrophic cardiomyopathy
Mechanical prosthetic valves
Psychosomatic disorders
Anxiety, panic attacks
Depression, somatization disorders
Systemic causes
Hyperthyroidism, hypoglycaemia, postmenopausal syndrome, fever,
anaemia, pregnancy, hypovolaemia, orthostatic hypotension,
postural orthostatic tachycardia syndrome, pheochromocytoma,
arteriovenous fistula
Effects of medical and recreational drugs
Sympathicomimetic agents in pump inhalers, vasodilators,
anticholinergics, hydralazine
Recent withdrawal of b-blockers
Alcohol, cocaine, heroin, amphetamines, caffeine, nicotine, cannabis,
synthetic drugs
Weight reductions drugs
Aetiological classification
From the aetiological point of view, the causes of palpitations can
be subdivided into five main groups (Table 1): cardiac arrhythmias,
structural heart diseases, psychosomatic disorders, systemic diseases,
and effects of medical and recreational drugs.3 9 It is not uncommon,
however, for the patient to have more than one potential cause or
type of palpitation. Electrocardiographic documentation of a
rhythm disorder during spontaneous symptoms provides the
strongest evidence of causality; whenever this proves possible,
therefore, the palpitations are classified as being of arrhythmic
origin. By contrast, they are considered to be of non-arrhythmic
origin when the underlying heart rhythm exhibits sinus rhythm
or sinus tachycardia. Thus, according to this aetiological hierarchy,
non-arrhythmic causes of palpitations emerge as definitive diagnoses only in cases in which the symptomelectrocardiogram
(ECG) correlation excludes the presence of rhythm disorders.8
When it is not possible to document the cardiac rhythm during
palpitations, non-arrhythmic causes are regarded as probable, but
not definitive.
Palpitations due to arrhythmias

Any type of tachyarrhythmia, regardless of whether or not there is
an underlying structural or arrhythmogenic heart disease, can give
rise to palpitations: atrial extrasystole, ventricular extrasystole,
tachycardias with regular ventricular activity (sinus tachycardia,
atrioventricular node reentrant tachycardia, atrioventricular reentrant tachycardia, atrial flutter, atrial tachycardias), and tachycardias
with irregular ventricular activity (atrial fibrillation, atrial flutter, or
Table 1 Main causes of palpitations
From the pathophysiological standpoint, the mechanisms underlying palpitations are somewhat heterogeneous: contractions of the
heart that are too rapid, irregular or particularly slow, as in cardiac
arrhythmias including sinus tachycardia secondary to mental disturbance, systemic diseases, or the use of certain medications;
very intense contractions and anomalous movements of the heart in
the chest, as in the case of some structural heart diseases associated
with increased stroke volume; anomalies in the subjective perception
of the heartbeat, whereby a normal heart rhythm or minimal irregularities in the cardiac rhythm are felt by the patient and are poorly
tolerated, as in the case of some psychosomatic disorders. It is
arguable that the pathophysiology of palpitations in these cases is
a centrally mediated fright reaction that initiates a series of
responses which include perception of the beating heart.1
It is important to underline the fact that, although cardiac
rhythm disorders generally give rise to palpitations (or other
related symptoms, such as fatigue, dyspnoea, dizziness, syncope,
and angina), in some subjects, for reasons not entirely known
but probably linked to some clinical characteristics (long-standing
arrhythmias with relatively low maximum ventricular rate, male
sex, absence of coronary heart disease, and congestive heart
failure) or to the presence of peripheral neuropathy (e.g. diabetic
patients), arrhythmias including prognostically relevant disorders
such as non-sustained ventricular tachycardias and atrial fibrillation
may remain completely asymptomatic.11,13 15 Thus, in such
patients, relevant arrhythmias might not be adequately diagnosed
and managed.15
922
atrial tachycardia with variable atrioventricular conduction, torsades
de pointes).16,17 By contrast, bradyarrhythmias are more rarely perceived as palpitations: these arrhythmias comprise sinus pauses and
severe sinus bradycardia seen in sick sinus syndrome, sudden onset
of high-degree atrioventricular block, or of intermittent left-bundle
branch block. Anomalies in the functioning and/or programming of
pacemakers and implantable cardioverter defibrillators (ICDs)
(pacemaker-mediated tachycardia, pectoral or diaphragmatic
stimulation, pacemaker syndrome, etc.) may also be responsible
for palpitations.
Palpitations due to structural heart

disease
Some structural heart diseases can give rise to palpitations in the
absence of true rhythm disorders. These include, among others,
mitral valve prolapse, severe mitral and aortic regurgitation, congenital heart disease with significant shunt, hypertrophic cardiomyopathy, and mechanical prosthetic valves.18,19
Palpitations due to psychosomatic

disorders
Palpitations due to systemic causes

A sensation of palpitation may stem from sinus tachycardia and/or
increased cardiac contractility, both of which may have various
causes: fever, anaemia, orthostatic hypotension, hyperthyroidism/
thyreotoxicosis, postmenopausal syndrome, pregnancy, hypoglycaemia, hypovolaemia, pheochromocytoma, arteriovenous fistula,
postural orthostatic tachycardia syndrome, among others.31 39
Palpitations due to the effects of medical

and recreational drugs
In such cases, palpitations may be linked to sinus tachycardia; drugs
involved include sympathomimetics, anticholinergics, vasodilators,
and hydralazine.40 The sudden suspension of b-blocker therapy
may also give rise to sinus tachycardia and palpitations through
the induction of a hyperadrenergic state as a result of the
rebound effect. Moreover, palpitations may even occur after the
initiation or dose-increase of b-blockers, due to the perception
of pulsations caused by increased stroke volume with lower
heart rate, or ventricular ectopic beats if sinus overdrive is withdrawn. Likewise, stimulants such as caffeine and nicotine, or the
use of illicit drugs (cocaine, heroin, amphetamines, LSD, synthetic
drugs, cannabis, etc.) can lead to sympathetic hyperactivation and
sinus tachycardia, even in young subjects without heart
disease.41,42 Drugs that prolong QT and predispose patients to torsades de pointes and other tachyarrhythmias, such as antidepressive
drugs, besides provoking dizziness or syncope, may also induce
arrhythmia-related palpitations.43,44 In the absence of other potential causes, palpitations are regarded as secondary to the use of
drugs when they are associated temporally to administration of
the drug and when they cease on suspension of the drug.
Epidemiology
The prevalence of palpitations is dependent on definitions and
diagnostic methods used and varies substantially in different populations. Nevertheless, there is evidence that palpitations are a very
frequent symptom in the general population2,9 and, in particular, in
patients suffering from hypertension or heart disease. In studies in
primary care settings, palpitations account for 16% of the symptoms
that prompt patients to visit their general practitioner, and are
second only to chest pain as the presenting complaint for specialist
cardiologic evaluation.1,3,4 This high prevalence of palpitations
emphasizes the need for a structured, ideally evidence-based, stepwise work-up that may allow to distinguish, since the beginning,
between patients with benign prognosis and those with poorer
prognosis.
With regard to the prevalence of the various causes of palpitations, clinical evidence indicates that a considerable number of subjects with palpitations have normal sinus rhythm or minor rhythm
anomalies, such as short bursts of supraventricular extrasystoles or
sporadic ventricular extrasystoles. Nevertheless, clinically significant arrhythmias such as atrial fibrillation/flutter or paroxysmal
supraventricular tachycardias are also a frequent finding.45,46 In a
prospective study by Weber and Kapoor47 in 190 patients presenting with a complaint of palpitations at an university medical centre,
palpitations were due to arrhythmias in 41% of these patients (16%
of whom had atrial fibrillation/flutter, 10% had supraventricular
tachycardia, and 2% had ventricular tachycardia), to structural
heart disease in 3%, to psychosomatic disorders in 31% (mainly
panic and anxiety disorders), to systemic causes in 4%, and to the
use of a medication, illicit substances, or stimulants in 6%. According
to the case records, the prevalence of anxiety syndrome and panic
attacks in patients with palpitations ranges from 15% to 31%.20 22
In the study by Weber and Kapoor,47 male sex, description of an
Psychosomatic disorders that are most frequently associated with

palpitations include anxiety, panic attacks, depression, and somatization, which can either induce sinus tachycardia or modify the
patients subjective perception of a heartbeat that is otherwise
normal or presents minimal irregularities.20 23 If no other potential causes can be identified, the palpitations are considered to
be of psychosomatic origin when the patient fulfils the criteria
specified in the literature for one or more of the abovementioned
psychosomatic disorders. It must be borne in mind, however, that
cardiac arrhythmias and psychosomatic disorders are not mutually
exclusive.5,24 In addition, the adrenergic hyperactivation connected
with intense emotions and anxiety can, in itself, predispose the
patient to supraventricular and/or ventricular arrhythmias.25 27
Indeed, in the last few years, some studies investigating the correlation between anxiety syndrome and the appearance of arrhythmias have suggested that anxiety exerts a facilitating effect on
arrhythmogenesis28 as well as on the patients perception of the
arrhythmia.29 Finally, in a study conducted on patients with documented supraventricular tachycardia, it was found that two-thirds
had previously been wrongly diagnosed as suffering from panic
attack disorder, and that the diagnosed psychosomatic disease
could be cured by catheter ablation in most of these patients.30
Thus, even in patients affected by psychosomatic disorders, it is
important to carry out a thorough investigation before excluding
an organic cause, particularly arrhythmic, of palpitations.
A. Raviele et al.
923
irregular heartbeat, history of heart disease, and event duration

.5 min were found to be independent predictors of a cardiac
aetiology. No specific cause of palpitations could be identified in
16% of the patients despite a thorough evaluation including the
use of loop recorders. Indeed, it is not always possible to establish
a definite cause of palpitations; often, only a likely cause can be
given, and, in some cases, several possible causes have to be
taken into consideration.8,42 In the literature, there are insufficient
data about the age and gender distribution of palpitations. In
general, however, older patients and men are more likely to
have an arrhythmic cause of palpitations and younger patients
and women a psychosomatic cause.47 51
Prognosis
Clinical presentation
Duration and frequency of palpitations
With regard to duration, palpitations may be either short-lasting or
persistent. In short-lasting forms, the symptom terminates spontaneously within a brief period of time. In persistent forms, the palpitations are ongoing and terminate only after adequate medical
treatment. With regard to frequency, palpitations may occur
daily, weekly, monthly, or yearly.
Types of palpitations
Patients report a wide range of sensations to describe their symptoms. The most common descriptions, and those most useful in
clinical practice in differential diagnoses among the various
causes of palpitations, enable palpitations to be classified according
to the rate, rhythm, and intensity of heartbeat5 9,59,60: extrasystolic
palpitations, tachycardiac palpitations, anxiety-related palpitations,
and pulsation palpitations (Table 2). It should, however, be stressed
that patients are not always able to describe the characteristics of
their symptoms precisely. It may therefore be difficult to identify
the type of palpitation accurately, especially in the case of normalrate palpitations.5,9,61
Extrasystolic palpitations, due to ectopic beats, generally produce
feelings of missing/skipping a beat and/or a sinking of the heart
interspersed with periods during which the heart beats normally;
patients report that the heart seems to stop and then start
again, causing an unpleasant, almost painful, sensation of a blow
to the chest. Linked to the presence of atrial or ventricular extrasystolic beats, this type of palpitation is frequently encountered
even in young subjects, often in the absence of heart disease,
and generally has a benign prognosis. In extrasystolic palpitations,
particularly if they are of ventricular origin, the sensation is due
to the increased strength of contraction of the post-extrasystolic
The prognostic implications of palpitations are dependent on the

underlying aetiology as well as clinical characteristics of the
patient. Available data, especially in terms of long-term prognosis,
are scarce. Although palpitations are generally associated with low
rates of mortality,4,47 they should bring to attention a potential
serious condition in patients with structural or arrhythmogenic
heart disease or a family history of sudden death. This is also
important to keep in mind if the palpitations are associated with
symptoms of haemodynamic impairment (dyspnoea, syncope, presyncope, dizziness, fatigue, chest pain, neurovegetative symptoms).5 On the one hand, depending on the clinical characteristics
of the patient, palpitations due to arrhythmias, in particular of ventricular origin, but also atrial fibrillation, are associated with different prognostic implications.15 17 On the other hand, in patients
without relevant heart disease, palpitations (especially if
anxiety-related or extrasystolic) generally have a benign prognosis.
A retrospective American study that analysed case records
obtained from general practitioners found no difference in 5-year
mortality and morbidity between patients with palpitations and a
group of asymptomatic control subjects.4 Also in the abovementioned study by Weber and Kapoor47 on a general population of
patients presenting with palpitations at an university medical
centre, despite the high rate of cardiac cause, 1-year mortality
was only 1.6%. However, even in patients without severe heart
disease, palpitations may be due to significant arrhythmias, such
as atrial fibrillation, atrial flutter, or ventricular ectopic beats, all
of which require adequate investigation and treatment. Moreover,
clinical characteristics of the patient, such as age, presence of heart
disease, and ECG abnormalities, do not always allow the physician
to identify a priori those cases in which palpitations are caused by
clinically significant rhythm disorders.8,47,48,52 54 An exception to
this is given by changes in the resting ECG that are indicative of
primary electrical heart diseases.
In athletes, palpitations are not uncommon. Sudden death, in
particular in younger athletes, is rare and mostly associated with
underlying structural heart disease or primary arrhythmic disorders, and palpitations may be the initial clinical symptom or an
incidental finding possibly leading to the recognition of a previously
undiagnosed relevant heart disease.55,56 Moreover, because of
potentially life-threatening haemodynamic consequences of even
supraventricular arrhythmias, such as rapidly conducted preexcited atrial fibrillation during exertion, careful cardiac evaluation,
in particular of symptomatic competitive as well as recreational

athletes, is warranted.57
Although palpitations display a low mortality rate, the recurrence
of symptoms is, however, very frequent. In the study by Weber and
Kapoor,47 77% of patients experienced at least one recurrence of
palpitations, and the effect on their quality of life was unfavourable:
one-third of patients reported an impairment of their ability to
attend to household chores, 19% claimed that their working
capacity had diminished, and 12% said that they had taken days
off work. These findings are confirmed by a prospective study conducted by Barsky et al.58 on 145 patients with palpitations, who
were followed up for 6 months and compared with an asymptomatic control group. These authors observed that patients with
palpitations, in spite of having a favourable prognosis in terms of
mortality, remained symptomatic and functionally impaired over
time and exhibited a high incidence of panic attacks and psychological symptoms.58 Frequent and recurrent palpitations, therefore,
can impair the patients quality of life, giving rise to anxiety and frequent visits to the emergency department.3 In many respects, palpitations seem to behave like a chronic disorder that has a
favourable prognosis, but with periodic attacks followed by transitory remission.3,4
924
A. Raviele et al.
Table 2 Types of palpitations and their clinical presentations

Type of
palpitation
Subjective
description
Heartbeat
Onset and
termination
Trigger
situations
Possible associated symptoms
Extrasystolic
Skipping/missing a
beat, sinking of the
heart
Irregular, interspersed with

periods of normal
heartbeat
Sudden
Rest
Tachycardiac
Beating wings in the

chest
Regular or irregular,
markedly accelerated
Sudden
Physical effort,
cooling down
Syncope, dyspnoea, fatigue, chest

pain
Anxiety-related
Anxiety, agitation
Regular, slightly
accelerated
Gradual
Stress, Anxiety
attacks
Pulsation
Heart pounding
Regular, normal frequency
Gradual
Physical effort
Tingling in the hands and face, lump

in the throat, atypical chest pain,
sighing dyspnoea
Asthenia
...............................................................................................................................................................................
Table 3 Clinical characteristics of tachycardiac palpitations

Type of arrhythmia
Heartbeat
Trigger situations
Associated symptoms
Vagal manoeuvres
AVRT, AVNRT
Sudden onset regular with periods of

elevated heart rate
Physical effort, changes in

posture
Polyuria, frog sign
Sudden interruption
Atrial fibrillation
Irregular with variable heart rate
Physical effort, cooling down,

post meal, alcohol intake
Polyuria
Transitory reduction
in heart rate
Atrial tachycardia and

atrial Flutter
Regular (irregular if A-V conduction is

variable) with elevated heart rate
Ventricular
tachycardias
Regular with elevated heart rate
...............................................................................................................................................................................
Physical effort
Signs/symptoms of
haemodynamic
impairment
No effect
AVRT, atrio-ventricular reentrant tachycardia; AVNRT, atrio-ventricular node reentrant tachycardia; A-V, atrioventricular.
beat, which accentuates the movement of the heart inside the

chest, or to the post-extrasystolic pause, or to the altered activation of the heart. When the extrasystoles are particularly numerous and/or repetitive, it may prove difficult to make a differential
diagnosis between extrasystolic and tachycardiac palpitations,
especially those due to atrial fibrillation.
In the case of tachycardiac palpitations, the sensation described by
the patient is that of a rapid fluctuation like beating wings in the
chest. The heartbeat is generally perceived to be very rapid (sometimes higher than the maximum heart rate estimated on the basis
of the patients age); it may be regular, as in atrioventricular reentrant tachycardia, atrial flutter, or ventricular tachycardia, or irregular or arrhythmic, as in atrial fibrillation or post-atrial
fibrillation-ablation atypical atrial flutter (Table 3). These palpitations are generally linked to supraventricular or ventricular
tachyarrhythmias, which begin and usually end suddenly (sometimes the termination is gradual due to the increase in sympathetic
tone during tachycardia that tends to persist and declines slowly
after its interruption), or to sinus tachycardia due to systemic
causes or to the use of drugs or illicit substances (in these cases,
palpitations begin and end gradually).
Anxiety-related palpitations are perceived by the patient as a form
of anxiety. The heartbeat is slightly elevated, but never higher than
the maximum heart rate estimated on the basis of the patients age.
These palpitations, whether paroxysmal or persistent, begin and
end gradually, and patients describe numerous other associated

unspecific symptoms, such as tingling in the hands and face, a
lump in the throat, mental confusion, agitation, atypical chest
pains, and sighing dyspnoea, that normally precede the palpitations.
Anxiety-related palpitations are due to psychosomatic disorders
and usually require exclusion of an arrhythmic cause of the
symptoms.
Pulsation palpitations are felt as strong, but regular and not particularly rapid, heartbeats. They tend to be persistent and are generally linked to structural heart diseases, such as aortic
regurgitation, or to systemic causes involving a high stroke
volume, such as fever and anaemia.
Associated symptoms and circumstances

Certain symptoms and circumstances associated to palpitations are
often connected with the various causes of the palpitations and may
be very helpful in making differential diagnoses.5 9,59,60 Palpitations
arising after sudden changes in posture are frequently due to intolerance to orthostatis or to episodes of atrioventricular nodal reentrant tachycardia. The occurrence of syncope or other symptoms,
such as severe fatigue, dyspnoea, or angina, in addition to palpitations, is much more frequent in patients with structural heart
disease. However, syncope may also occur at the onset of supraventricular tachycardia in patients with a normal heart, as the result of
the triggering of a vasovagal reaction.62,63
Transitory reduction
in heart rate
925
which a sudden reduction in sympathetic tone is accompanied by

an increase in vagal tone.
Accuracy of clinical features for the

diagnosis of arrhythmias
The utility of the features on history for diagnosing an arrhythmic
cause of palpitations has been examined in a recent systematic
review.48 The likelihood ratio of each feature is, in general, low
and only a few features are really predictive. They include history
of cardiac disease, palpitations affected by sleeping, or while the
patient is at work. Other features such as underlying history of
panic disorder and duration of palpitations less than 5 min
appear to be useful for ruling out a clinically significant arrhythmia.47 However, data in this regard come from studies with
small sample sizes.
Diagnostic strategy
In patients with palpitations the diagnostic strategy should aim at:
(i) distinguishing the mechanism of the palpitations; (ii) obtaining
an electrocardiographic recording during symptoms; and (iii) evaluating the underlying heart disease. All patients suffering from palpitations should therefore undergo an initial clinical evaluation
comprising history, physical examination, and a standard 12-lead
ECG (Figure 1). This usually should be performed in a primary
care setting.
In specific situations, specialist evaluation and certain specific
instrumental and laboratory investigations should be considered.59
history, physical examination, ECG, psychosomatic

counselling*
Definitive or
suspected diagnosis
confirmation
treatment
unexplained palpitations
no heart disease
and normal ECG
heart disease or
abnormal ECG
Echo,AECG,MRI*,
Stress Test*, EPS*
treatment
ILR
frequent or
severe
rare or well
tolerated
stop
Figure 1 Diagnostic flow-chart of patients with palpitations. *Indicated only in selected cases; refers to ECG symptom correlation available. ECG, electrocardiogram (12-lead); Echo, echocardiography; AECG, ambulatory ECG; MRI, magnetic resonance imaging; EPS, electrophysiological study; ILR, implantable loop recorder.
Polyuria, which is due to the hypersecretion of natriuretic

hormone, is typical of atrial tachyarrhythmias, particularly atrial
fibrillation. By contrast, the sensation of a rapid, regular pulse in
the neck (usually associated with the frog sign) raises suspicion
of supraventricular tachycardia, particularly atrioventricular nodal
reentrant tachycardia.64 It is the result of atria contracting against
closed tricuspid and mitral valves.9,65 An atrioventricular mechanical dissociation may also occur in the case of ventricular extrasystoles. In this case, however, only one or few pulses are felt in the
neck, and the rhythm is more irregular. In supraventricular tachycardias involving the atrioventricular node, patients often learn
to interrupt the episode by themselves by applying vagal stimulation through Valsalvas manoeuvre or carotid sinus massage.
Palpitations that arise in situations of anxiety or during panic
attacks are generally due to episodes of more or less rapid sinus
tachycardia secondary to the mental disturbance. In some cases,
however, the patient may have difficulty in discerning whether
the palpitations precede or follow the onset of the anxiety or
panic attack, and may therefore be unable to suggest whether
the palpitations are the cause or the effect of the psychological
distress.
During physical exercise, due to an increase in the sympathetic
drive, patients may experience, in addition to the normal sensation
of a rapid heart rate elicited by intense effort, palpitations due to
various types of arrhythmia, such as right ventricular outflow
tract tachycardia, atrioventricular node reentrant tachycardia, and
polymorphic catecholaminergic ventricular tachycardia. Finally, episodes of paroxysmal atrial fibrillation may occur in the phase
immediately following the cessation of physical effort, during
926
an arrhythmia centre, and second-level investigations should be considered; these include ambulatory ECG monitoring and electrophysiological study (EPS) (Figure 1). Finally, second-level
investigations should also be carried out in patients with palpitations
of unknown origin whose symptoms are frequent or associated with
impaired haemodynamic function or impaired quality of life or states of
anxiety.9
Initial clinical evaluation

History
It represents a major part of the initial examination as most
patients at the time they visit a physician have no palpitations
and the diagnosis has to be performed retrospectively.5 9,48 The
first step is to establish that symptoms described by the patient
match to palpitations and are not confused with chest pain or
other manifestations arising in the chest, but that do not correspond to the definition of palpitations described in this article.
When this first step has been achieved several important questions have to be asked, the most important of which are summarized in Table 5. Answers to some of these questions may require
Table 5 Main questions to ask a patient with

palpitations
Circumstances prior to the beginning of palpitations
Activity (rest, sleeping, during sport or normal exercise, change in
posture, after exercise)
Position (supine or standing)
Predisposing factors (emotional stress, exercise, squatting or
bending)
Onset of palpitations
Abrupt or slowly arising
Preceded by other symptoms (chest pain, dyspnoea, vertigo, fatigue,
etc.)
Episode of palpitations
Type of palpitations (regular or not, rapid or not, permanent or not)
Associated symptoms (chest pain, syncope or near syncope,
sweating, pulmonary oedema, anxiety, nausea, vomiting, etc.)
End of the episode
Abrupt or slowly decreasing, end or perpetuation of accompanying
symptoms, duration, urination
Spontaneously or with vagal manoeuvres or drug administration
Background
Table 4 Clinical features suggestive of palpitations of

arrhythmic origin
Age at the first episode, number of previous episodes, frequency

during the last year or month
Previous cardiac disease
Previous psychosomatic disorders
Structural heart disease
Previous systemic diseases
Primary electrical heart disease

Abnormal ECG
Previous thyroid dysfunction

Family history of cardiac disease, tachycardia or sudden cardiac
death
Medications at the time of palpitations
Family history of sudden death

Advanced age
Tachycardiac palpitations
Palpitations associated with haemodynamic impairment
Drug abuse (alcohol and/or others)

Electrolytes imbalance
Stress testing is indicated if the palpitations are associated with

physical exertion (e.g. right ventricular outflow tract extrasystoles),
in athletes and when coronary heart disease is suspected. The role
of echocardiography is of paramount importance to evaluate the
presence of structural heart disease. The need to conduct
further non-invasive cardiologic investigations (particularly
cardiac magnetic resonance imaging to evaluate patients with
structural normal heart, palpitations, and frequent ventricular
arrhythmias) or invasive investigations (coronary angiography,
etc.) will depend on the nature of the heart disease suspected
or ascertained. Comparable to exercise-induced syncope,
exercise-induced palpitations should raise suspicion for ischaemic,
valvular, or other structural heart disease with the corresponding
work-up. Whenever a systemic or pharmacological cause of palpitations is suspected, specific laboratory tests should be performed
on the basis of the clinical presentation of the symptom and the
patients clinical characteristics (e.g. haemochrome, electrolytes,
glycaemia, thyroid function, urinary catecholamines, detection of
illicit substances in the blood or urine). If, on the contrary, a psychosomatic cause is suspected, the patients mental state must be
assessed either by means of specific questionnaires or through
referral for specialist examination.7,8,20 23
The initial clinical evaluation leads to a definitive or probable
diagnosis of the cause of the palpitations in about half of patients,
and excludes with reasonable certainty the presence of causes that
have an unfavourable prognosis.47 Moreover, a thorough initial
clinical evaluation will indicate which specific investigations, if any,
are necessary.
If the initial clinical evaluation proves completely unremarkable
which is more frequent in paroxysmal, short-lasting
palpitationsthe palpitations are deemed to be of unknown
origin. In subjects with palpitations of unknown origin who have a
low probability of an arrhythmic cause (i.e. patients with gradual
onset of palpitations and without significant heart disease and those
with anxiety-related or extrasystolic palpitations), further investigations are often not required. The patient should be reassured and a
follow-up clinical examination may be scheduled. It should be underlined, however, that, in the absence of electrocardiographic recording during an episode of palpitations, only a presumed or probable
diagnosis can be made.30 By contrast, in instances of subjects with
palpitations of unknown origin presenting with clinical features suggestive of an arrhythmic cause66 (Table 4), or when palpitations are
suspected to be related to atrial fibrillation in individuals with risk
factors for thromboembolism,14,67 patients should be referred to
A. Raviele et al.
927
inputs from other members of the family or from individuals who

have witnessed an episode of palpitations. Description of the type
of palpitations (regular or not, rapid or not) could help to determine its underlying mechanism (Table 2). It may be useful to ask
the patient to mimic the perceived cardiac rhythm, either vocally
or by drumming with the fingers on a table.
Circumstances during which palpitations have occurred are generally helpful to evaluate their cause. Some of these circumstances
are presented in Table 3. When, after this history-taking, it
becomes likely that palpitations are not related to arrhythmia
but rather to psychosomatic disorders, before starting more
extensive cardiovascular procedures, it is judicious to take the
help of a mental health expert.1,22,23,47,58
It is naturally useless to perform this extensive history-taking if
the patient has the feeling of palpitation even during the consultation. The first examination in these circumstances is to instantaneously record ECG.
importance for the future evaluation.1,5 9,47 Furthermore, precise

analysis of ECG during arrhythmia either provides the mechanism
or gives important data that lead to this diagnosis. It should be
stressed, however, that P waves during rapid tachycardia are not
always visible, making the diagnosis difficult. Vagal manoeuvres
and pharmacological tests, such as intravenous adenosine or ajmaline, performed during ECG recording are of major interest as they
can unmask the atrial activity or interrupt suddenly the tachycardia,
resulting in the diagnosis of the type of arrhythmia.16,68 Alternatively, the possibility of taking a transoesophageal ECG during
tachycardia must be considered.
Table 6 Electrocardiographic features recorded on

standard electrocardiogram in absence of palpitations
and suggestive of palpitations of arrhythmic origin
Ventricular pre-excitation
Physical examination
In the absence of palpitations

When the patient is examined in the absence of the culprit
symptom, the aim is to find signs of structural heart disease that
could explain the occurrence of palpitations (cardiac murmur,
hypertension, vascular diseases, signs of heart failure, and so on).
It is also important to search for signs of systemic diseases.
Standard electrocardiogram
During palpitations
If the patient is examined during palpitations, 12-lead ECG represents the diagnostic gold standard. Thus, patients should be
advised to come as quickly as possible to an emergency department or a physician when an ECG has never been recorded
during symptoms. It allows the physician to analyse P and QRS
morphologies and the relationship between these two waves,
and the frequency and regularity of the heart rhythm, and finally
brings an accurate diagnosis on the concordance between palpitations and the presence or absence of arrhythmia. This distinction
between arrhythmic or non-arrhythmic palpitation is of paramount
P-wave abnormalities, supraventricular premature beats, sinus

bradycardia
Atrial fibrillation
Left ventricular hypertrophy
Ventricular tachycardia
Atrial fibrillation
Frequent ventricular premature beats
Ventricular tachycardia
Q wave, signs of arrhythmogenic right ventricular cardiomyopathy,
Brugada syndrome or early repolarization syndrome
Ventricular tachycardia/fibrillation
Long or short QT
Polymorphic ventricular tachycardia
A-V block, tri- or bifascicular block
Torsades de pointes
Paroxysmal A-V block
Table 7 List of eletrocardiographic signs indicative of

primary electrical heart diseases
ECG signs
Suspected disease
Corrected QT interval .0.46 s
Long QT syndrome
Corrected QT interval ,0.32 s

Right bundle branch block with coved type/
saddle type ST segment elevation in the
right precordial ECG leads (V1 V3) either
spontaneous or provoked by flecainide or
ajmaline
Short QT syndrome
Brugada syndrome
1-wave and/or T-wave inversion with QRS

duration .110 ms in the right precordial
ECG leads (V1 V3); ventricular ectopic
beats with left bundle branch block and
right-axis deviation morphology
High voltage in the precordial leads, Q wave,
ST changes
Arrythmogenic right
ventricular
cardiomyopathy
................................................................................
Hypertrophic
cardiomyopathy
During palpitations
The execution of the physical examination while the patient is still
symptomatic is not the most frequent situation. However, when
this occurs it is crucial to have some notions about frequency
and regularity of heart rhythm by listening to the patients chest
or by palpation of the arterial pulse. The differential diagnosis of
various types of tachycardia may be guided by vagal manoeuvres68
such as carotid sinus massage: sudden interruption of the tachycardia is highly suggestive of a tachycardia involving the atrioventricular junction whereas a temporary reduction of the frequency is
suggestive of atrial fibrillation, flutter, or atrial tachycardia (Table 3).
When this essential stage has been performed, examination
should aim to evaluate the tolerance of a possible heart rhythm
disturbance (blood pressure, signs of cardiac failure, and so on),
to assess the cardiovascular status (i.e. the presence of structural
heart disease), and, in case of a sinus rhythm or sinus tachycardia,
to evaluate the presence of systemic diseases potentially responsible for palpitations.
Atrioventricular reciprocating tachycardia

Atrial fibrillation
928
In the absence of palpitations
Even when the ECG is recorded in the absence of palpitations it
provides important data that can suggest the arrhythmic origin of
palpitations (Tables 6 and 7). In some instances, for example in
case of evident pre-excitation when the patient reports rapid
regular palpitations, the diagnosis is formal even if tachycardia
has never been recorded.
Ambulatory electrocardiogram
monitoring
Table 8 Technical characteristics of the different

ambulatory electrocardiogram monitoring devices
Device
Characteristics
Holter monitoring
Utilizes external recorders connected to the

patient by means of skin electrodes; these
recorders are able to perform continuous
beat-to-beat electrocardiographic
monitoring via several leads (up to 12 in
the latest models).
Event recorders
Small, easy-to-use, portable devices that are

applied to the patients skin whenever
symptoms are experienced. They provide
prospective one-lead
electrocardiographic recording for a few
seconds.
External loop
recorders
Connected continuously to the patient by

means of skin electrodes and equipped
with a memory loop, these devices
provide one to three-lead
electrocardiographic recording for a few
minutes before and after activation by the
patient when symptoms arise. The latest
devices are also able to self-activate
automatically when arrhythmic events
occur.
Mobile cardiac
outpatient
telemetry
Made up of an external loop recorder

connected to the patient by means of skin
electrodes, and of a portable receiver that
is able to transmit an electrocardiographic
trace to a remote operating centre or to a
dedicated website via the telephone. In
this way, the patients rhythm can be
monitored in real time.
Similar in size to a pacemaker, these devices
are implanted beneath the skin through a
small incision of about 2 cm in the left
precordial region. They are equipped with
a memory loop and, once activated by the
patient through an external activator at
the moment when the symptoms arise,
record one-lead electrocardiographic
trace for several minutes before and after
the event. They are also able to record any
arrhythmic event automatically (i.e. with
no intervention by the patient). In general,
monitoring lasts either until a diagnosis is
reached or until the battery runs down.
On completion of monitoring, the device
is removed from the patient.
................................................................................
Implantable loop
recorders
Pacemakers/ICDs
Provided by an internal memory, they are

able to detect and store an atrial and
ventricular IEGM separately (dual
chamber devices), and to record any
arrhythmic events automatically. Some
models may also be activated manually by
the patients when palpitations occur.
IEGM, intracardiac electrogram.
Diagnostic value
Ambulatory ECG monitoring is regarded as diagnostic only when it is
possible to establish a correlation between palpitations and an electrocardiographic recording.69,70 In patients who do not develop
symptoms during monitoring, therefore, this examination is often

non-contributory. In some patients without palpitations on monitoring, the presence of clinically significant arrhythmias that are
Ambulatory ECG monitoring serves to document the cardiac

rhythm during an episode of palpitations if this cannot be done
by means of standard ECG, as in the case of short-lasting symptoms. Indeed, ambulatory ECG monitoring utilizes electrocardiographic recorders that are able to monitor the patients cardiac
rhythm for long periods of time or that can be activated by the
patient when symptoms occur.69,70
The devices currently used for ambulatory ECG monitoring can
be subdivided into two main categories: external and implantable.
External devices comprise Holter recorders, hospital telemetry
(reserved for hospitalized patients at high risk of malignant arrhythmias), event recorders, external loop recorders, and, very recently,
mobile cardiac outpatient telemetry. Implantable devices comprise
pacemakers and ICDs equipped with diagnostic features (used
exclusively in patients requiring such devices for therapeutic purposes) and implantable loop recorders (ILRs).
Event recorders or handheld patient-operated ECG systems
have been shown to improve the diagnosis of transient ECG
changes in patients with palpitations.71,72 These devices are reasonably priced and easy to use. The external and implantable loop
recorders, mobile cardiac outpatient telemetry, and pacemakers
and ICDs can detect asymptomatic clinically significant arrhythmias
automatically (i.e. with no activation by the patient) and provide a
significantly higher yield than standard patient-activated loop recorders in patients with infrequent palpitations.49,73 79 Another major
benefit of the latest diagnostic systems is that many of them not
only allow automatic detection of the arrhythmias but also allow
immediate wireless transmission of pertinent ECG data to a central
monitoring station via a mobile telephone line or the Internet.
The alarms incorporated into the network providing telemetric
data to specialists improve the efficiency of patient management,
since the physicians can check their patients data remotely with
no delay. This permits greater emphasis on documentation and
characterization of spontaneous arrhythmic episodes, and it is
expected to allow prompt reaction to clinical events as well as
to act as a potential for reduced resource use.80 Moreover, the
ability to detect the onset of the episode provides valuable information on the mechanism of the arrhythmias. The main technical
characteristics of the different ambulatory ECG monitoring
systems are summarized in Table 8.
A. Raviele et al.
929
Limitations
Ambulatory ECG monitoring has some important limitations.
Indeed, it is not always possible to formulate a precise diagnosis
of the type of arrhythmia recorded, especially when single-lead
ECG devices are used. For example, it may be difficult to make a
correct differential diagnosis between a supraventricular tachycardia with aberrant conduction and a ventricular tachycardia. Moreover, ambulatory ECG monitoring is unable to distinguish with
certainty between bradyarrhythmias due to a reflex mechanism
and those caused by a disorder of the cardiac conduction
system, a distinction that has prognostic and therapeutic implications. Finally, ambulatory ECG monitoring requires the patient
to experience a recurrence of symptoms. This delays the diagnosis

and, should the palpitations be due to malignant arrhythmias,
exposes the patient to the potential risk of adverse events. The
main advantages and limitations of the different ambulatory ECG
monitoring systems are summarized in Table 9.
Indications
According to the ACC/AHA guidelines for the use of ambulatory
ECG monitoring,69,70 recurrent palpitations of unknown origin
constitute a class-I indication for long-term ECG monitoring. The
recommendations regarding the choice of the ambulatory ECG
monitoring device most suited to the individual patient are
reported in Table 9. ILRs are used in selected patients with
severe and infrequent palpitations (inter-symptom interval .4
weeks) and when all other investigations, including external ambulatory ECG monitoring, prove to be negative.66
Electrophysiological study
Electrophysiological study, as an invasive procedure, is usually considered at the end of the diagnostic work-up. However, EPS has
some important advantages over ambulatory ECG monitoring.
First of all, it is able to correctly identify the type of arrhythmia
responsible for the palpitations. Moreover, it enables ablative
therapy of the induced tachyarrhythmias to be performed during
the same session in which the diagnosis is made. Finally, while
EPS enables a diagnosis to be made and specific therapy to be
initiated immediately, ambulatory ECG monitoring requires the
patient to experience a recurrence of symptoms. This delays the
diagnosis and, should the palpitations be due to malignant arrhythmias, exposes the patient to the potential risk of adverse events.
For this reason, in patients with significant heart disease and in
those with palpitations that precede syncope, in whom the risk
of adverse events is higher, electrophysiological evaluation generally precedes the use of ambulatory ECG monitoring. In all other
cases, it normally follows ambulatory ECG monitoring when the
latter proves non-diagnostic. For the recommendations of EPS in
patients with palpitations of unknown origin we refer the
readers to the ACC/AHA/ESC 2003 Guidelines on supraventricular arrhythmias16 and the ACC/AHA/ESC 2006 Guidelines for
management of patients with ventricular arrhythmias and the prevention of sudden cardiac death.17
Specific needs in patients at risk

of stroke
It is well known that atrial fibrillation is associated with an
increased risk of thromboembolism, especially in patients with
certain risk factors as those considered in the CHA2DS2VASc
risk score.14 It is therefore important to exclude atrial fibrillation as
the underlying cause of the symptoms in patients with palpitations
of unknown origin and a high thromboembolic risk.
However, it must be underlined that once atrial fibrillation has
been diagnosed as a cause of palpitations, there is up to now
only limited data on the importance of assessing atrial fibrillation
asymptomatic (i.e. not associated with palpitations) may suggest a

probable diagnosis and/or guide the decision to undertake further
investigations.15,59 The specificity of ambulatory ECG monitoring, at
least in formulating a diagnosis of arrhythmic palpitations or nonarrhythmic palpitations, is optimal, whereas the sensitivity is extremely variable and depends on the following factors: the monitoring
techniques used, the duration of monitoring, patient compliance,
and, most importantly, the frequency of the attacks.
In patients with palpitations of unknown origin, Holter monitoring has displayed a rather low sensitivity value (3335%).81 In a
meta-analysis of seven studies conducted on patients with
syncope and/or palpitations of unknown origin, Holter monitoring
has been seen to have a sensitivity value of only 22%.82 By contrast,
in patients in whom the symptoms are quite frequent (i.e. daily or
weekly), external loop recorders and event recorders have shown
both a higher diagnostic value (66 83%) and a better cost/effectiveness ratio than Holter devices.71,83 Finally, in patients with
symptoms of possible arrhythmic origin, mobile cardiac outpatient
telemetry has been seen to exhibit a higher diagnostic value than
the other external devices.71,84,85
ILRs have been successfully used to study syncope, in which they
have shown a better cost/effectiveness ratio than the conventional
tests,86,87 and they can be useful in the study of palpitations of
unknown origin.69,88,89 Indeed, the RUP study (recurrent unexplained palpitations study) recently demonstrated the superiority
of ILR over the conventional diagnostic strategy of Holter and
event recorder monitoring and EPS in the evaluation of a relatively
small cohort of patients with infrequent palpitations (i.e. monthly
frequency) reporting both a higher diagnostic value (73% vs. 21%)
and a better cost/effectiveness ratio.52 In patients implanted with
pacemakers or ICDs, useful information on the origin of palpitations
can be obtained by interrogating the memory of the device.90
Although many patients with palpitations of unknown origin
who undergo ambulatory ECG monitoring prove to have rhythm
disorders that are generally benign, such as atrial or ventricular
premature beats, or episodes of sinus rhythm and sinus tachycardia, a substantial percentage (635%) of the arrhythmias diagnosed
prove to be clinically significant, such as supraventricular tachycardias and atrial fibrillation.5 Ventricular tachycardia is much less
common and is typical of patients with structural or arrhythmogenic heart diseases. Finally, a small percentage of patients with palpitations of unknown origin have major bradyarrhythmic disorders,
such as severe sinus bradycardia and paroxysmal advanced atrioventricular block.52,71
930
A. Raviele et al.
Table 9 Advantages, limitations, and indications of the different ambulatory electrocardiogram monitoring devices
Holter monitoring
Event recorders
External loop
recorders/MCOT
Implantable loop
recorders
Pacemakers/ICDs
Better discrimination
between ventricular and
supraventricular
arrhythmias, due to dual
chamber IEGM
recordings; better
definition of arrhythmic
burden; monitoring
duration for many years
(corresponding to the
expected life of the
device); possibility to
record asymptomatic
arrhythmias
automatically
Invasiveness; risk of early
and late local and
systemic complications;
high costs
...............................................................................................................................................................................
Low cost; possibility to
record asymptomatic
arrhythmias
Low cost; easy to use
Retrospective and
prospective ECG
records; possibility to
record asymptomatic
arrhythmias
automatically
Retrospective and
prospective ECG
records; quite good
ECG records;
monitoring capability up
to 36 months; possibility
to record asymptomatic
arrhythmias
automatically
Limitations
Monitoring limited to
24 h to 7 days; size
may prevent
activities that may
trigger the
arrhythmias; patients
often fail to complete
adequately the
clinical diary upon
which the
correlation between
symptoms and the
arrhythmias
recorded is based
Monitoring cannot be
carried out for more
than 3 4 weeks; very
brief arrhythmias are
not recorded;
arrhythmic triggers
are not revealed;
poor ECG records
Monitoring cannot be
carried out for more
than 3 4 weeks;
continual
maintenance is
required; devices are
uncomfortable; quite
poor ECG records
Invasiveness; risk of local

complications at the
implantation site: higher
cost; limited memory
and specificity
Indications
From daily to weekly

palpitations; patients
who are unable to
use other
ambulatory ECG
monitoring devices
From weekly to
monthly, fairly
long-lasting
palpitations not
accompanied by
haemodynamic
impairment;
compliant patients
From weekly to
monthly,
short-lasting
palpitations
associated to
haemodynamic
impairment; very
compliant patients
From monthly to yearly

palpitations associated
with haemodynamic
compromise; when all
the other examinations
prove inconclusive;
non-compliant patients
without haemodynamic
compromise when a
clinically significant
arrhythmic cause is
likely or must be ruled
out
Only for patients with

conventional indications
to pacemakers and ICDs
IEGM, intracardiac electrogram; MCOT, mobile cardiac outpatient telemetry.
burden for the evaluation of thromboembolic risk, and more information is still needed.67,91
Therapy
Therapy for palpitations is, of course, directed towards the aetiological cause (i.e. treatment of cardiac arrhythmias, structural heart
diseases, psychosomatic disorders, or systemic diseases) whenever
it can be determined. However, many of the suggestions that can
be made are based on clinical experience, without scientific documentation to rely on.
When a clear-cut aetiology is established and a low-risk curative

therapy is available (e.g. ablation for supraventricular arrhythmias),
there is no doubt that this is the treatment of choice.92 Moreover,
in many benign arrhythmias (e.g. premature beats), a number of
general factors may influence and modulate the frequency and
severity of the symptoms. In this context, changes in lifestyle
(e.g. restraining adrenergic substances such as caffeine or alcoholcontaining beverages) or non-cardiologic therapies (e.g. anxiolytic
drugs or psychiatric counselling) may be useful to control symptoms and should be considered. At times, reassurance of the
patient on the benign nature of the disorder can markedly
reduce symptoms.
Advantages
931
Table 10 General recommendations for the treatment

of palpitations
Therapy should be directed towards the aetiological cause.
Patients should be reassured in case of a benign cause.
Use of adrenergic substances such as caffeine or alcohol-containing
beverages should be restrained.
Good control of cardiovascular risk factors, specifically of
hypertension, should be ensured.
It is beyond the scope of this paper to discuss in depth the

specific therapy in all arrhythmic conditions causing palpitations.
In this regard, we refer the readers to current guidelines.16,17 In
the case that arrhythmias are found to be related to systemic diseases or to the use of pro-arrhythmic drugs, therapy, of course,
must aim to remove the underlying conditions. The general recommendations for the treatment of palpitations are listed in
Table 10.
If there is a recent stressful life-event, psychiatric counselling may be of

help.
When to hospitalize the patient
In patients with symptoms of anxiety and depression, a specific therapy

is warranted.
Diagnostic purposes
If a specific arrhythmia is found, the appropriate therapy may be

antiarrhythmic drugs, ablation, or even an implantable defibrillator.
In the case that arrhythmias are found to be related to systemic
diseases or to the use of pro-arrhythmic drugs, therapy, of course,
must aim to remove the underlying conditions.
Table 11 Criteria for the hospitalization of patients

with palpitations
Severe structural heart disease, suspected or ascertained

Primary electrical heart disease, suspected or ascertained
Family history of sudden death
Need to perform EPS, invasive investigations or in-hospital
telemetric monitoring
Therapeutic purposes
Bradyarrhythmias requiring implantation of pacemaker
Pacemaker/ICD malfunction not rectifiable by reprogramming
Ventricular tachyarrhythmias requiring immediate interruption and/
or ICD implantation or catheter ablation
Supraventricular tachycardias requiring interruption immediately or
in a short time, or catheter ablation
Presence of heart failure or other symptoms of haemodynamic
compromise
Severe structural heart diseases requiring surgery or interventional
procedures
Severe systemic causes
Severe psychotic decompensation
Clearly, patients with palpitations will benefit from the same

preventive measures recommended to the general population
and to patients with cardiovascular disease.93 Especially in patients
with ventricular ectopy94 and possibly also in patients with atrial
ectopic beats95, although scientific evidence is lacking, intensified
reduction of cardiovascular risk factors may be warranted. This
may comprise, among others, smoking cessation, therapy of dyslipidemia, management of hypertension, heart failure, and diabetes
mellitus, to name but a few. Moderate exercise is a healthy habit
that helps in controlling cardiovascular risk factors. On the other
hand, high-intensity endurance sport practice has been related to
an increased risk of atrial fibrillation.96
Therapeutic purposes
The criteria for the hospitalization of patients with palpitations for
therapeutic purposes are reported in Table 11. Generally, patients
with cardiac arrhythmias and/or structural heart disease will need
emergency hospitalization when they complain of palpitations
associated with haemodynamic compromise, chest pain, or
syncope, as well as if implantation or revision of implanted
devices is indicated.117 121
Conflicts of interest: A.R. is a consultant for sanofi-aventis,
Boehringer-Ingheleim, Biosense Webster, and St Jude Medical,
and has received honoraria from sanofi-aventis, Boehringer Ingheleim, and Medtronic. L.M. has received honoraria or consulting fees
from Bard, Biosense Webster, Medtronic, Boston Scientific, St Jude
Medical, Sanofi Aventis, Biotronik, and Sorin Group, and has
received research grants from Biosense Webster, Medtronic,
Boston Scientific, and St Jude Medical. C.B.-L. has received research
grants from Octopus, AtriCure, and Medtronic. M.J.P.R. is a consultant or advisory-board member for Biosense Webster, Boehringer Ingelheim, St Jude Medical, and Stereotaxis. J.M.M. is a
consultant to Medtronic, has received honoraria from Boston
Scientific and St Jude Medical, and has had research support
from all three companies.
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Management of patients with palpitations: a

Aim of the document

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Managing patients with palpitations

In normal resting conditions, the activity of the heart is generally

Palpitations due to arrhythmias

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Table 1 Main causes of palpitations

Palpitations due to structural heart

Palpitations due to psychosomatic

Palpitations due to systemic causes

Palpitations due to the effects of medical

Downloaded from by guest on August 30, 2015

Psychosomatic disorders that are most frequently associated with

Managing patients with palpitations

irregular heartbeat, history of heart disease, and event duration

Downloaded from by guest on August 30, 2015

The prognostic implications of palpitations are dependent on the

in particular of symptomatic competitive as well as recreational

Table 2 Types of palpitations and their clinical presentations

Possible associated symptoms

Irregular, interspersed with

Beating wings in the

Syncope, dyspnoea, fatigue, chest

Regular, normal frequency

Tingling in the hands and face, lump

Table 3 Clinical characteristics of tachycardiac palpitations

Sudden onset regular with periods of

Physical effort, changes in

Polyuria, frog sign

Irregular with variable heart rate

Physical effort, cooling down,

Atrial tachycardia and

Regular (irregular if A-V conduction is

Regular with elevated heart rate

beat, which accentuates the movement of the heart inside the

end gradually, and patients describe numerous other associated

Associated symptoms and circumstances

Downloaded from by guest on August 30, 2015

Managing patients with palpitations

which a sudden reduction in sympathetic tone is accompanied by

Accuracy of clinical features for the

history, physical examination, ECG, psychosomatic

Downloaded from by guest on August 30, 2015

Polyuria, which is due to the hypersecretion of natriuretic

Initial clinical evaluation

Table 5 Main questions to ask a patient with

Table 4 Clinical features suggestive of palpitations of

Age at the first episode, number of previous episodes, frequency

Structural heart disease

Previous systemic diseases

Primary electrical heart disease

Previous thyroid dysfunction

Family history of sudden death

Drug abuse (alcohol and/or others)

Downloaded from by guest on August 30, 2015

Stress testing is indicated if the palpitations are associated with

Managing patients with palpitations

inputs from other members of the family or from individuals who

importance for the future evaluation.1,5 9,47 Furthermore, precise

Table 6 Electrocardiographic features recorded on