Chapter 26: Palpitations Assessment & Diagnosis

The text emphasizes the critical diagnostic reasoning required to distinguish between benign etiologies—such as anxiety, caffeine intake, or premature contractions—and potentially life-threatening cardiac arrhythmias or structural defects. The content details the importance of a focused patient history, identifying red flags such as syncope, lightheadedness, chest pain, and a family history of sudden cardiac death (SCD), which may suggest underlying coronary artery disease (CAD) or inherited cardiomyopathies. Significant attention is given to interpreting patient descriptions, where sensations of skipped beats often correlate with premature atrial or ventricular contractions, while rapid fluttering or neck pounding (associated with cannon A waves and atrioventricular dissociation) may indicate supraventricular tachycardias. The chapter systematically categorizes causes into cardiac origins, including atrial fibrillation, ventricular tachycardia, and valvular diseases like mitral valve prolapse, and noncardiac origins, which encompass psychological conditions such as panic disorder and generalized anxiety disorder. Systemic metabolic drivers are also thoroughly examined, including hyperthyroidism (characterized by weight loss, tremors, and heat intolerance), anemia, electrolyte imbalances, and rare neuroendocrine tumors like pheochromocytoma. The physical examination section guides clinicians in assessing vital signs for pulse deficits, examining jugular venous pressure for specific wave patterns, and auscultating for murmurs indicative of hypertrophic cardiomyopathy or pericarditis. Furthermore, the summary outlines the diagnostic workup hierarchy, prioritizing the 12-lead electrocardiogram (ECG) as the initial investigation, followed by ambulatory cardiac monitoring options such as Holter monitors, continuous loop event recorders, and implantable devices to capture transient events. Laboratory assessments for thyroid-stimulating hormone (TSH), complete blood counts, and urine catecholamines are also integrated into the diagnostic algorithm to rule out toxic or metabolic precipitants like stimulant use or medication side effects.