Palpitation is an unpleasant subjective awareness of one’s own heartbeats. This usually occurs as a sensation in the chest of rapid, irregular, or unusually strong heartbeats. The patient describes it as pounding, jumping, racing, irregularity of the heartbeat, a “flip flopping” or “rapid fluttering“ in the chest, or pounding in the neck. Palpitation can be felt in the chest, throat, or neck. The pulse rate may become faster or rarely slower than normal. The term palpitation is used so loosely that specific questions must be asked to determine the exact nature of the symptom.
Palpitation is one of the most common cardiac symptoms encountered in medical practice, but it poorly corresponds to demonstrable abnormalities. Many palpitations are not serious. However, palpitation may indicate the possible presence of serious cardiac arrhythmias.
Box 32-1 lists causes of palpitation. The differential diagnosis can range from benign etiologies to life-threatening arrhythmias.
A high percentage of patients with palpitation have no cause that can be established.
Caffeine, a common stimulant, is found in many foods and drinks, such as coffee, tea, hot cocoa, soda, chocolate, and some medicines. Most energy drinks (e.g., Venom, Whoopass, Red Bull, Adrenalin Rush), which are the latest popular fad among youth, contain large doses of caffeine and other legal stimulants, including ephedrine, guarana, taurine, and ginseng.
Certain drugs and substances can be identified as causes of palpitation.
Some medical conditions, such as hyperthyroidism, anemia, and hypoglycemia, may be the cause of palpitation.
Although relatively rare, cardiac arrhythmias and structural heart disease should be looked into as a cause of palpitation. However, most palpitations are not accompanied by arrhythmias, and most arrhythmias are not perceived and reported as palpitations.
Rarely, slow heart rates may cause palpitation.
Occasionally, a psychogenic or psychiatric cause for the symptoms can be suspected. Some adult patients and adolescents with palpitations have panic disorder or panic attack. Panic attack and arrhythmias may be difficult to distinguish clinically because both may present as palpitations, shortness of breath, and lightheadedness.
Normal Physiologic Events
Exercise, excitement, fever
Psychologic or Psychiatric
Fear, anger, stress, anxiety disorders, panic attack or panic disorder
Certain Drugs and Substances
Stimulants: caffeine (coffee, tea, soda, chocolate), some energy drinks, smoking.\
Over-the-counter drugs: decongestants, diet pills, and so on
Drugs that cause tachycardia: catecholamines, theophylline, hydralazine, minoxidil, cocaine
Drugs that cause bradycardia: beta-blockers, antihypertensive drugs, calcium channel blockers
Drugs that cause arrhythmias: antiarrhythmics (some of which are proarrhythmic), tricyclic antidepressants, phenothiazines
Certain Medical Conditions
Poor physical condition
Certain congenital heart defects that are prone to arrhythmias or that result in a poor physical condition
After surgeries for congenital heart disease: Fontan connection, Senning operation
Mitral valve prolapse
Valvular disease: aortic stenosis
Cardiac tumors or infiltrative diseases
Premature atrial contractions
Premature ventricular contractions
Sick sinus syndrome