E v i denc e - B as ed A p p roa ch to

Palpitations
Clara Weinstock, DO*, Hilary Wagner, DO, Meghan Snuckel, MD, Marilyn Katz, MD

KEYWORDS
 Palpitations  Workup  Diagnose  Ambulatory ECG  Primary care  Heart monitor

KEY POINTS
 All patients presenting with a chief complaint of palpitations should undergo a detailed his-
tory, physical examination, and electrocardiogram (ECG).
 A thorough history is key in helping to diagnose the cause of the palpitations and is impor-
tant in triaging which patients will need additional evaluation.
 Physical examination is low yield for diagnosing the cause of palpitations but should be
used to guide further workup.
 A 2-week continuous loop event monitor has the highest diagnostic yield to cost ratio and
is the test of choice when pursuing ambulatory ECG monitoring. Holter monitors should
play a limited role in the evaluation of palpitations and should only be used when the pa-
tient’s typical symptoms reliably occur at least every 24 hours.
 Consumer grade wearable devices such as smartwatches have potential for medical use
in the future, but current data show their accuracy to be variable and their likelihood of
finding clinically irrelevant abnormalities to be high.

INTRODUCTION

Palpitations are a common chief complaint and can be seen in a variety of settings
including primary care, urgent care, the emergency department, and cardiology of-
fices. The complaint of palpitations can refer to tachycardia, skipped beats, premature
beats, or fluttering in the chest. The prevalence of palpitations in the community is 6%
to 11%.1,2 In a study evaluating the prevalence of chief complaints from multiple
outpatient primary care offices, 16% of patients indicated that palpitations were a
“major problem” for them.3 Palpitations are also the second most common reason
for referral to cardiology.4
A retrospective cohort study compared 109 patients who presented to primary
care with palpitations with age- and sex-matched controls who did not report pal-
pitations over a 5-year period and found no difference in the incidence of morbidity

University of Connecticut School of Medicine, 263 Farmington Avenue, Outpatient Pavilion-

2nd Floor East, Farmington, CT 06030, USA
* Corresponding author.
E-mail address: clweinstock@uchc.edu

Med Clin N Am 105 (2021) 93–106

https://doi.org/10.1016/j.mcna.2020.09.004 medical.theclinics.com
0025-7125/21/ª 2020 Elsevier Inc. All rights reserved.

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94 Weinstock et al

and mortality between these 2 groups.5 The overall mortality rate of patients with
palpitations in a study by Weber and Kapoor was also low at 1.6%. Although overall
morbidity and mortality is low, they found that palpitations resulted in missed work
days (12% of patients), self-reported decreased work productivity (19% of pa-
tients), and accomplishing less than usual amount of work at home (33% of
patients).6
It is therefore important to pursue a cost-conscious, evidence-based approach to
evaluation and workup of palpitations. This article outlines the evidence behind the
history, physical examination, laboratories, electrocardiogram (ECG), and additional
testing modalities for patients presenting to primary care with palpitations.

Differential Diagnosis of Palpitations

Any arrhythmia, including sinus tachycardia, atrial fibrillation, premature ventricular
contractions, ventricular tachycardia, and myocardial infarction can cause palpita-
tions. There are noncardiac reasons for palpitations as well, including anxiety, thyroid
issues, medications etc. Hypertrophic obstructive cardiomyopathy (HOCM) and ven-
tricular tachycardia represent a small proportion of patients presenting with palpita-
tions but are red flag diagnoses that can lead to sudden cardiac death. Box 1
displays a broader differential diagnosis for palpitations.
In the Weber and Kapoor study described earlier, the cause of palpitations was
found to be cardiac in 43% of patients, psychiatric in 31%, other in 10%, and unknown
in 16%. Forty percent of the causes could be determined with the history and physical
examination, an ECG, and/or laboratory data.6 Table 1 displays the prevalence break-
down of the different causes of palpitations in this study.

PATIENT HISTORY
Importance of History
Palpitations are a nonspecific symptom; the differential diagnosis of their origin is
broad. A detailed patient history can help narrow the scope of further testing.

History of Present Illness

When did the palpitations start? Did the palpitations start suddenly or gradually? One
study showed that the longer the palpitation lasts, the more likely it is to be related to
an arrhythmia rather than a noncardiac cause.7 On the other hand, palpitations that
last for only a moment are more likely to represent premature ventricular contractions
(PVCs) or premature atrial contractions. Sustained palpitations, lasting for minutes (or
longer), are more consistent with supraventricular arrhythmias, ventricular arrhyth-
mias, or anxiety.8
Where was the patient when the palpitations began and what were they doing?
Sitting at rest could be a sign of vagal nerve-mediated cause (eg, ventricular prema-
ture contraction), whereas occurring with exercise or exertion that could lead to dehy-
dration suggests worsening of mitral valve prolapse cardiomyopathy or exertional
syncope.9 One study showed that palpitations that occurred at work or palpitations
that awoke one from sleep were significantly more likely to have a cardiac cause.7
Onset while speaking in front of a large group of people could suggest a more benign
origin such as anxiety or supraventricular tachycardia. Posture and postural changes
are also important to note. For instance, atrioventricular nodal reentrant tachycardias
have been described as being triggered by standing up after bending over. Supraven-
tricular tachycardia and ventricular premature contractions have often been noted
while the patient is lying in bed.10

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 Evidence-Based Approach to Palpitations 95

Box 1
Differential diagnosis of palpitations

Cardiac—Arrhythmia
Atrial fibrillation/flutter
Bradycardia caused by arteriovenous block or sinus node dysfunction
Brugada syndrome
Multifocal atrial tachycardia
Premature supraventricular or ventricular contractions
Sinus tachycardia or arrhythmia
Supraventricular tachycardia
Ventricular tachycardia
Wolf-Parkinson-White syndrome/long QT syndrome
Pacemaker-mediated tachycardia
Cardiac—Structure
Atrial or ventricular septal defect
Atrial myxoma
Cardiomyopathy
Congenital heart disease
Congestive heart failure
Valvular disease (mitral valve prolapse, aortic insufficiency, aortic stenosis)
Drugs, Medications, Toxins
Alcohol
Tobacco/nicotine
Caffeine
Street drugs (cocaine, amphetamines, anabolic steroids, marijuana, ecstasy, heroin)
Prescription medications (beta agonists, theophylline, digitalis, phenothiazine, steroids,
methylphenidate, midodrine, epinephrine, anticholinergics)
Over-the-counter medications (pseudoephedrine, omega-3-polyunsaturated fatty acids,
coenzyme Q10, carnitine)
Withdrawal of medications (beta-blockers)
Physiologic
Exercise
Fever
Hypovolemia/dehydration
Pregnancy
Endocrinologic
Hyperthyroidism
Hypoglycemia
Paget disease of the bone
Pheochromocytoma
Hematologic
Anemia
Mastocytosis
Psychological
Anxiety, stress
Panic attacks
Neurologic
Autonomic dysfunction
Vasovagal syndrome
Postural Orthostatic Tachycardia Syndrome
Other
Electrolyte Imbalance
Pulmonary Disease

Courtesy of A. Abbott, M.D., Los Angeles, California.

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96 Weinstock et al

Table 1
Prevalence of causes of palpitations in Weber and Kapoor study

Causes of Palpitations No. Percent

Cardiac 82 43.2
Atrial fibrillation 19 10
Supraventricular tachycardia 18 9.5
Premature ventricular beats 15 7.9
Atrial flutter 11 5.8
Premature atrial beats 6 3.2
Ventricular tachycardia 4 2.1
Mitral valve prolapse 2 1.1
Sick sinus syndrome 2 1.1
Pacemaker failure 2 1.1
Aortic insufficiency 2 1.1
Atrial myxoma 1 0.5
Psychiatric 58 30.5
Panic attack or disorder plus anxiety 20 10.5
Panic attack alone 17 8.9
Panic disorder alone 14 7.4
Anxiety alone 6 3.2
Panic plus anxiety plus somatization 1 0.5
Miscellaneous 19 10
Medication 5 2.6
Thyrotoxicosis 5 2.6
Caffeine 3 1.6
Cocaine 2 1.1
Anemia 2 1.1
Amphetamine 1 0.5
Macrocytosis 1 0.5
Unknown 31 16.3

From Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. The American
Journal of Medicine. 1996;14(6):138-148; with permission.

Ask your patient to carefully describe the quality of the palpitation. A feeling of rapid
fluttering in the chest is typically seen in sustained ventricular or supraventricular ar-
rhythmias, including sinus tachycardia. The regularity or irregularity of the palpitation
may indicate what is causing the arrhythmia. As described by Zimetbaum and Joseph-
son, a sensation of “flip-flopping” in the chest, the experience of a pounding, or very
strong heart beat followed by the heart briefly “stopping” may be caused by premature
supraventricular or ventricular beats.8 An irregular, pounding feeling in the neck along
with palpitations has been reported by patients with PVCs, complete heart block,
pacemaker syndrome, or ventricular tachycardia.11 Patients frequently describe a
feeling of an “unpleasant awareness” with aortic regurgitation.12 Table 2 summarizes
some typical palpitation descriptions and the diagnosis with which they are classically
associated. Patients with palpitations on a regular basis were more than twice as likely
to have a significant cardiac arrhythmia as a cause for their palpitations versus those
who did not describe any regularity to their palpitations.7

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 Evidence-Based Approach to Palpitations 97

Table 2
Key clinical findings with palpitations and suggested diagnoses

Finding Suggested Diagnosis

Single skipped beats Benign ectopy
Feeling of being unable to catch one’s breath Ventricular premature contractions
Single pounding sensations Ventricular premature contractions
Rapid regular pounding in neck Supraventricular arrhythmias
Palpitations since childhood Supraventricular tachycardia
Palpitations terminated by vagal maneuvers Supraventricular tachycardia
Palpitations that are worse at night Benign ectopy or atrial fibrillation
Rapid irregular rhythm Atrial fibrillation, tachycardia with variable
block
Palpitations associated with emotional Psychiatric cause or catecholamine-sensitive
distress arrhythmia
General anxiety Panic attacks
Palpitations associated with activity Coronary heart disease
Rapid palpitations with exercise Supraventricular arrhythmia, palpitations
associated with exercise
Medication or recreational drug use Drug-induced palpitations
Positional palpitations Atrioventricular nodal tachycardia,
pericarditis
Friction rub Pericarditis
Heat intolerance, tremor, thyromegaly Hyperthyroidism
Heart murmur Heart valve disease
Midsystolic click Mitral valve prolapse

The information in this table is based on clinical experience and not data from clinical trials.
Courtesy of A. Abbott, M.D., Los Angeles, California.

Symptoms associated with the noncardiac causes outlined in Box 1 are important
to investigate to help build a differential. For instance, palpitations associated with
heat intolerance could be associated with hyperthyroidism, whereas fever may indi-
cate infection. Shortness of breath or choking sensation, nausea, dizziness, chest
pain/discomfort, and paresthesias may help guide the diagnosis toward anxiety or
panic attack.

Past Medical History

Past medical history is equally important as anxiety is the most common noncardiac
cause of palpitations.11 One study showed that a patient’s palpitations are more likely
to be of psychiatric nature if the patient is young, has a disability, has shown
hypochondria-like behavior, or has been previously diagnosed with a somatization
disorder.13 The prevalence of an underlying panic disorder in patients with palpitations
is 15% to 31%.6 If it is thought that anxiety is playing a role, a clinician could use the
Generalized Anxiety Disorder 7 item scale (GAD-7), a validated assessment tool to
further assess the severity of symptoms. Other associated symptoms, including
impending doom, diaphoresis, perioral numbness, and peripheral numbness, can
help point to a diagnosis of anxiety or panic attack. It is important to remember that
a person experiencing anxiety may have an underlying structural or additional medical
reason for the palpitations. One study showed that 13% of patients diagnosed with a

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98 Weinstock et al

psychiatric disorder had a nonpsychiatric cause of their palpitations,13 so anxiety as

the sole cause should remain a diagnosis of exclusion until after proper testing has
been completed.

Medications
Many medications, whether prescription, over the counter, or herbal supplements,
can trigger palpitations, so a complete medication reconciliation is paramount. Antide-
pressants and benzodiazepines have been shown to be associated with a decreased
risk of cardiac arrhythmia, whereas the use of beta-blockers, diuretics, angiotensin-
converting enzyme inhibitors, and other antihypertensives correlated with an
increased risk of cardiac arrhythmia.7 Changes in dose or withdrawal can also be a
source of palpitations, so ask for recent changes in dosage or frequency of use.
Over-the-counter medications such as nasal decongestants with pseudoephedrine,
omega-3-polyunsaturated fatty acids, coenzyme Q10, and carnitine have all been
shown to cause palpitations.14

Social History
Caffeine is a common culprit for palpitations and is integral in many patient’s routines.
Cigarettes and other nicotine products also can trigger palpitations. Although cocaine
and methamphetamines are commonly associated with palpitations and a combina-
tion of both accounts for 1.6% of patients presenting with palpitations,6 marijuana
has additionally been shown to cause arrhythmias.15 Athletes and weight lifters may
have tried performance-enhancing drugs such as anabolic steroids.15

Family History
A family history of diseases such as those described in Box 1 can also help direct
workup for palpitations. Prolonged QT syndrome and cardiomyopathies can run in
families, as well as anxiety and thyroid disease. Ask your patient specifically if anyone
in their family passed away from or had a heart attack before the age of 55 years for
men and 65 years for women.16

PHYSICAL EXAMINATION

The physical examination, although a wonderful tool, can have low yield for patients
with palpitations. This is likely due to the intermittent nature of palpitations, resulting
in lack of symptoms at the time of presentation to the office. However, it can be helpful
in ruling out many causes and help to refine the differential diagnosis.
The general appearance of the patient is important for many cardiac causes, partic-
ularly that of a myocardial infarction. Apparent distress due to pain or shortness of
breath will alter the urgency of the workup.
Reviewing vital signs, even if within the normal range, can be an important clue in the
workup for palpitations, particularly a change from the individual’s baseline. For
instance, an increase in the heart rate and a decrease in weight may indicate an
excess of thyroid hormone. Although lung causes are less commonly associated
with palpitations, an increased heart rate or respiratory rate and low pulse oximetry
may indicate a pulmonary-induced cause such as multifocal atrial tachycardia or a
pulmonary embolus. A lower blood pressure or orthostatic hypotension may indicate
volume depletion. Orthostatic vital signs can also diagnose postural orthostatic tachy-
cardia syndrome (POTS), which usually presents with complaints of intermittent palpi-
tations and lightheadedness or syncope. POTS is characterized as orthostatic
tachycardia, with an increase in heart rate by greater than 30 bpm (or an increase to

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 Evidence-Based Approach to Palpitations 99

120 bpm) when moving from lying down to standing position, in the absence of
orthostatic hypotension.17 If there is clinical suspicion of POTS, a set of orthostatic
blood pressures with pulse can make the diagnosis.
If a patient is actively having palpitations, a simple pulse check can begin to narrow
the differential greatly, especially for arrhythmia-induced palpitations. An irregular
pulse would lead a practitioner to think of atrial fibrillation or premature ventricular
contractions. A retrospective study by Zeldis and colleagues reviewed charts of 477
patients presenting with cardiovascular complaints including palpitations, dyspnea,
chest pain, dizziness, or syncope who underwent one or more 24-hour ECG monitor
recordings. Of those with an irregular pulse on examination, 91% had a significant
arrhythmia on 24-hour ECG (positive predictive value of 91%) and of those with a reg-
ular pulse on examination, 28% had a significant arrhythmia on their 24-hour ECG.18
The sensitivity of an irregular pulse for significant arrhythmia on ECG in this study was
only 7%. Thus, you would not have an irregular pulse on examination in most patients
with significant arrhythmia on 24-hour ECG, but if you do detect an irregular pulse on
examination then there is a very high chance of also detecting a significant arrhythmia
on ambulatory ECG monitoring. No other single history or physical examination finding
in this study could reliably predict detecting a significant arrhythmia on ambulatory
ECG monitoring.
Point of maximal impulse (PMI), which is determined by careful palpation of the
chest wall to determine the location of the apex, can be useful in assessing cardiome-
galy, particularly if it is displaced laterally and inferiorly. Noting the strength of the PMI
is also useful as stronger or weaker than anticipated may indicate a cardiac cause of
palpitations.
Heart auscultation is useful with structural heart causes. Mitral valve prolapse has
the classic sound of a mid- to late systolic click, and can be seen in isolation, or in
conjunction with hyperthyroidism, particularly in young white women.19 Some other
murmurs that are commonly associated with the symptom of palpitations include
aortic regurgitation and diastolic tumor plop. Aortic regurgitation is described as a
soft high-pitched early diastolic decrescendo murmur. Links to audio clips of these
murmurs can be found in Box 2.
Examination findings that could point to a thyroid cause include exophthalmos and/
or lid lag, thyromegaly and/or thyroid nodules, diaphoresis, hand tremor, hyperre-
flexia, widened pulse pressure, and irregular or elevated heart beat.
Although not as common of a presentation, anemia can also present with palpita-
tions, therefore looking for evidence of anemia on examination is reasonable. Individ-
uals with anemia may have diastolic flow murmur, pallor of the conjunctiva, nail beds,
and/or oral mucosa, or splenomegaly. In a 2017 study, researchers looked at signs/
symptoms of severe anemia (hemoglobin less than or equal to 7%) in 94 patients.

Box 2
Murmur sound clips

Mitral valve prolapse—Heart Sounds. Medzcool https://www.youtube.com/watch?v5sH_

KmHIHR70. Accessed March 30, 2020.
Aortic Regurgitation—Heart Sounds.; 2019. https://www.youtube.com/watch?
v5uZysrKXHJMM. Accessed March 30, 2020.

From Medzcool. Mitral Valve Prolapse - Heart Sounds. Youtube. Available at: https://www.
youtube.com/watch?v5sH_KmHIHR70. Accessed March 30, 2020; and Medzcool. Aortic Regur-
gitation - Heart Sounds. Available at: https://www.youtube.com/watch?v5uZysrKXHJMM.

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100 Weinstock et al

They found that 54 patients out of the 94 had a cardiac murmur and when followed-up,
most of these patients’ murmur resolved after treatment of their anemia. The same
study showed that 39 out of the 94 (41%) reported palpitations at presentation, which
improved or resolved after treating their anemia.20
In addition, abnormal pupil size may indicate medication or drug effect or with-
drawal. Oral examination should note moist or dry mucous membranes.
Although anxiety is a diagnosis of exclusion and is difficult to diagnose with physical
examination alone, patients can often present with a hyperdynamic pulse along with
diaphoresis, and abnormal speech patterns.

TESTING (EVALUATION)

Following a thorough history and physical examination, an ECG is warranted, as it has

been shown to reveal the cause of palpitations in 27% of patients.6 Even if the patient
is asymptomatic in the office, an ECG may identify many arrhythmias, including, Wolff-
Parkinson-White (WPW) syndrome, long QT syndrome, atrioventricular (AV) blocks,
atrial fibrillation, premature atrial complexes, and premature ventricular complexes.
It can also show evidence of structural heart disease such as atrial enlargement, right
ventricular hypertrophy, left ventricular hypertrophy, and prior myocardial infarction.
If the history, physical and/or ECG suggests the possibility of structural heart dis-
ease or congestive heart failure, then an echocardiogram should be ordered. This in-
cludes anyone with palpitations associated with syncope or presyncope, a family
history of HOCM, a murmur or signs of hypervolemia on examination (increased jugu-
lar venous pressure, crackles, bilateral lower extremity edema), ECG showing q
waves, left bundle branch block, left ventricular hypertrophy, atrial enlargement, AV
block, short PR interval and delta waves (WPW syndrome), or prolonged QT interval.11
There is no strong evidence to direct laboratory testing in patients presenting with
palpitations. Although some articles recommend that all patients presenting with pal-
pitations should have a thyroid stimulating hormone, complete blood count, and basic
metabolic panel checked,9,21 a position paper by the European Heart Rhythm Asso-
ciation states that targeted laboratory testing should be done only when history and
physical examination suggest a cause such as hyperthyroidism, anemia, drug use,
or pheochromocytoma.22 Abnormal renal function and derangements of potassium
and sodium can cause cardiac arrhythmias. Illicit substances can cause palpitations,
making urine toxicology important if there is history or clinical suspicion of drug
use.9,21,22 Based on the relative cost of bloodwork compared with other diagnostic
modalities (see Box 4), this remains a relatively cost-efficient starting point for the
workup of palpitations.23
Palpitations lacking a clear diagnosis after performing a history, physical examina-
tion, and ECG are classified as “unexplained palpitations.” According to the 2017
expert consensus statement by the International Society for Holter and Noninvasive
Electrocardiology and the Heart Rhythm Society (ISHNE-HRS), ambulatory ECG
monitoring is indicated for patients with unexplained palpitations who meet any of
the following criteria displayed in Box 3 (Class I Recommendation with level of evi-
dence B-R). The American College of Cardiology/American Heart Association guide-
lines from 1999 recommend ambulatory ECG monitoring to evaluate patients with
unexplained recurrent palpitations.24 There are multiple types of ambulatory ECG
monitors including 24- to 48-hour Holter monitors and continuous loop event moni-
tors. The ISHNE-HRS consensus statement gives a Class I recommendation with level
of evidence B-NR for doing a 24- to 48-hour Holter monitor when frequent symptom-
atic events reliably occur within the recording window (daily or more often).25 In

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 Evidence-Based Approach to Palpitations 101

Box 3
Indications for ambulatory electrocardiogram monitoring based on the 2017 consensus
statement from the International Society for Holter and Non-invasive Electrocardiology-Heart
Rhythm Society in patients with unexplained palpitations

1. When history, physical examination, and 12-lead ECG suggest a possibility of arrhythmia
2. In the setting of diagnosed structural heart disease, family history of sudden cardiac death,
or inherited channelopathy with known risk of arrhythmia
3. When patients need reassurance and specific explanation of their symptoms
4. When symptoms warrant therapy and specifics of treatment depend on a formal arrhythmic
diagnosis (eg, ablation, antiarrhythmic therapy)

Data from Steinberg JS, Varma N, Cygankiewicz I, et. al. 2017 ISHNE-HRS expert consensus state-
ment on ambulatory ECG and external cardiac monitoring/telemetry.Heart Rhythm. 2017
Jul;14(7):e55-e96.

addition, the consensus statement gives a Class I recommendation with level of evi-
dence B-R for doing 15- to 30-day ambulatory ECG monitoring for patients with unde-
fined symptom frequency or symptoms that do not reliably occur every day.
Holter monitors, when worn, record heart rhythms continuously for 24 to 48 hours
and are recommended to evaluate unexplained palpitations that occur at least daily.
Patients keep a diary of their symptoms during the recording period in order to corre-
late the time of the symptoms with a particular portion of ECG recording. One study
showed 53% of the patients did not experience their presenting symptoms during
the 24-hour Holter monitor period, 13% of patients had an arrhythmia correlating
with their symptoms, and 34% of patients had their typical presenting symptoms
associated with a recording of normal sinus rhythm.18 The diagnostic yield of a 24-
hour Holter monitor for evaluation of palpitations ranges between 5% and
39%.6,8,26–28 Forty-eight hour Holter monitor did not have a significantly higher diag-
nostic yield than 24-hour Holter monitoring for detection of maximal ventricular ectopy
in patients with coronary artery disease,29 and it is rarely valuable.
Holter monitors can inadvertently show asymptomatic arrhythmias. One retrospec-
tive study reviewing 518 consecutive Holter monitor recordings found that, of those
who did not experience their presenting symptoms during the Holter recording period,
56% were found to have an asymptomatic arrhythmia. Furthermore, of the patients
who did experience their typical presenting symptoms but had no correlating
arrhythmia, 33% were found to have an arrhythmia during their asymptomatic time
periods.18
Transtelephonic event monitors such as a continuous loop event monitor are worn
continuously for 7 to 30 days and will continuously record the heart rhythm. Durable
recordings will only be saved and sent to a central station for the few minutes before
and after the patient manually activates it. Many of these devices now have an auto-
trigger mode that will automatically save data when the heart rate goes greater or less
than a certain threshold. Continuous loop event monitors can miss asymptomatic ar-
rhythmias or arrhythmias associated with syncope, as the patient may not activate the
recorder during those events. There is another type of transtelephonic event monitor
that is not worn continuously but is carried with the patient and placed on the chest
when palpitations occur. This often misses the rhythm at the onset of the palpitations.
The diagnostic yield of transtelephonic event monitors for palpitations is 66% to
83%,8 which is considerably higher than the diagnostic yield of Holter monitors. A
study of 147 patients being worked up for cardiac arrhythmia directly compared the

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102 Weinstock et al

diagnostic yield of 24-hour Holter monitor with 2-week continuous event monitor by
having the patients wear both simultaneously and then remove the Holter after
24 hours but continue the event monitor for 2 weeks. During the first 24 hours of simul-
taneous use of both devices 60 arrhythmic events were noted in both devices and 1
arrhythmic event was detected in the Holter but not the event monitor. However, after
the first 24 hours once Holter was removed, the continuous event monitor continued
and subsequently detected an additional 36 arrhythmic events. There was a total of 61
events identified by Holter and 96 total events identified by 2 week monitor
(P < .001).30
Zimetbaum and colleagues conducted a prospective cohort study of 105 patients
with palpitations referred for continuous event monitor to assess the diagnostic yield
and cost of continuous event monitors for each week over a 4-week time period.
Table 3 shows the cost, cost per new diagnosis made, and number of new diagno-
ses made per patient in each week by continuous loop event monitors in the United
States in 1997. The probability of finding a diagnosis over the 4-week time period
took the shape of a logarithmic curve that plateaued around week 2 with marginal
additional diagnostic yield in weeks 3 and 4.8 One hundred percent of the “serious
diagnoses” made during this study (supraventricular tachycardia, atrial fibrillation/
atrial flutter, nonsustained ventricular tachycardia, high-degree heart block) were
made within the first 2 weeks of wearing continuous loop event monitors.8 Thus
2 weeks is considered the optimal duration of continuous loop event monitors for
a highest value balance between diagnostic yield and cost. If the 2-week continuous
event monitor does not reveal the cause of palpitations in either a high-risk patient or
a patient with significant impact on quality of life, then a referral to cardiology is
warranted.
A study evaluating syncope workup in Ontario, Canada in 2005 reported the cost
(including material, tech/labor, service, overhead, and professional) from Ontario-
based fee codes converted to US dollars of various diagnostic testing strategies
that are frequently used in the workup of palpitations. The relative costs may be appli-
cable to workup of palpitations in the United States and are displayed in Box 4
rounded to the nearest dollar amount.23
The cost per diagnosis is important because once a definitive diagnosis is estab-
lished, that halts further testing (associated with further diagnostic expenditures)
and shifts the focus to appropriate management. Overall, the Holter monitor is

Table 3
Cost, cost per new diagnosis made, and number of new diagnoses made per patient by
continuous loop event monitors in the United States in 1997

Number of New
Length of Time Cost per New Diagnoses Made per
Event Monitor Cost of Event Monitor Diagnosis Made in Patient during Each
Worn in 1997 US Dollars the Additional Time Additional Week
Week 1 $102 $98 1.04
Week 2 $96 (1$102 5 $198) $576 0.17
Week 3 $81 (1$198 5 $279) $5832 0.01
Week 4 $81 (1$279 5 $360) No new diagnoses 0.00
made

Data from Steinberg JS, Varma N, Cygankiewicz I, et. al. 2017 ISHNE-HRS expert consensus state-
ment on ambulatory ECG and external cardiac monitoring/telemetry.Heart Rhythm. 2017
Jul;14(7):e55-e96.

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 Evidence-Based Approach to Palpitations 103

Box 4
Cost of various testing in Ontario, Canada in 2005 in US dollars

Primary care doctor initial assessment: $49

Primary care doctor follow-up: $25
Emergency room visit: $64
ECG: $21
Bloodwork: $10
24-h Holter: $103
48-h Holter: $178
External loop (1 mo): $534
Echocardiogram: $228
Cardiology consult: $103
Electrophysiologic study: $937
Standard treadmill stress test: $142
Stress: MIBI $616
Cardiac catheterization: $462

Adapted from Rockx MA, Hoch JS, Klein GJ, et al. Is ambulatory monitoring for “communityac-
quired” syncope economically attractive? A cost-effectiveness analysis of a randomized trial of
external loop recorders versus Holter monitoring. American Heart Journal. 2005;150(5):1065;
with permission.

cheaper but of much lower diagnostic yield, making the event monitor more cost-
effective and the ambulatory ECG the test of choice unless palpitations are consis-
tently experienced at least every 24 hours.
Many patients currently use smartwatches or other “wearables,” which are con-
sumer grade devices that record heart rate (usually not heart rhythm) by photoplethys-
mography. Although some of these devices have achieved or are seeking Food and
Drug Administration (FDA) “clearance” (considered safe), none of these devices
currently have FDA “approval” (endorses evidence of accuracy for medical use). Ac-
cording to the 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and
external cardiac monitoring/telemetry, consumer grade devices currently have no
medical oversight and should not replace any medically indicated workup at this
time.25 One 2019 study of patients undergoing cardiac rehabilitation showed insuffi-
cient concordance of heart rate measurement between various wearable devices
and the gold standard of ambulatory ECG monitors.31 Other studies show some
(but not all) models of wearables with high concordance with ambulatory ECGs for
heart rate during certain controlled activities (eg, sitting, walking, running, etc.) and
overall. However, there is no standard for what level of concordance is considered
acceptable for medical use. Of the devices with a high overall concordance with
ambulatory ECGs, there was still significant variability in concordance during different
types of activities including low concordance during some activities of daily living
(chores, brushing teeth) or certain types of exercise (eg, elliptical, cycling). Different
devices had different activities during which their measurements were less accu-
rate.32–36 This is a rapidly evolving field of study with vast potential, given the rapid
improvement in device performance during a broad range of activities over the last
few years. There are several ongoing studies evaluating the ability of wearables to

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104 Weinstock et al

detect heart rhythm (not just heart rate) abnormalities such as atrial fibrillation and sup-
raventricular arrhythmias.37,38
Although these devices have high potential for helping diagnose medically relevant
arrhythmias, they may also lead to increased testing and overdiagnosis of asymptom-
atic benign arrhythmias. Given that Holter monitors have shown a high prevalence of
asymptomatic arrhythmias,18 it is likely that consumer grade wearables will as well. As
the technology of commercially available products is exploding, patients may begin to
present to their doctors with data from consumer grade devices rather than symp-
toms. For the time being, clinicians should remain focused on symptom driven evalu-
ation with evidence-based workup dictated by history, physical examination, and
ECG, but in the future, wearables may represent an easily accessible and cost-
effective way to evaluate palpitations.
Many patients with palpitations can be diagnosed and managed in the outpatient
setting without a cardiology referral. If the palpitations are caused by premature atrial
or ventricular contractions in the absence of structural heart disease, patients should
be reassured about this benign condition, and symptoms can be managed with a
beta-blocker, if needed. A longitudinal study demonstrated no increased mortality in
patients with frequent premature ventricular contractions without structural heart dis-
ease compared with the healthy general population.29 Red flags that warrant further
evaluation (sometimes urgently in the emergency room) include palpitations associ-
ated with syncope or presyncope, known or suspected family history of hypertrophic
obstructive cardiomyopathy, suspicion of active cardiac ischemia and/or abnormal
stress test, and abnormal echocardiogram showing structural heart disease. Practi-
tioners should consider cardiology referral for management of certain arrhythmias
diagnosed by primary care provider workup including supraventricular tachycardias,
ventricular arrhythmias, or second- or third-degree AV heart blocks. Cardiology
referral is also recommended for patients with a negative workup by primary care
who are poorly tolerating their symptoms.

SUMMARY

Palpitations are a common chief complaint of patients in the primary care setting, ur-
gent care, emergency department, and cardiology offices. A thorough history is cen-
tral in helping to narrow down the cause of the palpitations. All components of the
patient’s history should be addressed, including their personal social and medical his-
tory along with their family history. A comprehensive history will help determine who
will need further testing and monitoring. Although the physical examination may pro-
vide limited additional information, it should be used to guide further workup. There are
many options available for additional investigation of the cause of palpitations. Of the
available tests, a 2-week continuous loop event monitor has been shown to have the
highest diagnostic yield to cost ratio when pursuing ambulatory ECG monitoring.8 If a
patient’s symptoms are reportedly occurring at least every 24 hours, a Holter monitor
can be used. Currently, there are multiple consumer grade wearable heart monitor de-
vices available to our patients such as smartwatches. Their use and efficacy are still
being investigated. At this point their accuracy seems to be variable, and they are likely
to provide a lot of clinically irrelevant data. Nevertheless, they do have an exciting po-
tential for medical use in the future and may have the ability to reduce the overall cost
of a palpitations workup.

DISCLOSURE

The authors have no conflicts of interest to disclose.

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 Evidence-Based Approach to Palpitations 105

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