Dr. John Day, Cardiologist

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How to Diagnose Palpitations

A reader recently shared with me, “Last July I was laying on the couch and out of nowhere I had a weird series of beats. Thump thump thump thump….just hard, slightly faster, off rhythm beats. I sat up and my heart beat returned to normal.

For whatever reason, I had a totally random thought that this was an indicator of some serious underlying heart issue and I panicked. I basically had a full on panic attack that night.

Since that time, I have been hyper-focused on my heart. So, over the next several months, I would have odd beats and would freak out and have a panic attack. This led me to several Urgent Care visits. ECGs always came back totally normal. ”

Sadly, thousands of patients have shared similar experiences with me.  Their palpitations are so severe that they struggle to exercise, sleep, or even go to work.

What Are Palpitations?

Palpitations are the perceived sensation of abnormal heart beats.  They are often described as “hard beats,” “skipped beats,” or some patients will even tell me “my heart stopped.”

These palpitations are often associated with anxiety, stress, sleep deprivation, poor diet, or stimulants.  For many patients, in addition to the palpitations, they also get chest discomfort, shortness of breath, fatigue, dizziness, or lightheadedness.

Are Palpitations Dangerous?

For many patients, palpitations make them feel like they are having a heart attack.  The more concerned they are about their heart, the worse the palpitations.

Fortunately, 99% of the time, palpitations are totally benign.  Everyone’s heart skips from time-to-time.  For the vast majority of people, they never feel these premature beats unless they are taking their pulse.  For many patients who feel premature beats, once they learn their palpitations are benign their symptoms often go away without treatment.

How, then do you know if your palpitations are part of the 1% that are worrisome?

How to Diagnose Palpitations

By the time patients have made it to the cardiologist, they have already had blood work to look for electrolyte abnormalities, thyroid problems, etc.  Thus, in my cardiology practice, we generally focus on two additional tests:

1. Stress echocardiogram to rule out other heart problems.

An echocardiogram or “echo” uses ultrasound technology to evaluate the heart.  We can see if the heart is enlarged, if there are valve problems, or other cardiac abnormalities.

The “stress” portion of the examination consists of a treadmill.  Often, exercise can reproduce the palpitations.  The addition of an exercise component to the examination can also help to rule out any serious heart blockages.

2. ECG documentation of the palpitations when they are happening

Mysteriously, palpitations rarely, if ever, happen in the doctor’s office.  If you are that rare patient that has palpitations in the doctor’s office, then a simple ECG there can cinch the diagnosis.

For those who do not have palpitations at the doctor’s office, some form of a heart monitor to go home with is what is needed to make the diagnosis.  This usually consists of a Holter monitor, event monitor, or one of the new smart phone ECG apps.

What is a Holter Monitor?

If the palpitations occur every day, I generally order a Holter monitor.  At our hospital, Holter monitors can be for 24 or 48 hours and they look like the photo to the right.

One of our ECG technicians attaches the Holter monitor system to the chest.  Patients are instructed not to swim or shower until the test is completed.  Each time they experience their typical symptoms they are instructed to push the button and then record their symptoms.

Every heart beat is recorded with the Holter monitor.  It becomes very easy to quickly see what the heart is doing while they are having symptoms.

The advantage of the Holter monitor is that it is generally a much quicker and cheaper test.  While it is cumbersome to wear, as long as the symptoms occur while the monitor is on it is a great test.

What Is An Event Monitor?

Event monitors are monitors that patients can put on and take off each day.   This allows patients to shower each day.

At our hospital we use monitors that have three ECG leads, as shown in this photo.  Typically, we will check out these monitors to patients for a month.

Most event monitors now utilize cell phone technology to transmit ECGs in near real time.  With up to a month to make the diagnosis, it is usually very easy to identify the cause of the palpitations.  As with the Holter monitor, when patients have symptoms they push the button and record their symptoms.

What are the New Smart Phone ECG Apps?

In recent years, ECG technology has moved to the cell phone.  While insurance companies generally don’t cover this technology, the out-of-pocket costs are often much cheaper than the copay with a Holter or event monitor.

An additional advantage is that there are no electrodes stuck to the chest so that skin rashes can be avoided.  Also, as people own this device and usually have their phone with them, this can be an ongoing monitoring device for many years.

The two main options at this time are Alivecor and ECG Check.  For around $75 you can have your own high quality ECG app.  I know that if I suffered from palpitations I would definitely purchase one of these devices.

While most of my patients have opted for Alivecor, I have found that both devices deliver a high quality ECG.  My patients love this technology.

Once you have these ECGs on your smart phone you can then fax, email, or text them to your physician.  Other physicians may prefer that you bring your phone with you to your next doctor visit and then review the ECGs as part of your clinic visit.

What Do You Usually Find on ECG with Palpitations?

1. Nothing

For reasons that I still cannot explain, at least half of the time that patients report palpitations, the ECG only shows normal rhythm.  These patients are not “crazy,” — they are feeling something in their chest, it just is not their heart.

2. PACs and PVCs

The next most common finding are premature beats.  These can be premature atrial contractions (PACs) or premature ventricular contractions (PVCs).

Most of the time these are isolated beats.  Sometimes, you can have 3, 4, or more consecutive premature beats.  People suffering from long runs of these consecutive premature beats are also at risk for more serious rhythms like #3 or #4 as described below.

Except for rare cases, premature beats are benign.  For people suffering from premature beats, please read this article I wrote on how to make them stop.

3. Atrial Fibrillation or Flutter

In my experience, a very distant but third most common cause of palpitations are atrial fibrillation and atrial flutter.  These two rhythms can be dangerous as they can cause strokes, heart failure, dementia, or premature death.

4. Other Rhythms

Lastly, there can be other rhythms that can cause palpitations such as supraventricular tachycardia (SVT) or ventricular tachycardia (VT).  Of these two rhythms, VT can trigger a cardiac arrest.

How to Diagnose Palpitations

In closing, the most important two things to remember when trying to diagnose palpitations is to rule out other conditions and to capture an ECG while the palpitations are occurring.  Fortunately, 99% of the time these palpitations are completely benign.

Do you suffer from palpitations?  How were your palpitations diagnosed?  What has helped you to control the symptoms?

Disclaimer

Do not self diagnose or treat based on anything you have read in this article.  If you suffer from palpitations, please work closely with your physician to both make the diagnosis and to design the right treatment approach for you.