Character of palpitations

Ask the patient about:

• the rate of the palpitations (fast or slow)
• the regularity
• are the palapitations felt only in the chest (neck-) or are they felt in the neck as well (neck+)

The suspected diagnoses will be as follows:

• rapid, regular, neck+
  • atrioventricular nodal tachycardia
    
    
• rapid, regular, neck-
  • circus movement tachycardia via accessory pathway
    • atrial tachycardia
    • ventricular tachycardia
      
      
• rapid, irregular
  • atrial fibrillation
  • atrial flutter
  • atrial tachycardia
    
    
• slow, irregular, neck+
  • ventricular premature beats
    
    
• slow, irregular, neck-
  • any premature beat
    
    

(Palpitations are felt in the neck if the atria contract against closed atrioventricular valves).

• a feeling of 'flip-flopping' in the chest is usually secondary to a premature atrial or ventricular contraction
• sensation that the heart has stopped is secondary to the pause (compensatory or noncompensatory) that follows a prematture beat, whereas pounding is often the manifestation of a forceful beat caused by postextrasystolic potentiation after a premature beat
• feeling of rapid flutterng in the chest is usually secondary to supraventricular or ventricular tachyarrhythmias

Notes:

• pounding feeling in the neck is caused by the dissociation of atrial and ventricular contractions so that the atria contract against closed tricuspid and mitral valves, producing cannon A waves
  • cannon A waves are perceived as neck pulsations and, when rapid and regular, may be seen as a bulging in the neck (sometimes termed a 'frog sign')
    • sensation of rapid and regular pounding in the neck is most typical of reentrant supraventricular arrhythmias, particularly atrioventricular nodal tachycardia
      • patients with neck palpitations may have atrioventricular nodal tachycardia caused by simultaneous contraction of the atria and ventricles, which causes reflux of blood in the superior vena cava
      • atrioventricular nodal tachycardia is the most common form of paroxysmal supraventricular tachycardia
        • three times as common in women as in men
        • in the typical form of atrioventricular nodal tachycardia, the atria and ventricles are activated simultaneously at an average rate of 160 to 180 beats per minute
  • atrioventricular dissociation can also result from ventricular premature contractions called ventricular premature depolarizations
    • premature ventricular contractions also cause atrioventricular dissociation, resulting in pounding sensations in the neck and often a physical finding of cannon waves
    • in these cases only one or a few pounding sensations are felt in the neck, and the rhythm is often more irregular and less sustained than with atrioventricular nodal tachycardia
    • palpitations caused by ventricular premature depolarizations with cannon A waves are also often described as a feeling of being unable to catch one's breath

Reference:

• Zimetbaum PZ, Jospephson ME. Evaluation of Patient with Palpitations. NEJM 1998; 338 (19): 1369-1373.
• Yalamanchili M et al. Evaluation of Palpitations: Etiology and Diagnostic Methods. Hosp Physician 2003:53-58.