Does this patient with palpitations have a cardiac arrhythmia?
Abstract
CONTEXT: Many patients have palpitations and seek advice from general practitioners. Differentiating benign causes from those resulting from clinically significant cardiac arrhythmia can be challenging and the clinical examination may aid in this process. OBJECTIVE: To systematically review the accuracy of historical features, physical examination, and cardiac testing for the diagnosis of cardiac arrhythmia in patients with palpitations. Data Source, Study Selection, and DATA EXTRACTION: MEDLINE (1950 to August 25, 2009) and EMBASE (1947 to August 2009) searches of English-language articles that compared clinical features and diagnostic tests in patients with palpitations with a reference standard for cardiac arrhythmia. Of the 277 studies identified by the search strategy, 7 studies were used for accuracy analysis and 16 studies for diagnostic yield analysis. Two authors independently reviewed articles for study data and quality and a third author resolved disagreements. DATA SYNTHESIS: Most data were obtained from single studies with small sample sizes. A known history of cardiac disease (likelihood ratio [LR], 2.03; 95% confidence interval [CI], 1.33-3.11), having palpitations affected by sleeping (LR, 2.29; 95% CI, 1.33-3.94), or while the patient is at work (LR, 2.17; 95% CI, 1.19-3.96) slightly increase the likelihood of a cardiac arrhythmia. A known history of panic disorder (LR, 0.26; 95% CI, 0.07-1.01) or having palpitations lasting less than 5 minutes (LR, 0.38; 95% CI, 0.22-0.63) makes the diagnosis of cardiac arrhythmia slightly less likely. The presence of a regular rapid-pounding sensation in the neck (LR, 177; 95% CI, 25-1251) or visible neck pulsations (LR, 2.68; 95% CI, 1.25-5.78) in association with palpitations increases the likelihood of a specific type of arrhythmia (atrioventricular nodal reentry tachycardia). The absence of a regular rapid-pounding sensation in the neck makes detecting the same arrhythmia less likely (LR, 0.07; 95% CI, 0.03-0.19). No other features significantly alter the probability of clinically significant arrhythmia. Diagnostic tests for prolonged periods of electrocardiographic monitoring vary in their yield depending on the modality used, duration of monitoring, and occurrence of typical symptoms during monitoring. Loop monitors have the highest diagnostic yield (34%-84%) for identifying an arrhythmia. CONCLUSIONS: While the presence of a regular rapid-pounding sensation in the neck or visible neck pulsations associated with palpitations makes the diagnosis of atrioventricular nodal reentry tachycardia likely, the reviewed studies suggest that the clinical examination is not sufficiently accurate to exclude clinically significant arrhythmias in most patients. Thus, prolonged electrocardiographic monitoring with demonstration of symptom-rhythm correlation is required to make the diagnosis of a cardiac arrhythmia for most patients with recurrent palpitations.
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In general, older patients and men are more likely to have an arrhythmic cause of palpitations and younger patients and women a psychosomatic cause.
“In general, however, older patients and men are more likely to have an arrhythmic cause of palpitations and younger patients and women a psychosomatic cause.47 -51”
From Management of patients with palpitations: a position paper from the European Heart Rhythm Association (2011) · cites this paper as [48]
Clinical characteristics of the patient, such as age, presence of heart disease, and ECG abnormalities, do not always allow the physician to identify a priori those cases in which palpitations are caused by clinically significant rhythm disorders.
“Moreover, clinical characteristics of the patient, such as age, presence of heart disease, and ECG abnormalities, do not always allow the physician to identify a priori those cases in which palpitations are caused by clinically significant rhythm disorders.8,47,48,52 -54”
From Management of patients with palpitations: a position paper from the European Heart Rhythm Association (2011) · cites this paper as [48]
The utility of the features on history for diagnosing an arrhythmic cause of palpitations has been examined in a recent systematic review.
“The utility of the features on history for diagnosing an arrhythmic cause of palpitations has been examined in a recent systematic review.48”
From Management of patients with palpitations: a position paper from the European Heart Rhythm Association (2011) · cites this paper as [48]
The likelihood ratio of each feature for diagnosing an arrhythmic cause of palpitations is, in general, low and only a few features are really predictive. They include history of cardiac disease, palpitations affected by sleeping, or while the patient is at work.
“The likelihood ratio of each feature is, in general, low and only a few features are really predictive.They include history of cardiac disease, palpitations affected by sleeping, or while the patient is at work.”
From Management of patients with palpitations: a position paper from the European Heart Rhythm Association (2011) · cites this paper as [48]
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- Authors
- Thavendiranathan, P.
- Affiliations
- University of Toronto (CA)
- Corresponding author
- Thavendiranathan, Paaladinesh
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2009-11-18
- Volume
- 302
- Issue
- 19
- Pages
- 2135
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W2017648852
- Cited by
- 75
- References
- 51
- Citations by year
- 2026: 5 · 2025: 5 · 2024: 2 · 2023: 8 · 2022: 4 · 2021: 9 · 2020: 5 · 2019: 4 · 2018: 1 · 2016: 2 · 2015: 2 · 2014: 3 · 2013: 6 · 2012: 9
- FWCI
- 4.10
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Keywords
- palpitations, cardiac arrhythmias, diagnostic accuracy, physical examination, medical history, cardiac testing, likelihood ratios, panic disorder, atrioventricular nodal reentrant tachycardia, diagnostic yield, general practitioners, reference standard comparison, sensitivity and specificity, diagnostic cost-effectiveness
- MeSH terms
- Arrhythmias, Cardiac, Diagnostic Techniques, Cardiovascular, Electrocardiography, Heart Rate, Humans, Medical History Taking, Physical Examination
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