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Symptom: Palpitations
CAPT Kurt Strosahl, MC, USNIntroduction: Palpitations are the sensation of a change in the heartbeat. A patient may complain of
a sensation of skipped, missed, strong, fast, or accelerating heartbeats. The majority of palpitations are
unlikely to cause harm but cause concern for the patient. Ventricular Tachycardia and Fibrillation (VT/VF) are
followed immediately by collapse and imminent death without appropriate resuscitation. Premature Ventricular
Contractions (PVCs) and Premature Atrial Contractions (PACs) feel like skipped or single hard beats and are
found in all normal healthy persons. While PVCs may be harbingers of a bad outcome in patients with
known heart disease, they do not require a search for heart disease in the otherwise healthy person. Short
runs of Paroxysmal Supraventricular (or Atrial) Tachycardia (PSVT or PAT) are frequent, particularly when
straining against a load or drinking cold beverages after heavy physical exertion. Unless there is loss of
consciousness, they can be readily aborted by the vagal maneuver (bearing down as if you are having
a bowel movement). Frequent episodes of palpitations may require further evaluation when the mission is
completed, but should not remove the service member from the field.
Subjective: Symptoms
Focused History: Quantity: How often does this occur? (PVCs and PACs may occur daily, hourly, or rarely.
They cause anxiety, which heightens the member’s awareness of them and increases the frequency, since
they are driven by adrenalin.) How long do they last? (Most runs of PSVT are self-limited and the member
nds that lying down or bearing down stops them. If the rapid heart beating lasts for hours, they usually are
gone after a nap.) Quality: Do you feel dizzy or lightheaded with them? (If the heart rate goes over 180,
the member usually must sit or lay down. If the heart rate is <180, the member usually can continue with their
activities, affected only by their concern over what is happening.) Alleviating factors: What makes them go
away or lessen? (Sitting down, lying down, or taking a nap will often stop the symptoms. Bearing down will
abruptly terminate PSVT. Splashing cold water on the face [the diving reex] may also abruptly stop rapid
beating.) Aggravating factor: What seems to bring these on? (Caffeine, alcohol, nicotine, over-the-counter
cold remedies and lack of sleep are the most common aggravating factors. Some members utilize anabolic
steroids, weight reduction supplements or other health food supplements that contain ephedrine or similar
drugs. Asthma medications are largely derivatives of adrenaline and can cause palpitations. Non-sedating
antihistamines and hypermotility agents such as Propulsid cause PVCs and VT. Discontinuation of these
factors will usually make the symptoms go away. Fear and anxiety worsen the symptoms but not necessarily
the rhythm disturbance. Most people incorrectly associate palpitations with a heart attack, which is VERY
rarely the case.) Associated symptoms: Nausea, thirst, frequent urination, and complaints of pain in the
chest are non-specic and of little value in determining the cause.
Objective: Signs
Using Basic Tools: Take pulse for 60 seconds to determine the rate, and assess for skipped beats (PVC or
PAC) or irregular beating (atrial brillation).
Altered vital signs: Hypotension with dizziness indicates the rhythm is compromising cardiac output.
Orthostatic hypotension (BP drop of 20mm and HR increase of 10 comparing standing to supine) suggests
volume depletion as cause of arrhythmia
Respirations >30 may result from anxiety and hyperventilation, which can cause arrhythmias
Lungs: Pneumonia or pneumothorax is a cause of tachycardia
Heart: Irregular beating suggests atrial fibrillation. Skips indicate PVC/PAC, which cannot be differentiated in
the field. Click(s) between heart sounds result from mitral valve prolapse (associated with benign PVCs)
Neck: An enlarged, tender thyroid, associated with tremor of the hands strongly suggests hyperthyroidism as
the cause of arrhythmia.
Using Advanced Tools: Lab: CBC for anemia (cause of tachycardia); EKG to identify the rhythm (25%
of reported symptomatic palpitations correlate with normal sinus rhythm during 24 hrs continuous ambulatory
EKG monitoring).