Palpitations

Disease Description (Causes and Symptoms)

• Definition: Palpitations refer to a rapid, irregular, or forceful sensation of the heartbeat that can be felt by the person themselves or by others.
• Main causes
  • Cardiac: Various arrhythmias (atrial fibrillation, paroxysmal supraventricular tachycardia, ventricular tachycardia, etc.), myocardial ischemia (angina pectoris and myocardial infarction), heart failure, heart valve disease, congenital heart disease
  • Endocrine and metabolic: Hyperthyroidism, hypokalemia or hyperkalemia, anemia
  • Drugs and substances: Caffeine, alcohol, nicotine, sympathomimetics (such as amphetamines), and some anti-asthmatic drugs, antidepressants, and vasoconstrictors
  • Psychiatric: Anxiety disorders, panic attacks, stress
  • Other: Fever, dehydration, overexertion
• Summary of pathophysiology: Electrical abnormalities such as increased automaticity of the cardiac electrical conduction system or reentry circuits alter the pulse rate or rhythm, or systemic metabolic and endocrine changes excessively increase the heartbeat, causing symptoms.
• Main symptoms: Sudden rapid pulse, palpitations, chest tightness/chest pain, dizziness or presyncope, shortness of breath, and sometimes nausea. Duration and associated symptoms (fever, weight changes, anxiety, etc.) vary depending on the cause.

Treatment Methods

• Initial (emergency) treatment
  • If an electrocardiogram shows a life-threatening arrhythmia (e.g., ventricular fibrillation or sustained significant ventricular tachycardia with hemodynamic instability), immediate defibrillation (electric shock) and application of the ACLS protocol are required.
  • In cases of hemodynamic instability (hypotension, decreased consciousness, severe chest pain, or shortness of breath), seek emergency medical care or treatment in an emergency department.
• Medication treatment
  • Symptom control: Beta-blockers (e.g., metoprolol), non-dihydropyridine/non-dihydropyridine agents (e.g., verapamil, diltiazem)—useful for supraventricular tachycardia.
  • Antiarrhythmic drugs: Depending on the type (class I: flecainide, propafenone / class III: amiodarone, sotalol, etc.), use them after considering electrocardiographic findings and underlying diseases.
  • In cases of atrial fibrillation: Rhythm control (antiarrhythmic drugs, electrical cardioversion) or rate control (beta-blockers/calcium channel blockers) + anticoagulation when indicated (based on CHA2DS2-VASc).
• Procedures/Surgery
  • Catheter ablation (atrial fibrillation, supraventricular tachycardia, etc.): High cure rates when the causative site is ablated (especially for SVT).
  • Mechanical treatment: Pacemaker implantation for bradycardic conditions; an implantable cardioverter-defibrillator (ICD) with defibrillation function when there is a risk of life-threatening ventricular tachycardia or cardiac asystole.
  • Special procedures such as left atrial appendage occlusion (when anticoagulation is not possible).
• Treatment of the cause
  • Correct hyperthyroidism, anemia, electrolyte abnormalities, and drug-induced causes.
  • Treatment for anxiety and panic (cognitive behavioral therapy, anxiolytics, etc.) may be provided concurrently.
• Lifestyle management and precautions
  • Avoid triggers: Limit caffeine, excessive alcohol consumption, and stimulants; get sufficient sleep and manage stress; engage in regular exercise (after consulting a doctor).
  • Follow medication instructions (check dosage and interactions). If anticoagulant treatment is started, bleeding risk must be managed.
• Prognosis: Varies depending on the underlying cause. Cases triggered by simple nervousness or caffeine generally have a good prognosis, while structural heart disease and untreated dangerous arrhythmias increase the risk of stroke, heart failure, and sudden death.

Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items to bring (recommended)
  • A list of current medications (including prescriptions, OTC drugs, herbal medicines, and supplements) or medication packets
  • Previous electrocardiograms (ECGs), Holter monitoring, echocardiography, and blood test results (originals or summaries if possible)
  • Symptom diary (time the episode started, duration, triggers, accompanying symptoms, and time until recovery)
  • Blood pressure and pulse records (if available)
  • Family history (especially unexplained death or sudden death at a young age, and heart disease)
• Items recommended for observation and recording before the outpatient visit
  • When the symptoms began and how often they occur
  • Recent weight changes, sweating, body temperature, and thyroid-related symptoms (weight loss, tremor, etc.)
  • Intake of caffeine, alcohol, and medications (painkillers, antidepressants, thyroid medications)
• Example questions (prepare to answer these yourself during the doctor’s visit)
  • How often do the symptoms occur, and how long do they last?
  • Are there situations that trigger or worsen the symptoms? (Exercise, caffeine, stress, etc.)
  • Have you ever experienced fainting or loss of consciousness?

Examples of General Questions to Ask the Doctor

• "What is the most likely cause of my palpitations?"
• "What tests are needed, and what is the purpose of each one?"
• "What are the major side effects of the medication you plan to prescribe, and what precautions should I take while taking it?"
• "Do I need anticoagulant treatment? How should the associated bleeding risk be managed?"
• "Are there any lifestyle changes I need to make immediately? Are there restrictions on exercise, alcohol consumption, or driving?"
• "When should I go to the emergency department if my symptoms worsen?"

Examples of Disease-Specific Questions (1–2)

• If atrial fibrillation is suspected:
  • "What is my CHA2DS2-VASc score, and do I need anticoagulation? Which anticoagulant is suitable for me?"
  • "Do you recommend catheter ablation for atrial fibrillation? What are the success rate and risks?"
• If paroxysmal supraventricular tachycardia (SVT) or reentrant tachycardia is suspected:
  • "Could self-treatment such as the Valsalva maneuver (safety of Valsalva) help during an episode? How should it be performed?"
  • "What is the likelihood of a cure with catheter ablation, and what are the hospitalization period and possible complications?"

Additional guidance: If palpitations are sudden and accompanied by severe chest pain, fainting, shortness of breath, or decreased consciousness, go immediately to an emergency medical institution or contact emergency medical services (such as 119) to receive emergency treatment.