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Causes of Palpitations

The term “palpitations” corresponds to the perception of an abnormal heart rhythm, sometimes the exact manner in form of extrasystoles or sustained and repetitive form of tachycardia.

This is a very common reason for consultation, which can correspond to various ventricular or supraventricular arrhythmias, benign or malignant. Out cases in which palpitations are documented, the etiologic diagnosis and estimation of prognosis will be based on history, diagnosis of underlying heart disease or of malignant arrhythmic disorders.

Causes – Etiology

Sinus tachycardia

– Regular tachycardia characterized by a heart rate which varies from moment to moment;
– P wave of normal morphology;
– Good tolerance, except evolved underlying cardiomyopathy;
– Obvious etiology, evocative context: emotion, stress, fever, heart failure, hypoxemia, anemia, hyperthyroidism, pheochromocytoma, carcinoid syndrome, iatrogenic (sympathomimetics, vasodilators, thyroid hormones).

Atrial Arrhythmias

Premature atrial contraction– Premature atrial contraction

  • premature P wave in relation to the preceding and succeeding PP cycles,
  • P wave of different morphology followed by a ventricular contraction, except a very early premature atrial contraction;

Atrial fibrillation ecgAtrial fibrillation

  • Multiple micro-reentries in the two atria,
  • irregular tachycardia, except when is associated a third degree AV block,
  • narrow QRS, except functional or organic bundle branch block (dependent of tachycardia),
  • no organized atrial activity (baseline oscillation);

Atrial flutter

  • Atrial fluttermacro-reentry in the right atrium,
  • regular tachycardia,
  • narrow QRS, except functional or organic bundle branch block (dependent of tachycardia),
  • organized and regular atrial activity aspect of “sawtooth “, with a frequency of 300/min,
  • transmission to ventricles 2/1, 3/1, 4/1 … sometimes variably;

– Atrial tachycardia

  • intra-atrial outbreak with automaticity,
  • tachycardia often regular,
  • narrow QRS, except functional or organic bundle branch block (dependent of tachycardia),
  • organized and regular atrial activity with returning to the isoelectric line between two P waves, similar to the appearance of a flutter,
  • transmission to ventricles in 2/1, 3/1, 4/1 … sometimes variably;

Etiology of atrial rhythm disorders

  • Cardiac causes: valvular heart disease, cardiomyopathy: dilated, hypertrophic, restrictive, ischemic, congenital, pericardial effusion, after surgery, respiratory failure,
  • adrenergic stimulation: strain, stress, temperature,
  • Metabolic causes: hyperthyroidism, pheochromocytoma, acute alcoholism,
  • Iatrogenic: sympathomimetics, thyroid hormones,
  • frequent: idiopathic on “healthy” heart.

Junctional rhythm disorders (Bouveret tachycardia)

– Junctional tachycardia with intra-nodal reentry

  • regular tachycardia due to a reentry in atrioventricular node,
  • narrow QRS,
  • P waves generally invisible.

– Junctional reentrant tachycardia with a Kent fascicle

  • regular tachycardia linked with atrioventricular node and His reentry on one side (way down) and atrioventricular accessory pathway, such as a Kent fascicle (upward path),
  • narrow QRS,
  • retrograde P waves,

Causes of junctional rhythm disorders: generally idiopathic on healthy heart.

Ventricular arrhythmias

Ventricular extrasystoles– Ventricular extrasystoles

  • wide and early QRS,
  • unpreceded by P wave,
  • Isolated, repeated (doublets, triplets, salvos, bi-or trigeminy), over 3 consecutive PVCs: ventricular tachycardia;

– Ventricular tachycardia

  • tachycardia with wide QRS (> 120 msec) and regular;
  • between 100 and 250/min (<100/min: RIVA,> 250/min: ventricular flutter);
  • unsupported or supported (± 30 seconds),
  • presence of atrioventricular dissociation, the phenomena of capture or fusion;
  • Ventricular fibrillation is not cause for palpitations, but cardiac arrest;

Causes of extrasystoles and ventricular tachycardia

  • cardiac causes: ischemic heart disease, cardiomyopathy: dilated, valvular, hypertrophic, restrictive, congenital, pericardial effusion, after surgery,
  • adrenergic stimulation: strain, stress, temperature,
  • Iatrogenic: sympathomimetics, digitalis.

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