Palpitations: A Symptom-Based Clinical Approach

Learn how to assess palpitations using clinical reasoning, physical findings, and POCUS – with key USMLE tips included.

---

🚪 Doorway Case

• Age: 62
• Gender: Male
• Chief Complaint: “My heart suddenly started racing while watching TV.”
• Vitals: BP 110/72, HR 145, RR 18, SpO₂ 98%, Temp 36.8°C

How would you approach this?
What are your first concerns?
What could you ask to differentiate benign from dangerous causes?

1. First Priorities: Red Flags

Before diving deep, rule out dangerous conditions. Ask about:

• Syncope or near-syncope → Risk of arrhythmic origin
• Chest pain or pressure → Rule out ischemia
• Severe dyspnea → Consider heart failure or PE
• Sudden onset at rest → SVT or AF
• Fever, recent infection → Myocarditis or endocarditis
• Structural heart disease → Higher arrhythmia risk

Why urgent? These symptoms may indicate hemodynamically unstable rhythms, ischemia, or systemic conditions that require prompt care.

2. Clarify the Nature of Palpitations

• “Can you describe the sensation?”
• “Was it fast or slow? Regular or irregular?”
• “How long did it last?”
• “Did it start suddenly or gradually?”
• “What were you doing when it started?”
• “Can you tap out the rhythm for me?” (Critical question)

💡 Patients who tap out regular fast rhythms → likely AVNRT or AVRT. Irregular → AF.

3. Associated Symptoms & Diagnostic Clues

• Weight loss, tremor → Hyperthyroidism
• Pallor, fatigue → Anemia
• Anxiety, hyperventilation → Panic disorder
• Dehydration signs → Volume depletion
• Substance use → Alcohol, stimulants

4. PMH & Risk Profile

• History of AF, SVT, CHF, valvular disease
• Alcohol binge → Holiday heart syndrome
• Medications → Digoxin, beta-blockers, antipsychotics
• Family history of sudden cardiac death

🧠 Always check electrolytes and thyroid panel.

5. Physical Exam Pearls

• Irregularly irregular pulse → Atrial fibrillation
• Rapid regular rhythm → SVT
• JVD, crackles, edema → CHF
• Dehydration signs → IVC POCUS
• Systolic murmur → HCM or valvular lesion

6. EKG Is Key

• Irregular rhythm, no P waves → AF
• Regular narrow QRS → SVT
• Delta wave → WPW
• Long QTc → Torsades risk

🔗 Link to ECG Learning Series (Coming Soon)

7. POCUS in Palpitations

• IVC collapse → Hypovolemia
• B-lines → Pulmonary edema
• EPSS → LV dysfunction
• Effusion → Tamponade

8. USMLE Key Points

• AF + RVR = common presentation
• Use CHADS2 / CHA2DS2-VASc to assess stroke risk
• Aspirin ≠ anticoagulation → Use DOAC or warfarin
• Fun fact: Edoxaban = “Lixiana,” made in Japan (Edo!)

9. Clinical Pearls

• Don’t miss dehydration — especially in elderly
• Get an EKG early
• Check thyroid, check electrolytes
• Ask about mood & anxiety
• Explore triggers in new-onset AF

10. Back to Our Case

62M with sudden palpitations at rest. HR 145, irregular. EKG shows narrow QRS, no P waves.

Likely AF with RVR. Management:

• Rate control: beta-blocker or diltiazem
• Anticoagulation: based on CHADS2
• TSH, electrolytes, echo

🔗 Related Articles

• How to Think Like a Clinician
• Symptom-Based: Fatigue
• Symptom-Based: Dizziness