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Palpitations
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==Causes== The responsibility for the perception of heartbeat by neural pathways is not clear. It has been hypothesized that these pathways include different structures located both at the intra-cardiac and extra-cardiac level.<ref name="Robinson Sanchack 2019"/> Palpitations are a widely diffuse complaint and particularly in subjects affected by structural heart disease.<ref name="Robinson Sanchack 2019"/> The list of causes of palpitations is long, and in some cases, the etiology is unable to be determined.<ref name="Robinson Sanchack 2019"/> In one study reporting the etiology of palpitations, 43% were found to be cardiac, 31% psychiatric, and approximately 10% were classified as miscellaneous (medication induced, [[thyrotoxicosis]], caffeine, cocaine, [[anemia]], [[amphetamine]], [[mastocytosis]]).<ref name="Robinson Sanchack 2019"/> The cardiac etiologies of palpitations are the most life-threatening and include ventricular sources ([[premature ventricular contraction|premature ventricular contractions (PVC)]], [[ventricular tachycardia]] and [[ventricular fibrillation]]), atrial sources ([[atrial fibrillation]], [[atrial flutter]]) high output states ([[anemia]], [[AV fistula]], [[Paget's disease of bone]] or [[pregnancy]]), structural abnormalities ([[congenital heart disease]], [[cardiomegaly]], [[aortic aneurysm]], or acute [[left ventricular failure]]), and miscellaneous sources ([[postural orthostatic tachycardia syndrome]] abbreviated as POTS, [[Brugada syndrome]], and [[sinus tachycardia]]).<ref name="Robinson Sanchack 2019"/> Palpitations can be a symptom of [[mast cell activation syndrome|mast cell activation syndrome (MCAS)]].<ref name="PMID27012973">{{cite journal |vauthors=Afrin LB, Butterfield JH, Raithel M, Molderings GJ |title=Often seen, rarely recognized: mast cell activation disease--a guide to diagnosis and therapeutic options |journal=The American Journal of the Medical Science |volume=48 |issue=3 |date=2016 |pages=190-201 |DOI=10.3109/07853890.2016.1161231 |PMID=27012973 |url=|doi-access=free}}</ref><ref name="PMID38948000">{{cite journal |vauthors=Özdemir Ö, Kasımoğlu G, Bak A et al. |title=Mast cell activation syndrome: An up-to-date review of literature |journal=World J Clin Pediatr |date=2024-06-09 |DOI=10.5409/wjcp.v13.i2.92813 |PMC=11212760 |PMID=38948000 |url=|doi-access=free}}</ref> Palpitation can be attributed to one of five main causes: # Extra-cardiac stimulation of the [[sympathetic nervous system]] (inappropriate stimulation of the sympathetic and parasympathetic, particularly the [[vagus nerve]], (which [[Innervation|innervates]] the heart), can be caused by anxiety and stress due to acute or chronic elevations in [[glucocorticoids]] and [[catecholamines]].<ref name="Robinson Sanchack 2019"/> Gastrointestinal distress such as [[bloating]] or [[indigestion]], along with [[muscular imbalance]]s and [[poor posture]], can also irritate the [[vagus nerve]] causing palpitations) # Sympathetic overdrive ([[panic disorder]], [[hypoglycemia|low blood sugar]], [[Hypoxia (medical)|hypoxia]], [[antihistamines]] ([[levocetirizine]]), [[anemia|low red blood cell count]], [[heart failure]], [[mitral valve prolapse]]).<ref>[https://www.nlm.nih.gov/medlineplus/ency/article/003081.htm MedlinePlus Medical Encyclopedia: Heart palpitations<!-- Bot generated title -->]</ref> # [[Hyperdynamic circulation]] ([[valvular incompetence]], [[thyrotoxicosis]], [[hypercapnia]], [[pyrexia|high body temperature]], low red blood cell count, [[pregnancy]]). # [[Cardiac dysrhythmia|Abnormal heart rhythms]] ([[ectopic beat]], [[premature atrial contraction]], [[junctional escape beat]], [[premature ventricular contraction]], [[atrial fibrillation]], [[supraventricular tachycardia]], [[ventricular tachycardia]], [[ventricular fibrillation]], [[heart block]]). # [[Pectus excavatum|Pectus Excavatum]], also known as funnel chest, is a chest wall deformity. When the breastbone (sternum) and attached ribs are sunken in enough to put excess pressure on the heart and lungs which can cause [[tachycardia]] and [https://intermountainhealthcare.org/services/heart-care/conditions/pectus-excavatum/#:~:text=In%20more%20serious%20cases%20of,heart%20that%20skips%20a%20beat skipped beats]. Palpitations can occur during times of catecholamine excess, such as during exercise or at times of stress.<ref name="Robinson Sanchack 2019"/> The cause of the palpitations during these conditions is often a sustained supraventricular tachycardia or ventricular tachyarrhythmia.<ref name="Robinson Sanchack 2019"/> Supraventricular tachycardias can also be induced at the termination of exercise when the withdrawal of catecholamines is coupled with a surge in the [[vagal tone]].<ref name="Robinson Sanchack 2019"/> Palpitations secondary to catecholamine excess may also occur during emotionally startling experiences, especially in patients with a [[long QT syndrome]].<ref name="Robinson Sanchack 2019"/> ===Psychiatric problems=== [[File:Epinephrine.svg|thumb|[[Adrenaline]], a natural hormone released during periods of emotional and physical stress, can cause palpitations as a result of its effects on the [[parasympathetic nervous system]].]] Anxiety and stress elevate the body's level of [[cortisol]] and [[adrenaline]], which in turn can interfere with the normal functioning of the parasympathetic nervous system resulting in overstimulation of the vagus nerve. Vagus nerve induced palpitation is felt as a thud, a hollow fluttery sensation, or a skipped beat, depending on at what point during the heart's normal rhythm the vagus nerve fires. In many cases, the anxiety and panic of experiencing palpitations cause a patient to experience further anxiety and increased [[vagus nerve stimulation]]. The link between anxiety and palpitation may also explain why many panic attacks involve an impending sense of cardiac arrest. Similarly, physical and mental stress may contribute to the occurrence of palpitation, possibly due to the depletion of certain [[List of micronutrients|micronutrients]] involved in maintaining healthy psychological and physiological function.<ref>{{cite journal |pmid=10761188|year=2000|last1=Cernak|first1=I|title=Alterations in magnesium and oxidative status during chronic emotional stress|journal=Magnesium Research |volume=13|issue=1|pages=29–36|last2=Savic|first2=V|last3=Kotur|first3=J|last4=Prokic|first4=V|last5=Kuljic|first5=B|last6=Grbovic|first6=D|last7=Veljovic|first7=M}}</ref> Gastrointestinal bloating, indigestion and hiccups have also been associated with overstimulation of the vagus nerve causing palpitations, due to branches of the vagus nerve innervating the GI tract, diaphragm, and lungs.{{citation needed|date=February 2021}} Many psychiatric conditions can result in palpitations including [[Major depressive disorder|depression]], [[generalized anxiety disorder]], [[panic attack]]s, and [[somatization]]. However one study noted that up to 67% of patients diagnosed with a mental health condition had an underlying [[arrhythmia]].<ref name="Robinson Sanchack 2019"/> There are many metabolic conditions that can result in palpitations including, [[hyperthyroidism]], [[hypoglycemia]], [[hypocalcemia]], [[hyperkalemia]], [[hypokalemia]], [[hypermagnesemia]], [[hypomagnesemia]], and [[pheochromocytoma]].<ref name="Robinson Sanchack 2019"/> ===Medication=== The medications most likely to result in palpitations include [[sympathomimetic agent]]s, [[anticholinergic drug]]s, [[vasodilator]]s and withdrawal from [[beta blocker]]s.<ref name="Robinson Sanchack 2019"/><ref name="Weitz Weinstock 1995 pp. 449–56">{{cite journal | last1=Weitz | first1=HH | last2=Weinstock | first2=PJ | title=Approach to the patient with palpitations. | journal=The Medical Clinics of North America | volume=79 | issue=2 | year=1995 | issn=0025-7125 | pmid=7877401 | pages=449–456| doi=10.1016/S0025-7125(16)30078-5 }}</ref> Excessive consumption of [[caffeine]], commonly found in coffee, tea, and energy drinks, is a well-known trigger.<ref name="Robinson Sanchack 2019" /> Recreational drugs such as [[cocaine]], amphetamines, and [[MDMA]] (Ecstasy) are also associated with palpitations and pose significant cardiovascular risks.<ref>{{Cite journal |last1=Dominic |first1=Paari |last2=Ahmad |first2=Javaria |last3=Awwab |first3=Hajra |last4=Bhuiyan |first4=Md. Shenuarin |last5=Kevil |first5=Christopher G. |last6=Goeders |first6=Nicholas E. |last7=Murnane |first7=Kevin S. |last8=Patterson |first8=James C. |last9=Sandau |first9=Kristin E. |last10=Gopinathannair |first10=Rakesh |last11=Olshansky |first11=Brian |date=January 2022 |title=Stimulant Drugs of Abuse and Cardiac Arrhythmias |journal=Circulation: Arrhythmia and Electrophysiology |language=en |volume=15 |issue=1 |pages=e010273 |doi=10.1161/CIRCEP.121.010273 |issn=1941-3149 |pmc=8766923 |pmid=34961335}}</ref> These substances can lead to serious health issues, including vasospasm-related angina, heart attacks, and strokes. Understanding the impact of these substances is crucial for both prevention and management of palpitations.<ref>{{Cite web |title=Illicit drugs, high alcohol consumption both linked to first-time, irregular heart rhythm |url=https://newsroom.heart.org/news/illicit-drugs-high-alcohol-consumption-both-linked-to-first-time-irregular-heart-rhythm |access-date=2025-01-27 |website=American Heart Association |language=en-us}}</ref>
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