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Character of palpitations

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Ask the patient about:

  • the rate of the palpitations (fast or slow)
  • the regularity
  • are the palapitations felt only in the chest (neck-) or are they felt in the neck as well (neck+)

The suspected diagnoses will be as follows:

  • rapid, regular, neck+
    • atrioventricular nodal tachycardia

  • rapid, regular, neck-
    • circus movement tachycardia via accessory pathway
      • atrial tachycardia
      • ventricular tachycardia

  • rapid, irregular
    • atrial fibrillation
    • atrial flutter
    • atrial tachycardia

  • slow, irregular, neck+
    • ventricular premature beats

  • slow, irregular, neck-
    • any premature beat

(Palpitations are felt in the neck if the atria contract against closed atrioventricular valves).

  • a feeling of 'flip-flopping' in the chest is usually secondary to a premature atrial or ventricular contraction
  • sensation that the heart has stopped is secondary to the pause (compensatory or noncompensatory) that follows a prematture beat, whereas pounding is often the manifestation of a forceful beat caused by postextrasystolic potentiation after a premature beat
  • feeling of rapid flutterng in the chest is usually secondary to supraventricular or ventricular tachyarrhythmias


  • pounding feeling in the neck is caused by the dissociation of atrial and ventricular contractions so that the atria contract against closed tricuspid and mitral valves, producing cannon A waves
    • cannon A waves are perceived as neck pulsations and, when rapid and regular, may be seen as a bulging in the neck (sometimes termed a 'frog sign')
      • sensation of rapid and regular pounding in the neck is most typical of reentrant supraventricular arrhythmias, particularly atrioventricular nodal tachycardia
        • patients with neck palpitations may have atrioventricular nodal tachycardia caused by simultaneous contraction of the atria and ventricles, which causes reflux of blood in the superior vena cava
        • atrioventricular nodal tachycardia is the most common form of paroxysmal supraventricular tachycardia
          • three times as common in women as in men
          • in the typical form of atrioventricular nodal tachycardia, the atria and ventricles are activated simultaneously at an average rate of 160 to 180 beats per minute
    • atrioventricular dissociation can also result from ventricular premature contractions called ventricular premature depolarizations
      • premature ventricular contractions also cause atrioventricular dissociation, resulting in pounding sensations in the neck and often a physical finding of cannon waves
      • in these cases only one or a few pounding sensations are felt in the neck, and the rhythm is often more irregular and less sustained than with atrioventricular nodal tachycardia
      • palpitations caused by ventricular premature depolarizations with cannon A waves are also often described as a feeling of being unable to catch one's breath


  • Zimetbaum PZ, Jospephson ME. Evaluation of Patient with Palpitations. NEJM 1998; 338 (19): 1369-1373.
  • Yalamanchili M et al. Evaluation of Palpitations: Etiology and Diagnostic Methods. Hosp Physician 2003:53-58.

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