This document provides guidance on evaluating palpitations in children. It describes how to take a history regarding the sensations, triggers, and associated symptoms. A physical exam and ECG can help identify potential cardiac causes like arrhythmias. While most palpitations have non-serious causes like anxiety, further workup may be needed if risk factors are present like a family history of sudden cardiac death. Conditions like supraventricular tachycardia and long QT syndrome can potentially cause palpitations.

2. Palpitations
• Palpitations are sensations of the heart’s
actions.
• They may be described as rapid or slow,
skipping or stopping, and regular or irregular.
• Most cases are not due to serious cardiac
etiologies.
• The goal of the evaluation is to identify the
small proportion of patients who are at risk
for serious cardiac disease.

3. History and physical examination
• An accurate description of the sensation may aid
in the diagnosis.
• For children old enough to articulate the
sensation, racing, heart stopping or pausing, and
skipping beats are common descriptors.
• Inquire about the duration of symptoms, whether
the onset and termination of symptoms are
subtle or abrupt, and the factors associated with
onset (e.g., such as exercise) or termination (e.g.,
Valsalva maneuver).

4. • Infants may manifest nonspecific symptoms
of irritability and poor feeding; some cases
may progress to congestive heart failure prior
to identification of an abnormal rhythm.
• When appropriate, consider instructing
parents on how to take the child’s pulse
during future episodes.
History and physical examination

5. Past medical and Surgical History
• Special attention should be paid to a history of
structural cardiac abnormalities or cardiac
surgery because those factors increase the risk
of both arrhythmias and adverse outcomes
associated with them.
• Certain medications can be responsible for
arrhythmias.
• Symptoms suggestive of endocrine disorders
may also indicate etiologies.

6. Social & Familial history
• A social history should investigate stress
levels, caffeine intake, and tobacco use.
• Familial disorders that may be a cause of
palpitations include Wolff-Parkinson-White
syndrome, long QT syndrome (deafness is
associated with one of these inherited
syndromes), and Kearns-Sayre syndrome (e.g.,
retinal degeneration, ophthalmoplegia,
muscle weakness).

7. • An association of palpitations with syncope or
exertion is ominous and warrants urgent cardiac
consultation to direct an evaluation for an
underlying cardiac etiology.
• Other worrisome history components include
severe chest pain, a family history of long QT
syndrome, and unexplained or aborted sudden
death.
• If the history reveals any of these risk factors, an
urgent cardiac evaluation is recommended.

8. Electrocardiogram (ECG)
• A resting electrocardiogram (ECG) may identify an
arrhythmia or suggest a cardiac abnormality that could
be associated with an arrhythmia (e.g.,
cardiomyopathy, long QT syndrome).
• It can also reveal abnormalities that may cause
symptoms other than palpitations (e.g., AV block,
bradycardia).
• When the complaint of palpitations is a minor one and
is associated with a likely causative condition (e.g.,
fever, anxiety), an ECG may not be necessary acutely;
clinical judgment should be applied.

9. Electrocardiogram (ECG)

10. Electrocardiogram (ECG)

11. Electrocardiogram (ECG)

12. Sinus tachycardia
• Sinus tachycardia needs to be distinguished from supraventricular
tachycardia (SVT).
• Both are narrow complex tachycardias.
• Sinus tachycardia is characterized by a normal P-wave axis, a
gradual onset and termination, and a rate higher than the age-
specific upper limit of normal (usually less than 230 to 240 beats
per minute [bpm]); variability in the heart rate is a characteristic
distinguishing it from SVT.
• Fever, pain, anemia, and dehydration are common causes of sinus
tachycardia.

13. Drug History
• When drugs are responsible for palpitations, the most
common mechanism is a transient increased heart
rate, but they may occasionally cause more serious
rhythm disturbances.
• Medications associated with palpitations include
tricyclic antidepressants, aminophylline, stimulants (for
ADHD treatment), and thyroid replacement
medications.
• Drugs of abuse (e.g., cocaine, amphetamines) can also
cause cardiac side effects ranging from benign
palpitations to serious cardiac arrhythmias.

14. Non cardiac causes
• Clinical characteristics of hyperthyroidism
include goiter, accelerated linear growth,
failure to gain weight (or weight loss),
abnormal eyelid retraction, exophthalmos,
tremor, and weakness.
• Pallor on examination, a history of lethargy or
easy fatigability, excessive blood loss, or a diet
history suggestive of iron deficiency may be
clues to anemia.

15. Holter monitoring
• Holter monitoring is an extended rhythm
recording (24 or 48 hours) recommended to
attempt to capture an abnormal rhythm when
a patient experiences frequent symptoms.
• If events are more intermittent, an incident or
event recorder is preferable; these require
activation by the patient when symptoms
develop.

16. Sinus arrhythmia
• Sinus arrhythmia is a normal variation of the
heart rate with a slowing during expiration
and acceleration during inspiration.
• Occasionally it can be prominent; careful
auscultation will identify the relationship to
the respiratory phases and distinguish it from
premature atrial contractions

17. Premature ventricular complexes
(PVCs)
• Premature ventricular complexes (PVCs) are
common, occurring in approximately 25% of
the general population.
• PVCs usually are followed by a compensatory
pause preceding the next beat.
• They are often asymptomatic, although
patients may describe a “skipped” beat
followed by a strong beat or a sensation of the
“heart turning over.”

18. • Anxiety, fever, and certain drugs, especially
stimulants, may increase the occurrence of PVCs.
• Although usually benign, a history of syncope,
heart disease, chest pain or other symptoms, a
family history of sudden death, aggravation by
exercise, frequent or prolonged runs, or a
nonuniform appearance of the QRS complex
(suggesting a multifocal origin) are worrisome
characteristics and warrant additional evaluation.
Premature ventricular complexes
(PVCs)

19. Premature atrial contractions (PACs)
• Premature atrial contractions (PACs) are also
benign rhythm variations.
• They are usually asymptomatic; patients may
occasionally complain of skipped beats or
pauses in their heart rate.

20. Supraventricular tachycardias (SVTs)
• Supraventricular tachycardias (SVTs) originate in the atria,
atrioventricular node, or one or more accessory pathways
between the atria and ventricles or within the AV node
(reentrant tachycardias).
• Reentrant tachycardias are characterized by an abrupt
onset and cessation and tend to occur when the patient is
at rest.
• They demonstrate a narrow QRS complex, an abnormal P-
wave axis, and an unvarying rate that usually exceeds 180
bpm.
• It may be as high as 300 bpm.
• Congenital heart disease and use of over-the-counter
decongestants are common causes of SVTs.

21. Wolff-Parkinson-White syndrome
• Wolff-Parkinson-White syndrome is
characterized by an SVT due to an accessory
conduction pathway between the atria and
the ventricles, which manifests (between
episodes of SVT) with delta waves (a slow
upstroke of the QRS) on the ECG.

22. Atrial flutter
• Atrial rates of 250 to 300 bpm occur in atrial
flutter (higher rates can occur in infants);
ventricular conduction can be 1:1 but some
degree of heart block (2:1, 3:1) is more common,
so QRS complexes may appear normal.
• It usually occurs in children with congenital heart
disease, especially postoperatively, but may occur
in neonates with normal hearts.
• Onset and termination are abrupt; the ECG shows
atrial saw-toothed flutter waves.

23. Atrial fibrillation
• In atrial fibrillation, chaotic atrial excitation at a
rapid rate (typically 350 to 400 bpm, sometimes
higher) produces an irregular ventricular rhythm.
• It usually occurs in the presence of cardiac
abnormalities.
• Otherwise healthy children experiencing atrial
fibrillation should be evaluated for thyrotoxicosis,
pulmonary emboli, and pericarditis.

24. Long QT syndrome
• Long QT syndrome and Brugada syndrome are
examples of inherited cardiac ion channel
abnormalities with characteristic ECG findings.
• Genetic defects have been identified for several
variations of long QT syndrome; these conditions can
cause lethal ventricular arrhythmias. They may present
with palpitations, syncope, drowning, or cardiac arrest.
Calculation of the
• corrected QT interval (QTc) corrects the interval for the
patient’s heart rate.

25. • Jervell-Lange-Nielsen is a congenital long QT
syndrome associated with congenital deafness.
• Acquired long QT syndrome can occur secondary
to myocarditis, mitral valve prolapse, electrolyte
abnormalities, and medications (e.g., tricyclic
antidepressants, antipsychotics, macrolide
antibiotics, antihistamines, antifungals, cisapride,
multiple cardiac medications).
Long QT syndrome

26. Ventricular tachycardia
• Ventricular (wide QRS complex) tachycardia
necessitates prompt treatment.
• It may be asymptomatic in children with
normal hearts; children with structural heart
disease are more likely to be symptomatic.

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