Most normal individuals are intermittently aware of their heart action, particularly at the time of physical and emotional stress. When the heart action is more vigorous than usual or its perception is unpleasant, the term palpitation is appropriate.1 The patient may complain of a "pounding," "stopping," "jumping," or "racing" in the chest. Palpitation is frequently a benign symptom without any serious cardiac disease present; at other times it may indicate a potentially life-threatening condition. Simple premature beats may be perceived as a "floating" or "flopping" sensation in the chest due to the more forceful beat that occurs after the pause following the premature beat. Sometimes a transient feeling of fullness in the neck (due to cannon a waves) is perceived with premature beats. Certain patients perceive almost every premature beat, whereas others are totally unaware of frequent or advanced arrhythmias. A report of skips or irregularity during uninterrupted sinus rhythm is not uncommon. Generally, thin, tense individuals are likely to be more aware of their cardiac activity than others. Individuals with and without arrhythmias often are aware of their cardiac activity when they first lie down on their side to sleep, especially if they lie on their left side.1

Rapid heart action of a paroxysmal tachycardia usually begins and terminates abruptly and causes a pounding sensation in the chest.! Patients often will indicate whether the tachycardia is regular or irregular and may be able to tap out the rate and rhythm of the episode (see Chap. 24). Chest pressure suggesting angina may occur with an episode of tachycardia even in young, healthy patients without CAD. Patients with CAD, however, often develop severe angina with a sustained arrhythmia because of increased MV(r)O2. Depending on the rate and mechanism of the arrhythmia, faintness and syncope may be described during questioning. Nevertheless, sustained ventricular tachycardia can occur in the setting of serious underlying cardiac disease without a significant compromise in hemodynamics (see Chap. 24). Syncope due to tachyarrhythmias may occur without the patient being aware of palpitations.

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