symptoms must be occurring at least once a day. if they are less frequent, the chances of detecting anything with continuous 24- or even 48-hour monitoring are substantially lowered. more recent technology such as the zio patch allows continuous recording for up to 14 days; the patient indicates when symptoms occur by pushing a button on the device and keeps a log of the events. other forms of monitoring are available, and these can be useful when symptoms are infrequent. a continuous-loop event recorder monitors the ecg continuously, but only saves the data when the wearer activates it. once activated, it will save the ecg data for a period of time before the activation and for a period of time afterwards – the cardiologist who is investigating the palpitations can program the length of these periods. an implantable loop recorder may be helpful in people with very infrequent but disabling symptoms. this recorder is implanted under the skin on the front of the chest, like a pacemaker. it can be programmed and the data examined using an external device that communicates with it by means of a radio signal. investigation of heart structure can also be important. the heart in most people with palpitation is completely normal in its physical structure, but occasionally abnormalities such as valve problems may be present. usually, but not always, the cardiologist will be able to detect a murmur in such cases, and an ultrasound scan of the heart (echocardiogram) will often be performed to document the heart's structure. this is a painless test performed using sound waves and is virtually identical to the scanning done in pregnancy to look at the fetus. evaluation a 12-lead electrocardiogram must be performed on every patient complaining of palpitations. the presence of a short pr interval and a delta wave (wolff-parkinson-white syndrome) is an indication of the existence of ventricular pre-excitation. significant left ventricular hypertrophy with deep septal q waves in i, l, and v4 through v6 may indicate hypertrophic obstructive cardiomyopathy. the presence of q waves may indicate a prior myocardial infarction as the etiology of the palpitations, and a prolonged qt interval may indicate the presence of the long qt syndrome. laboratory studies should be limited initially. complete blood count can assess for anemia and infection. serum urea, creatinine and electrolytes to assess for electrolyte imbalances and renal dysfunction. thyroid function tests may demonstrate a hyperthyroid state. most patients have benign conditions as the etiology for their palpitations. the goal of further evaluation is to identify those patients who are at high risk for an arrhythmia. recommended laboratory studies include an investigation for anemia, hyperthyroidism and electrolyte abnormalities. echocardiograms are indicated for patients in whom structural heart disease is a concern. further diagnostic testing is recommended for those in whom the initial diagnostic evaluation (history, physical examination, and ekg) suggest an arrhythmia, those who are at high risk for an arrhythmia, and those who remain anxious to have a specific explanation of their symptoms. people considered to be at high risk for an arrhythmia include those with organic heart disease or any myocardial abnormality that may lead to serious arrhythmias. these conditions include a scar from myocardial infarction, idiopathic dilated cardiomyopathy, clinically significant valvular regurgitant, or stenotic lesions and hypertrophic cardiomyopathies. an aggressive diagnostic approach is recommended for those at high risk and can include ambulatory monitoring or electrophysiologic studies. there are three types of ambulatory ekg monitoring devices: holter monitor, continuous-loop event recorder, and an implantable loop recorder. people who are going to have these devices checked should be made aware of the properties of the devices and the accompanying course of the examination for each device. the holter monitor is a 24-hour monitoring system that is worn by exam takers themselves and records and continuously saves data. holter monitors are typically worn for a few days. the continuous-loop event recorders are also worn by the exam taker and continuously record data, but the data is saved only when someone manually activates the monitor. the continuous-loop recorders can be long worn for longer periods of time than the holter monitors and therefore have been proven to be more cost-effective and efficacious than holter monitors. also, because the person triggers the device when he/she feel the symptoms, they are more likely to record data during palpitations. an implantable loop recorder is a device that is placed subcutaneously and continuously monitors for cardiac arrhythmias. these are most often used in those with unexplained syncope and can be used for longer periods of time than the continuous loop event recorders. an implantable loop recorder is a device that is placed subcutaneously and continuously monitors for the detection of cardiac arrhythmias. these are most often used in those with unexplained syncope and are a used for longer periods of time than the continuous loop event recorders. electrophysiology testing enables a detailed analysis of the underlying mechanism of the cardiac arrhythmia as well as the site of origin. eps studies are usually indicated in those with a high pretest likelihood of a serious arrhythmia. the level of evidence for evaluation techniques is based upon consensus expert opinion. treatment treating palpitation will depend on the severity and cause of the condition. radiofrequency ablation can cure most types of supraventricular and many types of ventricular tachycardias. while catheter ablation is currently a common treatment approach, there have been advances in stereotactic radioablation for certain arrythmias. this technique is commonly used for solid tumors and has been applied with success in management of difficult to treat ventricular tachycardia and atrial fibrillation. the most challenging cases involve palpitations that are secondary to supraventricular or ventricular ectopy or associated with normal sinus rhythm. these conditions are thought to be benign, and the management involves reassurance of the patient that these arrhythmias are not life-threatening. in these situations when the symptoms are unbearable or incapacitating, treatment with beta-blocking medications could be considered, and may provide a protective effect for otherwise healthy individuals. people who present to the emergency department who are asymptomatic, with unremarkable physical exams, have non-diagnostic ekgs and normal laboratory studies, can safely be sent home and instructed to follow up with their primary care provider or cardiologist. patients whose palpitations are associated with syncope, uncontrolled arrhythmias, hemodynamic compromise, or angina should be admitted for further evaluation. palpitation that is caused by heart muscle defects will require specialist examination and assessment. palpitation that is caused by vagus nerve stimulation rarely involves physical defects of the heart. such palpitations are extra-cardiac in nature, that is, palpitation originating from outside the heart itself. accordingly, vagus nerve induced palpitation is not evidence of an unhealthy heart muscle. treatment of vagus nerve induced palpitation will need to address the cause of irritation to the vagus nerve or the parasympathetic nervous system generally. it is of significance that anxiety and stress are strongly associated with increased frequency and severity of vagus nerve induced palpitation. anxiety and stress reduction techniques such as meditation and massage may prove extremely beneficial to reduce or eliminate symptoms temporarily. changing body position (e.g. sitting upright rather than lying down) may also help reduce symptoms due to the vagus nerve's innervation of several structures within the body such as the gi tract, diaphragm and lungs. prognosis direct-to-consumer options for monitoring heart rate and heart rate variability have become increasingly prevalent using smartphones and smartwatches. these monitoring systems have become increasingly validated and may help provide early identification for those at risk for a serious arrhythmia such as atrial fibrillation. palpitations can be a very concerning symptom for people. the etiology of the palpitations in most patients is benign. therefore, comprehensive workups are not indicated. however, appropriate follow up with the primary care provider can provide the ability to monitor symptoms over time and determine if consultation with a cardiologist is required. people who are determined to be at high risk for palpitations of serious or life-threatening etiologies require a more extensive workup and comprehensive management. once a cause is determined, the recommendations for treatment are quite strong, with moderate to high quality therapies studied. partnership with the people who have the chief complaint of palpitation, using a shared decision-making model and involving an interprofessional team including a nurse, nurse practitioner, physician assistant, and physician can help best direct therapy and provide good followup. prevalence palpitations are a common complaint in the general population, particularly in those affected by structural heart disease. clinical presentation is divided into four groups: extra-systolic, tachycardic, anxiety-related, and intense. anxiety-related is the most common.