What is the appropriate workup for palpitations?

From the Guidelines

A palpitations workup should begin with a thorough history and physical examination, focusing on the nature, frequency, and triggers of palpitations, as this approach is crucial in guiding the diagnosis and management of the underlying condition, which can range from benign to life-threatening arrhythmias 1.

Initial Evaluation

The initial evaluation should include:

• A 12-lead ECG to assess for any underlying cardiac abnormalities
• Complete blood count, comprehensive metabolic panel, and thyroid function tests to rule out any underlying metabolic or thyroid-related causes
• Assessment of caffeine, alcohol, and medication use, as these can contribute to palpitations

Ambulatory Cardiac Monitoring

For intermittent symptoms, ambulatory cardiac monitoring is essential, with options including:

• 24-48 hour Holter monitoring for frequent symptoms
• Event monitors for symptoms occurring within 2-4 weeks
• Implantable loop recorders for very infrequent episodes

Additional Testing

Additional testing may include:

• Echocardiography to assess structural heart disease
• Exercise stress testing if symptoms are exercise-related
• Electrophysiology studies for patients with concerning arrhythmias or structural heart disease

Management

Management depends on the underlying cause, ranging from:

• Lifestyle modifications (reducing caffeine, alcohol, and stress)
• Medication adjustments
• Antiarrhythmic drugs
• Ablation procedures for specific arrhythmias It is essential to note that a systematic approach is necessary because palpitations can represent benign conditions or life-threatening arrhythmias, and proper diagnosis guides appropriate treatment 1.

Patient Education

Patients should be instructed to document their symptoms, including timing, duration, associated symptoms, and potential triggers, to help correlate with monitoring results. Some key points to consider in the workup and management of palpitations include:

• The importance of a thorough history and physical examination in guiding the diagnosis and management
• The use of ambulatory cardiac monitoring to diagnose intermittent symptoms
• The consideration of additional testing, such as echocardiography and electrophysiology studies, in certain cases
• The range of management options, from lifestyle modifications to ablation procedures, depending on the underlying cause.

From the Research

Palpitations Workup

The workup for palpitations typically involves a combination of the following steps:

• A detailed history and physical examination to identify potential underlying causes 2, 3, 4
• A 12-lead electrocardiogram (ECG) to evaluate cardiac rhythm and identify potential arrhythmias 5, 2, 3, 4
• Ambulatory ECG monitoring, such as a Holter monitor, to detect intermittent arrhythmias 3, 4
• Limited laboratory testing to evaluate for underlying conditions, such as electrolyte abnormalities 6
• Cardiology referral for further evaluation and management if necessary 2

Diagnostic Approach

The diagnostic approach to palpitations involves:

• Initial evaluation with history, physical examination, and 12-lead ECG to yield a prognostic stratification of patients and a suspected diagnosis in a good proportion of cases 3
• Use of ambulatory ECG monitoring and/or electrophysiological study if the initial evaluation results are negative and the patient is suffering from heart disease, or if the palpitations are frequent or poorly tolerated and with a high probability of an arrhythmic origin 3
• Consideration of the underlying cause of palpitations, with cardiac causes being the most concerning etiology 4

Importance of Early ECG Recording

Early ECG recording is a key element in the diagnostic approach to palpitations, with prehospital ECG and ECG at admission having the best positivity rates 5