What is the plan for managing palpitations?

From the Guidelines

For palpitations, I recommend a comprehensive approach that prioritizes identifying and addressing underlying causes, with a focus on reducing morbidity, mortality, and improving quality of life. This approach should include both immediate management and long-term strategies.

Immediate Management

Start by identifying and reducing triggers such as caffeine, alcohol, nicotine, and stress, as suggested by 1. Keep a symptom diary noting when palpitations occur and what might have precipitated them. For immediate relief during episodes, try vagal maneuvers like the Valsalva maneuver (bearing down as if having a bowel movement) or splashing cold water on your face.

Long-term Strategies

Regular exercise, adequate sleep, and stress management techniques like meditation can help reduce frequency, as implied by the general principles of managing supraventricular arrhythmias 1. If palpitations are frequent or concerning, medical evaluation is essential to rule out underlying heart conditions, such as atrial fibrillation, which may require anticoagulation therapy as per the guidelines outlined in 1.

Treatment Considerations

Treatment may include beta-blockers like metoprolol (25-100 mg twice daily) or calcium channel blockers like diltiazem (120-360 mg daily) if appropriate, considering the patient's specific condition and the guidelines for managing atrial fibrillation 1. For those with anxiety-related palpitations, SSRIs such as sertraline (50-200 mg daily) might be beneficial. Electrolyte imbalances can trigger palpitations, so maintaining adequate hydration and balanced intake of potassium and magnesium is important.

Urgent Situations

Seek immediate medical attention if palpitations are accompanied by chest pain, shortness of breath, dizziness, or fainting, as these may indicate a more serious condition requiring urgent intervention, such as stroke prevention strategies outlined in 1.

Key Considerations

• Identify and address underlying causes of palpitations to reduce morbidity and mortality.
• Use vagal maneuvers and lifestyle modifications as first-line management for palpitations.
• Consider medical evaluation for frequent or concerning palpitations to rule out underlying heart conditions.
• Follow guidelines for managing specific conditions like atrial fibrillation, including anticoagulation therapy when necessary 1.

From the FDA Drug Label

Once adequate control of the arrhythmia has been achieved, it may be possible in some patients to reduce the dose as necessary to minimize side effects or effects on conduction. Flecainide should be used cautiously in patients with a history of CHF or myocardial dysfunction Plasma trough (less than one hour pre-dose) flecainide levels and electrocardiograms should be obtained at presumed steady state (after at least five doses) either after initiation or change in flecainide dose

The palpitations plan for patients taking flecainide involves:

• Monitoring plasma trough flecainide levels and electrocardiograms at steady state
• Cautious use in patients with a history of CHF or myocardial dysfunction
• Dose adjustment to minimize side effects or effects on conduction once adequate control of the arrhythmia has been achieved 2

From the Research

Palpitations Plan

The following steps can be taken to approach palpitations:

• History and physical examination are important in the assessment of patients with palpitations 3, 4, 5, 6
• A 12-lead electrocardiogram (ECG) is a crucial diagnostic tool and should be used on presentation 3, 4, 5, 6
• Ambulatory electrocardiographic monitoring and/or electrophysiological study may be undertaken if the initial evaluation results are negative and the patient is suffering from heart disease, or if the palpitations are frequent or poorly tolerated 3, 5
• Limited laboratory testing and cardiology referral may be indicated in some cases 6
• The intensity of ambulatory electrocardiographic monitoring and diagnostic work-up will be dictated by the frequency, nature, and severity of symptoms 3

Diagnostic Considerations

• Not all palpitations are due to arrhythmia 3
• The cause of palpitations can be difficult to diagnose due to their intermittent and sometimes infrequent nature 6
• A step-wise guide to the evaluation and management of patients with palpitations can help identify patients at highest risk for serious arrhythmias 7
• Direction from history, examination, and 12-lead electrocardiography will guide further investigations and may include an echocardiogram 3

Management Strategies

• Management must be tailored on a case-by-case basis depending on the cause of palpitations and symptom severity 3
• Treatment and follow-up of patients presenting with palpitations as the main complaint will depend on the aetiology and investigation findings 4
• Patients with palpitations accompanied by dizziness, excessive fatigue, or chest pains should receive adequate acute care aiming to stabilise their condition before referring to a higher level of care 4