From the Guidelines
For a patient with palpitations, I recommend starting with a thorough history and physical examination, followed by an electrocardiogram (ECG) to assess the heart's electrical activity. This approach is supported by the most recent guidelines, such as the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.
Initial Evaluation
The initial evaluation should include:
- A thorough history to identify the pattern of palpitations, including the number of episodes, duration, frequency, mode of onset, and possible triggers, as emphasized in the ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias 1.
- A physical examination to assess for signs of structural heart disease or other underlying conditions.
- An electrocardiogram (ECG) to evaluate the heart's electrical activity and identify any potential arrhythmias, as recommended in the guidelines 1.
Additional Tests
Additional first-line tests should include:
- Basic laboratory studies such as complete blood count, electrolytes (particularly potassium, magnesium, and calcium), thyroid function tests, and possibly cardiac enzymes if cardiac ischemia is suspected.
- If the initial evaluation doesn't reveal the cause or if palpitations are recurrent, consider ordering a 24-48 hour Holter monitor or a 14-30 day event monitor depending on symptom frequency, as suggested in the guidelines 1.
- For less frequent episodes, a loop recorder might be appropriate.
- An echocardiogram should be ordered to evaluate structural heart disease, especially if there are abnormal physical exam findings or ECG changes, as recommended in the guidelines 1.
- Exercise stress testing may be valuable if palpitations are exercise-induced.
Referral to a Specialist
Indications for referral to a cardiac arrhythmia specialist include presence of a wide complex tachycardia of unknown origin, drug resistance or intolerance, and severe symptoms such as syncope or dyspnea during palpitations, as outlined in the guidelines 1.
By following this approach, healthcare providers can effectively diagnose and manage palpitations, reducing morbidity, mortality, and improving quality of life for patients.
From the Research
Initial Evaluation
- A detailed history, physical examination, and electrocardiogram (ECG) are essential in evaluating palpitations and may yield a probable diagnosis 2, 3, 4, 5.
- The initial evaluation involves history, physical examination, and 12-lead electrocardiogram, which can provide a prognostic stratification of the patients and a definitive suspected diagnosis of the cause of symptoms in a good proportion of cases 3.
Additional Testing
- Limited laboratory testing, ambulatory ECG monitoring, and cardiology referral may be indicated in some cases 4.
- Additional testing may include echocardiography, cardiac stress testing, electrocardiogram monitoring, or electrophysiologic studies to distinguish whether symptoms correlate with cardiac arrhythmia or structural or ischemic heart disease 5.
- Extended electrocardiogram monitoring, such as 24-hour Holter monitoring, 30-day external continuous monitoring, and implantable loop recorders, can be used to document arrhythmias in the workup of a patient with palpitation 6.
Diagnostic Tools
- Holter monitor, event monitor, transtelephonic electrocardiographic monitor, treadmill exercise stress test, echocardiography, and electrophysiologic studies are available for the evaluation of palpitations caused by a presumed cardiogenic cause 2.
- Wearable smart devices with ambulatory electrocardiogram monitoring technologies can be used to detect arrhythmias and allow patients to participate in their healthcare 5.