From the Guidelines
The initial work-up for palpitations should include a thorough history, physical examination, and an electrocardiogram (ECG). Start with a detailed patient history, focusing on the nature, frequency, and duration of palpitations, as well as any associated symptoms or triggers, as emphasized in the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. Perform a comprehensive physical exam, paying particular attention to heart rate, rhythm, and signs of underlying cardiac or systemic diseases. Obtain a 12-lead ECG to assess for any arrhythmias or structural abnormalities, which can potentially identify the arrhythmia mechanism, as discussed in the 2015 ACC/AHA/HRS guideline executive summary 1.
If the initial ECG is normal, consider ambulatory ECG monitoring:
- 24-48 hour Holter monitor for frequent symptoms
- Event recorder for 2-4 weeks for less frequent episodes
- Implantable loop recorder for very infrequent but concerning symptoms, as recommended in the ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias 1.
Additional tests based on clinical suspicion:
- Echocardiogram to evaluate cardiac structure and function
- Blood tests: Complete blood count, thyroid function, electrolytes, and cardiac enzymes
- Exercise stress test if symptoms are exertion-related. If initial evaluation is inconclusive and symptoms persist, consider referral to a cardiologist or electrophysiologist for further assessment, as suggested in the ACC/AHA/ESC guidelines 1.
This approach allows for the detection of both intermittent arrhythmias and underlying cardiac or systemic conditions that may be causing palpitations. The combination of history, physical exam, and appropriate diagnostic tests helps identify the cause and guide treatment decisions, ultimately prioritizing morbidity, mortality, and quality of life as the outcome.
From the Research
Diagnostic Work-up for Palpitations
The diagnostic work-up for palpitations typically involves a combination of the following steps:
- A detailed history to understand the characteristics of the palpitations, including their duration, frequency, and any triggers or associated symptoms 2, 3, 4, 5, 6
- A physical examination to look for any signs of underlying cardiac or non-cardiac conditions 2, 3, 4, 5, 6
- A 12-lead electrocardiogram (ECG) to evaluate the heart's rhythm and identify any potential arrhythmias 2, 3, 4, 5, 6
- Limited laboratory testing, such as blood work, to rule out any underlying conditions that may be contributing to the palpitations 3
- Ambulatory ECG monitoring, such as Holter monitoring or event monitoring, to capture any episodes of palpitations and evaluate the heart's rhythm over a longer period of time 2, 6
- Other diagnostic tests, such as echocardiography, treadmill exercise stress test, or electrophysiologic studies, may be ordered based on the results of the initial evaluation and the patient's symptoms 2, 6
Special Considerations
In some cases, the diagnostic work-up for palpitations may need to be more extensive, such as:
- If the patient has a history of cardiac disease or is at high risk for cardiac complications 2, 4
- If the patient is experiencing symptoms such as syncope, chest pain, or shortness of breath 4
- If the patient has a family history of cardiac disease or sudden cardiac death 4 In these cases, the patient may need to be referred to a cardiologist or other specialist for further evaluation and treatment.