From the Guidelines
Palpitations can be a symptom of an underlying heart condition, and it is crucial to seek medical evaluation, especially if they occur with other concerning symptoms such as chest pain, dizziness, shortness of breath, or fainting. The risks associated with palpitations include transient cerebral ischemic episodes, stroke syndromes, and arrhythmias, as reported in patients with mitral valve prolapse 1. Common causes of palpitations include stress, anxiety, caffeine, alcohol, certain medications, and medical conditions like arrhythmias, thyroid disorders, or heart disease. Treatment depends on the underlying cause, and for benign palpitations, lifestyle modifications such as reducing caffeine and alcohol intake, managing stress through meditation or yoga, getting adequate sleep, and avoiding stimulant medications can help 1. For arrhythmia-related palpitations, medications may be prescribed, such as beta-blockers (e.g., metoprolol, propranolol) to slow heart rate, as recommended in the 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1. Some key points to consider in the management of palpitations include:
- Identifying triggers through a symptom diary to help manage episodes
- Considering procedures like cardioversion, catheter ablation, or pacemaker/defibrillator implantation for more serious cases
- The importance of follow-up with healthcare providers to monitor the condition and adjust treatment as needed
- The role of anti-arrhythmic drugs, such as amiodarone, in the treatment of ventricular arrhythmias, as discussed in the 2015 ESC guidelines 1. In patients with mitral valve prolapse and palpitations, beta blockers may be effective in managing symptoms, and daily aspirin therapy may be recommended for those with high-risk echocardiographic characteristics or a history of transient focal neurological events 1.
From the FDA Drug Label
WARNINGS Mortality ... Proarrhythmic Effects Propafenone HCl, like other antiarrhythmic agents, may cause new or worsened arrhythmias Such proarrhythmic effects range from an increase in frequency of PVCs to the development of more severe ventricular tachycardia, ventricular fibrillation or torsade de pointes; Overall in clinical trials with propafenone, 4. 7% of all patients had new or worsened ventricular arrhythmia possibly representing a pro-arrhythmic event (0.7% was an increase in PVCs; 4. 0% a worsening, or new appearance, of VT or ventricular fibrillation [VF]). Although most proarrhythmic events occurred during the first week of therapy, late events also were seen and the CAST study (see above) suggests that an increased risk is present throughout treatment.
The risks for palpitations include new or worsened arrhythmias, such as:
- Increased frequency of PVCs
- Ventricular tachycardia
- Ventricular fibrillation
- Torsade de pointes The treatment options for palpitations with propafenone include:
- Evaluation electrocardiographically and clinically prior to, and during therapy
- Discontinuation of propafenone HCl if congestive heart failure worsens
- Reduction in dosage or discontinuation of propafenone HCl if second or third degree AV block occurs
- Monitoring and programming of pacemakers accordingly during therapy 2
From the Research
Risks Associated with Palpitations
- Palpitations can be a symptom of life-threatening conditions, although they are mostly associated with benign underlying diseases 3, 4.
- Cardiac causes are the most concerning etiology, and distinguishing cardiac from noncardiac causes is crucial due to the risk of sudden death in those with an underlying cardiac etiology 5.
- Patients with a history of cardiovascular disease, palpitations at work, or palpitations that affect sleep have an increased risk of a cardiac cause 5.
- Ischemic symptoms may signal coronary heart disease and associated ventricular premature contractions that may warrant exercise stress testing 5.
Treatment Options for Palpitations
- Treatment and follow-up of patients presenting with palpitations depend on the aetiology and investigation findings 3.
- 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 3.
- Management of palpitations is based on the suspected etiology, and in most cases of cardiac-induced palpitations, treatment can include reassurance, education, trigger avoidance, or use of atrioventricular nodal blockers 6.
- Tachyarrhythmias may require cardiac ablation, and patients who have palpitations with no arrhythmia causality and no cardiac disease should be reassured, with screening for psychosomatic disorders considered 6.
Diagnostic Approach
- A thorough history and physical examination, followed by targeted diagnostic testing, can distinguish cardiac conditions from other causes of palpitations 5, 7.
- A 12-lead electrocardiogram (ECG) is the gold standard of diagnosis, and ambulatory ECG monitoring may be indicated if the aetiology cannot be determined 3, 7.
- Additional testing may include echocardiography, cardiac stress testing, or electrophysiologic studies to distinguish whether symptoms correlate with cardiac arrhythmia or structural or ischemic heart disease 6.