What is the next best step for a 32-year-old healthy woman with daily episodes of palpitations, lightheadedness, and occasional chest tightness at rest, with a normal electrocardiogram (EKG) and vital signs, including a normal heart rate, normal respiration, and normal blood pressure?

From the Guidelines

The next best step for this 32-year-old healthy woman with daily palpitations, lightheadedness, and occasional chest tightness at rest would be to obtain a 24-48 hour Holter monitor or a 14-30 day event monitor to capture these episodes. Despite her normal EKG and vital signs during the clinical evaluation, her symptoms suggest possible paroxysmal arrhythmia that may not be present during the brief office visit. The ambulatory cardiac monitoring would allow correlation between her symptoms and any cardiac rhythm disturbances, as recommended by the 2019 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1. While waiting for this evaluation, the patient should be instructed to avoid potential triggers such as excessive caffeine, alcohol, and stimulants. She should also keep a symptom diary noting the time, duration, and circumstances of each episode, which can help identify patterns or triggers. If the monitoring reveals a specific arrhythmia such as supraventricular tachycardia or atrial fibrillation, appropriate treatment can be initiated, as suggested by the 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy 1. If cardiac monitoring is negative but symptoms persist, further evaluation for non-cardiac causes such as anxiety, thyroid dysfunction, or electrolyte abnormalities would be warranted through appropriate laboratory testing and possibly referral to cardiology for more specialized evaluation. Some key points to consider in the evaluation and management of this patient include:

• The use of ambulatory electrocardiographic monitoring to detect ventricular tachycardia and identify patients who may be candidates for ICD therapy, as recommended by the 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy 1.
• The consideration of a 48-hour ambulatory electrocardiography in patients with frequent palpitations, as suggested by the 2014 ESC guidelines on diagnosis and management of hypertrophic cardiomyopathy 1.
• The potential use of an implantable loop recorder (ILR) in patients with infrequent but severe symptoms, as recommended by the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias 1.

From the Research

Next Steps for Diagnosis

The patient's symptoms of daily palpitations, lightheadedness, and occasional chest tightness at rest, with a normal electrocardiogram (EKG) and vital signs, require further evaluation. The following options are considered:

• Reassurance: Although the patient's vital signs and EKG are normal, her symptoms are distressing and require attention.
• Continuous, ambulatory monitoring: This option is supported by studies such as 2, which highlights the value of Holter monitoring in documenting intermittent arrhythmias.
• Exercise stress test: This test may be indicated if the patient's symptoms are suggestive of ischemic heart disease, as mentioned in 3.

Diagnostic Approach

The diagnostic approach to palpitations involves a detailed history, physical examination, and electrocardiogram (ECG), as outlined in 4. Limited laboratory testing, ambulatory ECG monitoring, and cardiology referral may also be indicated. The initial evaluation should yield a prognostic stratification of the patients and a suspected diagnosis of the cause of symptoms, as stated in 5.

Considerations for Ambulatory Monitoring

Ambulatory monitoring, such as Holter monitoring, is a valuable diagnostic tool for documenting intermittent arrhythmias, as mentioned in 2 and 6. However, its use is limited in patients with rare symptoms or recordings full of artifacts. A patient diary accompanying the ECG recording is crucial for interpreting the results, as noted in 2.

Evaluation of Palpitations

The evaluation of palpitations in the primary care setting involves a thorough history and physical examination, followed by targeted diagnostic testing, as outlined in 3. Distinguishing cardiac from noncardiac causes is important due to the risk of sudden death in those with an underlying cardiac etiology. A history of cardiac symptoms, family history, or abnormal physical examination or ECG findings should prompt a more in-depth evaluation for heart disease, as mentioned in 3.