What is the workup for a 30-year-old woman with daily symptomatic palpitations?

From the Guidelines

The workup for a 30-year-old woman with daily symptomatic palpitations should begin with a thorough history and physical examination, followed by an electrocardiogram (ECG) to assess baseline cardiac rhythm and structure. A 24-48 hour Holter monitor or 14-30 day event recorder should be ordered to capture the palpitations during symptoms, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. Basic laboratory tests including complete blood count, comprehensive metabolic panel, thyroid function tests (TSH, free T4), and electrolytes (particularly potassium, magnesium, and calcium) are essential, as they can help identify underlying conditions that may be contributing to the palpitations. If initial testing is unrevealing but symptoms persist, an echocardiogram should be performed to evaluate cardiac structure and function, as suggested by the ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias 1. For patients with concerning features such as syncope, family history of sudden cardiac death, or abnormal initial testing, referral to a cardiologist or electrophysiologist is warranted. Additional testing may include exercise stress testing, extended monitoring with an implantable loop recorder, or electrophysiology studies. It's also important to assess for common triggers including caffeine, alcohol, stimulants, stress, anxiety, and certain medications, as these can exacerbate palpitations, and patients should be advised to keep a symptom diary correlating palpitations with potential triggers, as recommended by the 2006 ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation 1. This comprehensive approach is necessary because palpitations in young women can range from benign causes like premature atrial or ventricular contractions to more serious arrhythmias requiring specific treatment. Some key points to consider in the workup include:

• The importance of a thorough history and physical examination to identify underlying conditions and potential triggers
• The use of a 24-48 hour Holter monitor or 14-30 day event recorder to capture palpitations during symptoms
• The need for basic laboratory tests to identify underlying conditions
• The potential for referral to a cardiologist or electrophysiologist for further evaluation and treatment
• The importance of assessing for common triggers and advising patients to keep a symptom diary. Overall, the workup for a 30-year-old woman with daily symptomatic palpitations requires a comprehensive approach that takes into account the patient's medical history, physical examination, and diagnostic test results, as well as potential triggers and underlying conditions, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.

From the Research

Initial Evaluation

The workup for a 30-year-old woman with daily symptomatic palpitations should begin with a thorough history and physical examination to identify potential causes 2, 3, 4, 5, 6. This initial evaluation is crucial in determining the underlying cause of the palpitations.

Diagnostic Tests

• A 12-lead electrocardiogram (ECG) is the gold standard of diagnosis and should be performed on presentation 4.
• If the etiology cannot be determined from the patient's history, physical examination, and resting ECG, ambulatory electrocardiographic (ECG) monitoring may be indicated 2.
• For patients with daily palpitations, Holter monitoring for 24 to 48 hours may be appropriate 2, 4.
• Trans-telephonic event monitors are more effective and cost-effective than Holter monitors for most patients 2.

Considerations

• Palpitations can be caused by cardiac arrhythmias, anxiety, nonarrhythmic cardiac problems, and noncardiac problems such as hyperthyroidism, vasovagal syncope, and hypoglycemia 2.
• The patient's history and physical examination should be used to guide targeted diagnostic testing to distinguish cardiac from noncardiac causes 5.
• Patients with palpitations accompanied by dizziness, excessive fatigue, or chest pains should receive adequate acute care aiming to stabilize their condition before referring to a higher level of care 4.

Further Evaluation

• If the initial evaluation does not yield a diagnosis, further testing such as event monitors, treadmill exercise stress tests, echocardiography, and electrophysiologic studies may be necessary 3.
• Limited laboratory testing and cardiology referral may also be indicated in some cases 6.