From the Guidelines
The next best step for this healthy 30-year-old woman with near daily palpitations, occasional lightheadedness, and chest pain would be ambulatory cardiac monitoring, specifically a Holter monitor for 24-48 hours or an event recorder for 2-4 weeks. Despite normal EKG and bloodwork, her symptoms suggest possible cardiac arrhythmia that may not be captured on a single EKG. Ambulatory monitoring allows for continuous recording of cardiac activity during daily activities and when symptoms occur. The patient should be instructed to keep a symptom diary during the monitoring period, noting when palpitations or other symptoms occur so these can be correlated with any rhythm abnormalities detected. This approach is preferred over more invasive testing since basic evaluations have been normal, as supported by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. If monitoring reveals an arrhythmia such as supraventricular tachycardia or frequent premature beats, appropriate treatment can be initiated. Some key points to consider in the management of such patients include:
- The importance of a thorough clinical history and physical examination to assess the probability of cardiac disease, as emphasized in the ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias 1.
- The role of ambulatory ECG monitoring in evaluating patients with chest pain and palpitations, as highlighted in the 2024 ESC guidelines for the management of chronic coronary syndromes 1 and the synopsis of the National Institute for Health and Clinical Excellence guideline for management of transient loss of consciousness 1.
- The consideration of non-cardiac causes of symptoms, such as anxiety, thyroid disorders, or stimulant use, if cardiac monitoring is normal, as suggested in the example answers provided. If cardiac monitoring is normal, further evaluation might include stress testing, echocardiogram, or consideration of these non-cardiac causes. Given the recency and relevance of the 2024 ESC guidelines 1, these should guide the decision-making process in this scenario.
From the Research
Diagnostic Approach
The patient's symptoms of near daily palpitations, occasional lightheadedness, and chest pain for a month, with normal electrocardiogram (EKG) and bloodwork, require further evaluation. The next best step would be to use ambulatory electrocardiographic (ECG) monitoring to correlate the symptoms with an electrocardiographic record, allowing for the identification or ruling out of a possible rhythm disorder 2, 3, 4.
Monitoring Options
The following monitoring options are available:
- 24-hour Holter monitoring: suitable for patients with daily palpitations 2, 4
- 30-day external continuous monitoring: useful for patients with infrequent symptoms 4
- Implantable loop recorders: can be used for long-term monitoring 4
- Trans-telephonic event monitors: more effective and cost-effective than Holter monitors for most patients 2
Exercise Stress Test
An exercise stress test may not be the most appropriate next step, as the patient's symptoms are not typically associated with exertion. However, stress echocardiography can be useful in evaluating patients with atypical chest pain and no known coronary artery disease, as it can identify those at risk for cardiac events 5.
Transthoracic Echocardiogram
A transthoracic echocardiogram may not be necessary at this stage, as the patient's EKG and bloodwork are normal, and the symptoms are more likely related to a rhythm disorder rather than a structural heart disease.
Reassurance
Reassurance alone may not be sufficient, as the patient's symptoms are persistent and require further evaluation to rule out any underlying cardiac condition. Ambulatory ECG monitoring can help to reassure the patient if no significant arrhythmias are detected, and can also help to identify any potential causes of the symptoms 2, 6.