What is the initial approach to a patient presenting with palpitations, including history (HPI) and physical examination, and what are the management options?

From the Guidelines

The initial approach to a patient with palpitations involves a thorough history and physical examination to determine the underlying cause and guide management. Begin by characterizing the palpitations: onset, duration, frequency, precipitating factors, associated symptoms (syncope, chest pain, dyspnea), and termination patterns. Inquire about medical history, focusing on cardiac conditions, thyroid disorders, and psychiatric diagnoses. Ask about medication use, caffeine, alcohol, and recreational drug consumption. The physical examination should include vital signs (particularly heart rate and blood pressure), cardiac auscultation for murmurs or irregular rhythms, signs of heart failure, and thyroid examination.

Initial diagnostic testing typically includes a 12-lead ECG, basic laboratory tests (electrolytes, thyroid function, CBC), and possibly ambulatory cardiac monitoring if the diagnosis remains unclear, as suggested by 1. Management depends on the underlying cause. For benign palpitations, reassurance and lifestyle modifications (reducing caffeine, alcohol, and stress) may suffice. For arrhythmias, options include rate-controlling medications (beta-blockers like metoprolol 25-100mg twice daily or calcium channel blockers like diltiazem 30-120mg three times daily), rhythm control with antiarrhythmics (such as amiodarone 200mg daily after loading), anticoagulation for atrial fibrillation (based on CHA₂DS₂-VASc score), cardioversion, or ablation procedures.

Some key points to consider in the history and physical examination include:

• Characterizing the pattern of the arrhythmia as paroxysmal or persistent
• Determining the cause of the arrhythmia
• Defining associated cardiac and extracardiac factors pertinent to the etiology, tolerability, and management, as emphasized by 1
• Physical examination findings such as irregular pulse, irregular jugular venous pulsations, variation in the intensity of the first heart sound, or absence of a fourth sound heard previously during sinus rhythm

Urgent intervention is required for hemodynamically unstable patients, including immediate cardioversion for unstable tachyarrhythmias. Treatment of underlying causes such as thyroid disorders, anemia, or electrolyte abnormalities is essential for long-term management.

From the Research

Initial Approach to Palpitations

The initial approach to a patient presenting with palpitations involves a thorough history (HPI) and physical examination, as well as a 12-lead electrocardiogram (ECG) 2, 3, 4, 5, 6.

• History:
  • The patient's history is crucial in determining the cause of palpitations, including the onset, duration, and frequency of symptoms, as well as any potential triggers or associated symptoms 3, 5.
  • The history should also include questions about the patient's medical history, family history, and social history, including the use of substances that may contribute to palpitations, such as caffeine, nicotine, or certain medications 3, 5.
• Physical Examination:
  • A thorough physical examination is essential in evaluating patients with palpitations, including vital signs, cardiovascular examination, and neurological examination 3, 4, 5.
  • The physical examination can help identify signs of underlying cardiac or non-cardiac conditions that may be contributing to the patient's symptoms 4, 5.
• Electrocardiogram (ECG):
  • A 12-lead ECG is an essential diagnostic tool in evaluating patients with palpitations, as it can help identify underlying cardiac arrhythmias or other cardiac conditions 2, 3, 4, 5, 6.
  • The ECG can also help guide further diagnostic testing and management, if necessary 2, 5.

Management Options

The management of palpitations depends on the underlying cause, which can be determined through a combination of history, physical examination, and diagnostic testing 4, 5, 6.

• Cardiac Causes:
  • If the palpitations are determined to be of cardiac origin, management may involve treatment of the underlying cardiac condition, such as arrhythmias or structural heart disease 5.
  • Cardiac imaging, such as echocardiography, may be recommended if there is suspicion of structural heart disease 5.
• Non-Cardiac Causes:
  • If the palpitations are determined to be of non-cardiac origin, management may involve treatment of the underlying condition, such as anxiety or other psychiatric disorders 5.
  • Lifestyle modifications, such as reducing caffeine and nicotine intake, may also be recommended 3.
• Further Diagnostic Testing:
  • If the initial evaluation is negative, further diagnostic testing, such as ambulatory ECG monitoring or electrophysiological study, may be necessary to determine the cause of palpitations 2, 4, 5.
  • Referral to a cardiologist may be indicated in certain cases, such as supraventricular tachycardia, long QT syndrome, or ventricular tachycardia 5.