What is the workup for new onset intermittent painless palpitations, especially when lying down, in a 71-year-old female with a history of psoriasis on adalimumab (adalimumab), hyperlipidemia (elevated lipid levels) on rosuvastatin (rosuvastatin), and hypertension (hypertension) on losartan (losartan)?

Workup for New Onset Intermittent Painless Palpitations in 71-Year-Old Female

The recommended workup for new onset intermittent painless palpitations in this 71-year-old female should include a 12-lead ECG, 24-hour Holter monitoring, comprehensive laboratory testing, and echocardiography, with extended cardiac monitoring if initial tests are non-diagnostic. 1

Initial Evaluation

History and Specific Symptoms to Assess

• Detailed characterization of palpitations:
  • Regular vs. irregular rhythm (regular palpitations are more likely to have a cardiac cause) 2
  • Duration of episodes (longer duration may indicate significant arrhythmia)
  • Triggers (particularly noting occurrence when lying down)
  • Associated symptoms (dizziness, syncope, chest pain)

Medication Review

• Evaluate current medications for potential cardiac effects:
  • Adalimumab: May rarely cause heart failure in susceptible individuals 1
  • Rosuvastatin: Generally well-tolerated from cardiac perspective 3
  • Losartan: May actually be protective against certain arrhythmias 1

Risk Factor Assessment

• Age (71 years) increases risk of cardiac arrhythmias 1
• Hypertension is a significant risk factor for arrhythmias, particularly atrial fibrillation 1
• Hyperlipidemia contributes to cardiovascular risk

Diagnostic Testing

First-Line Testing

1. 12-lead ECG: Essential baseline test to identify conduction abnormalities, ischemic changes, or evidence of structural heart disease 1

2. Laboratory studies:

   • Complete blood count
   • Comprehensive metabolic panel (including electrolytes, particularly potassium, magnesium)
   • Thyroid function tests
   • Cardiac biomarkers if acute presentation

3. 24-hour Holter monitoring: Appropriate for frequent symptoms (daily or near-daily) 4, 5

Second-Line Testing

1. Echocardiography: To evaluate for structural heart disease, valvular abnormalities, and assess left ventricular function 1

   • Particularly important given patient's age and hypertension
   • Should include assessment of ejection fraction (especially important given adalimumab use)

2. Extended cardiac monitoring: If 24-hour Holter is non-diagnostic 4, 5

   • 30-day event recorder or patch monitor for less frequent symptoms
   • Consider implantable loop recorder for very infrequent but concerning symptoms

Special Considerations

Medication-Related Concerns

• Adalimumab monitoring: TNF antagonists can potentially worsen or cause new-onset heart failure 1
  • Consider screening echocardiogram to assess cardiac function
  • If ejection fraction <50%, consider medication adjustment 1
  • Avoid TNF antagonists in NYHA class III-IV heart failure 1

Age-Related Considerations

• Elderly patients have higher prevalence of complex ventricular ectopy, even when asymptomatic 1
• Palpitations occurring at rest or when lying down may suggest increased vagal tone or atrial arrhythmias

Follow-up Plan

• If initial testing is negative but symptoms persist, proceed to extended monitoring
• Consider cardiology referral if:
  • Abnormal findings on initial workup
  • Symptoms are associated with hemodynamic compromise
  • Symptoms significantly impact quality of life despite negative initial workup

Pitfalls to Avoid

• Dismissing palpitations as benign without adequate evaluation, particularly in elderly patients
• Failing to correlate symptoms with ECG findings (symptom-rhythm correlation is essential)
• Not considering medication effects or interactions
• Overlooking the need for extended monitoring when symptoms are infrequent

By following this systematic approach, you can effectively evaluate this patient's palpitations and identify any underlying cardiac abnormalities that may require treatment.