Workup and Management Plan for Palpitations
The initial evaluation of patients with palpitations should include a 12-lead ECG, detailed history focusing on onset/offset patterns, and basic laboratory tests, followed by appropriate cardiac monitoring based on symptom frequency and severity. 1
Initial Assessment
History - Key Elements to Assess
- Pattern of palpitations:
- Abrupt onset/offset (suggests SVT or VT)
- Gradual onset/offset (suggests sinus tachycardia or non-cardiac causes) 1
- Triggering factors:
- Exercise, emotional stress
- Caffeine, alcohol, nicotine, recreational drugs
- Positional changes (standing, lying down)
- Associated symptoms:
- Syncope or presyncope (concerning for arrhythmia)
- Chest pain, dyspnea (suggests cardiac origin)
- Lightheadedness, anxiety 2
Physical Examination
- Vital signs with orthostatic measurements
- Cardiac examination for murmurs, extra heart sounds, irregular rhythm
- Signs of thyroid disease, anemia, or heart failure
Initial Testing
- 12-lead ECG (mandatory for all patients) 2
- Basic laboratory tests:
- Complete blood count
- Electrolytes, renal function
- Thyroid function tests
- Consider toxicology screen if substance use suspected 1
Risk Stratification
High-Risk Features (Require Urgent Evaluation)
- Syncope or presyncope with palpitations
- Known structural heart disease or family history of sudden death
- Abnormal ECG findings (pre-excitation, prolonged QT, etc.)
- Sustained palpitations with hemodynamic compromise 2
Moderate-Risk Features
- Palpitations with abrupt onset/offset
- Older patients with paroxysmal symptoms
- History of cardiac disease 1
Diagnostic Testing Algorithm
For Frequent Palpitations (Several Episodes Per Week)
- 48-hour ambulatory ECG monitoring (Class I recommendation) 2
- Consider echocardiography to exclude structural heart disease 2
For Less Frequent Episodes
- Event recorder or wearable loop recorder (more useful than 24-hour Holter) 2
- For very infrequent but severe symptoms (fewer than two episodes per month):
- Implantable loop recorder may be considered 2
For Exercise-Induced Palpitations
- Exercise stress testing is recommended 2
Specialized Testing (When Initial Workup Is Inconclusive)
For Suspected Supraventricular Arrhythmias
- Electrophysiological studies are indicated for:
- Persistent or recurrent supraventricular tachycardia
- Evidence of sino-atrial disease or AV block
- Ventricular pre-excitation 2
For Suspected Structural Heart Disease
- Echocardiography to exclude structural abnormalities 2
- Consider cardiac MRI in selected cases
Management Plan
For Benign Causes
- Reassurance
- Lifestyle modifications:
- Reduce/eliminate caffeine, alcohol, nicotine
- Stress management techniques
- Adequate hydration 1
For Arrhythmia-Related Palpitations
- Beta-blockers for symptomatic patients 1
- For specific arrhythmias like SVT:
- Teach vagal maneuvers
- Consider antiarrhythmic medications
- Referral for electrophysiology study and possible catheter ablation 2
For Orthostatic-Related Palpitations
- Volume expansion
- Liberal fluid and salt intake
- Support stockings 1
Referral Criteria
Immediate Cardiology Referral
- Palpitations with syncope or presyncope
- Evidence of structural heart disease
- Abnormal ECG findings
- Sustained ventricular arrhythmias 2
Routine Cardiology Referral
- Recurrent symptoms despite initial management
- Patients desiring to be free of drug therapy
- All patients with Wolff-Parkinson-White syndrome 2
Common Pitfalls to Avoid
- Dismissing palpitations as anxiety without adequate cardiac evaluation
- Relying solely on 24-hour Holter monitoring for infrequent episodes
- Failing to consider non-cardiac causes (thyroid disease, anemia, medications)
- Overlooking the need for echocardiography in patients with suspected arrhythmias
By following this systematic approach, most causes of palpitations can be identified and appropriately managed, reducing morbidity and improving quality of life for affected patients.