What is the appropriate workup for a patient presenting with chest palpitations?

Diagnostic Approach to Chest Palpitations

The appropriate workup for a patient presenting with chest palpitations should begin with a 12-lead ECG, detailed history, physical examination, and basic laboratory tests, followed by cardiac monitoring appropriate to the frequency of symptoms. 1

Initial Evaluation

History - Key Elements to Assess

• Pattern, onset, duration, frequency of palpitations
• Triggering factors (exercise, position changes, meals)
• Associated symptoms (syncope, chest pain, dyspnea)
• Predisposing factors:
  • Caffeine, alcohol, nicotine consumption
  • Medication use (stimulants, thyroid supplements)
  • Stress levels and anxiety
  • Family history of sudden death or arrhythmias

Physical Examination - Focus Areas

• Vital signs with attention to heart rate and rhythm
• Cardiac examination for murmurs, gallops, or irregular rhythm
• Signs of thyroid disease
• Evidence of heart failure

Initial Testing

1. 12-lead ECG - Class I recommendation 1
2. Basic laboratory tests:
   • Complete blood count
   • Electrolytes (potassium, magnesium, calcium)
   • Thyroid function tests
   • Consider toxicology screen if substance use suspected

Risk Stratification

High-Risk Features (Require Urgent Evaluation)

• Palpitations with syncope or presyncope
• Family history of sudden cardiac death
• Known structural heart disease
• Palpitations during exertion
• Abnormal ECG findings

Monitoring Strategy Based on Symptom Frequency

For Frequent Palpitations (Daily or Near-Daily)

• 24-48 hour Holter monitoring 1

For Less Frequent but Recurrent Palpitations

• Event recorder or mobile cardiac telemetry (2-4 weeks) 1

For Very Infrequent but Severe Symptoms

• Implantable loop recorder 1

For Exercise-Induced Palpitations

• Exercise stress testing 1

Additional Testing Based on Initial Findings

Echocardiography Indications

• Abnormal cardiac examination
• Abnormal ECG findings
• High-risk features
• Suspected structural heart disease

Advanced Testing When Indicated

• Electrophysiology study for:
  • Recurrent supraventricular tachycardia
  • Evidence of pre-excitation
  • Suspected sino-atrial disease or AV block 1

Common Pitfalls to Avoid

1. Dismissing palpitations as anxiety without adequate cardiac evaluation 1
2. Relying solely on 24-hour Holter monitoring for infrequent episodes 1
3. Failing to consider non-cardiac causes (thyroid disease, anemia, medications) 1
4. Premature reassurance before capturing the rhythm during symptomatic episodes 1

Special Considerations

• For patients with palpitations and chest pain, continuous multi-lead ECG ischemia monitoring is recommended 2
• In patients with suspected arrhythmias, if initial evaluation is negative but symptoms persist, extended monitoring (>24 hours) is necessary 1
• For patients with palpitations associated with syncope, a more comprehensive evaluation including carotid sinus massage and tilt testing may be indicated 2

By following this structured approach, the underlying cause of palpitations can be identified in most patients, allowing for appropriate treatment and management.