What is the appropriate workup for palpitations in a young patient?

Evaluation of Palpitations in Young Patients

The most appropriate workup for palpitations in a young patient should include a detailed history, physical examination, 12-lead ECG, and targeted cardiac monitoring based on symptom frequency, with additional testing guided by initial findings.

Initial Assessment

History

• Document specific characteristics of palpitations:
  • Description (racing, skipping, fluttering, pounding)
  • Duration and frequency
  • Onset (sudden vs. gradual)
  • Termination pattern
  • Associated symptoms (syncope, near-syncope, chest pain, dyspnea)
  • Precipitating factors (exercise, emotional stress, position changes)
  • Alleviating factors
  • Family history of sudden cardiac death or arrhythmias

Physical Examination

• Vital signs with orthostatic measurements
• Cardiac examination focusing on:
  • Murmurs suggesting structural heart disease
  • Irregular rhythm
  • Extra heart sounds
  • Signs of heart failure
• Thyroid examination

Diagnostic Testing

First-Line Testing

1. 12-lead ECG - Essential initial test for all patients with palpitations 1

   • Evaluate for:
     • Pre-excitation syndromes (WPW)
     • Long QT syndrome
     • Brugada syndrome
     • Arrhythmias
     • Conduction abnormalities

2. Basic laboratory tests - Only if clinically indicated 1

   • Thyroid function tests
   • Electrolytes (potassium, magnesium)
   • Complete blood count
   • Drug screen if substance use suspected

Second-Line Testing (Based on Initial Findings)

1. Ambulatory ECG monitoring - Selection based on symptom frequency:

   • For frequent daily palpitations: 24-48 hour Holter monitoring 1
   • For less frequent episodes: Event monitor or loop recorder for 2 weeks 1, 2
   • For very infrequent episodes: Implantable loop recorder may be considered

2. Echocardiography - Indicated if:

   • Abnormal cardiac examination
   • Abnormal ECG
   • Family history of structural heart disease
   • Palpitations associated with exertion 1

3. Exercise stress testing - Consider if:

   • Palpitations occur during or after exercise
   • Suspicion of exercise-induced arrhythmias 1

Special Considerations for Young Patients

High-Risk Features Requiring Urgent Evaluation

• Palpitations associated with syncope or near-syncope 1
• Family history of sudden cardiac death
• Palpitations during exercise
• Known structural heart disease
• Abnormal ECG findings

Specific Conditions to Consider in Young Patients

• Supraventricular tachycardia (most common arrhythmia in young patients)
• Wolff-Parkinson-White syndrome
• Long QT syndrome
• Hypertrophic cardiomyopathy
• Congenital heart disease 1

Referral Criteria

Cardiology referral is indicated for:

• Palpitations with syncope or near-syncope
• Documented arrhythmias
• Abnormal ECG findings
• Palpitations associated with exercise
• Family history of sudden cardiac death or genetic arrhythmias
• Structural heart disease on echocardiography 3

Common Pitfalls to Avoid

1. Attributing palpitations to anxiety without adequate cardiac evaluation

   • Even in patients with anxiety disorders, cardiac causes must be excluded 3

2. Inadequate monitoring duration

   • Match monitoring strategy to symptom frequency
   • Consider longer monitoring periods for infrequent symptoms

3. Overlooking non-cardiac causes

   • Thyroid disorders
   • Stimulant medications or substances
   • Electrolyte abnormalities

4. Dismissing palpitations in young patients

   • While most are benign, potentially serious conditions can present in young patients

By following this systematic approach, clinicians can effectively evaluate young patients with palpitations and identify those who require further cardiac evaluation or intervention.