What is the best management approach for a 31-year-old female patient with palpitations, lightheadedness, and a history of anxiety, asthma, iron deficiency anemia, and hypermobile joints, with normal sinus rhythm and rare premature atrial contractions (PACs) and premature ventricular contractions (PVCs) on Holter monitor?

Management of Palpitations in a 31-Year-Old Female with Normal Cardiac Testing

Beta blockers are the first-line treatment for this patient with palpitations, lightheadedness, and normal cardiac testing, given her reported episodes of tachycardia and anxiety history. 1

Diagnostic Assessment Summary

The patient presents with:

• Palpitations with heart rate up to 180 bpm and associated lightheadedness
• Normal cardiac testing:
  • Holter monitor showing normal sinus rhythm (average HR 89 bpm)
  • Rare PACs and PVCs
  • Normal echocardiogram
  • Normal tilt table test
• Medical history significant for anxiety, asthma, iron deficiency anemia, and hypermobile joints

Management Approach

First-Line Treatment

1. Beta blocker therapy

   • Start with a cardioselective beta blocker (e.g., metoprolol) to minimize exacerbation of asthma
   • Initial dose: metoprolol 25mg twice daily, titrated as needed
   • Beta blockers are recommended for symptomatic patients with palpitations, especially when associated with tachycardia 1

2. Lifestyle modifications

   • Limit caffeine intake (currently one cup in morning)
   • Ensure adequate hydration
   • Regular sleep schedule
   • Stress management techniques (given history of anxiety)
   • Avoid stimulants and alcohol

Monitoring and Follow-up

• Follow-up in 2-4 weeks to assess symptom response
• Consider extended monitoring if symptoms persist despite treatment
• For very frequent symptoms, a 30-day event monitor may be appropriate 1, 2

Alternative Treatments

If beta blockers are ineffective or poorly tolerated:

1. Non-dihydropyridine calcium channel blockers

   • Consider verapamil or diltiazem if beta blockers are contraindicated or ineffective 3
   • Particularly useful if asthma worsens with beta blockers

2. Flecainide

   • May be considered for paroxysmal supraventricular arrhythmias if other treatments fail
   • Starting dose: 50 mg every 12 hours, may increase in increments of 50 mg bid every four days until efficacy is achieved 4
   • Requires in-hospital initiation with rhythm monitoring

Special Considerations

Anxiety Management

• Consider referral for cognitive behavioral therapy
• Assess for correlation between anxiety episodes and palpitations
• Teach vagal maneuvers for acute episodes (e.g., Valsalva)

Asthma Considerations

• Monitor for worsening of asthma symptoms with beta blocker therapy
• Use cardioselective beta blockers (metoprolol, bisoprolol) to minimize respiratory effects
• If asthma worsens, consider switching to calcium channel blockers 3

Hypermobile Joints

• Consider autonomic dysfunction as a potential contributor to symptoms
• Ensure adequate hydration and salt intake
• Compression stockings may be beneficial if orthostatic symptoms develop

Common Pitfalls to Avoid

1. Attributing all symptoms to anxiety without adequate cardiac evaluation

   • Even with normal testing, continue to monitor for cardiac causes if symptoms persist

2. Relying solely on short-term monitoring

   • If symptoms are infrequent, consider longer monitoring periods 1, 5

3. Overlooking medication side effects

   • Monitor for bronchospasm with beta blockers
   • Watch for hypotension, especially with combination therapy

4. Dismissing patient symptoms

   • Despite normal testing, the patient's symptoms are real and require management
   • Correlation between reported symptoms and cardiac rhythm is essential 1

Beta blockers remain the cornerstone of treatment for this patient with palpitations and normal cardiac testing, with careful monitoring of her asthma and consideration of alternative therapies if needed.