Propranolol for Management of Palpitations
Propranolol is effective for managing palpitations, particularly in patients with tachyarrhythmias, atrial fibrillation, or conditions with increased adrenergic tone. 1, 2
Mechanism of Action and Efficacy
Propranolol works as a nonselective beta-adrenergic receptor-blocking agent that:
- Competes with beta-adrenergic stimulating agents for receptor sites
- Decreases chronotropic (heart rate) and inotropic (contractility) responses
- Reduces oxygen requirements of the heart during exertion
- Blocks catecholamine-induced increases in heart rate and blood pressure 2
Clinical Applications for Palpitations
First-Line Therapy for:
- Palpitations associated with atrial fibrillation (AF) (Class I recommendation) 1
- Junctional tachycardia (Class IIa recommendation) 1
- Palpitations related to high adrenergic states (e.g., anxiety, post-operative states) 1
- Supraventricular tachycardias (SVTs) 1
Dosing Recommendations:
- Acute management: 0.15 mg/kg IV (for rapid control) 1
- Chronic management: Starting at 30-60 mg daily in divided doses, with long-acting formulations available
- Maximum dose: 40-160 mg in divided or single doses with long-acting formulations 1
Patient Selection Considerations
Best candidates:
- Patients with palpitations due to AF or SVT
- Patients with coexisting anxiety or migraine 1
- Patients with high adrenergic tone states 1
Use with caution in:
- Patients with COPD or bronchospasm (calcium channel blockers preferred) 3
- Patients with decompensated heart failure 1
- Patients with hypotension 1
- Patients with AV block greater than first degree 1
Monitoring and Side Effects
Common side effects:
- Hypotension
- Bradycardia
- Bronchospasm
- Heart block
- Worsening heart failure in predisposed patients 1
Monitoring recommendations:
- Heart rate and blood pressure
- Signs of bronchospasm in susceptible patients
- Exercise tolerance (propranolol may blunt appropriate heart rate response) 1
Alternative Options
When propranolol is contraindicated or not tolerated:
- Calcium channel blockers (diltiazem, verapamil) - especially in COPD patients 3
- Digoxin - for rate control at rest in sedentary patients 1
- Amiodarone - when other measures are unsuccessful 1
Special Considerations
- In patients with palpitations related to Post-Acute Sequelae of SARS-CoV-2 infection (PASC), low-dose beta-blockers including propranolol may help control symptoms 1
- Some patients may experience exacerbation of panic disorder with propranolol 4
- A biphasic dose-response has been observed in some patients with ventricular arrhythmias 5
Propranolol remains a valuable and effective option for managing palpitations across various clinical scenarios, with strong evidence supporting its use in reducing symptoms and improving quality of life when appropriately prescribed.