How to manage stress-induced palpitations?

Management of Stress-Induced Palpitations

Beta-blockers are the first-line treatment for stress-induced palpitations, particularly cardioselective agents like metoprolol that block catecholamine effects on the heart. 1 This approach directly addresses the adrenergically mediated process that underlies stress-induced cardiac symptoms.

Understanding Stress-Induced Palpitations

Stress-induced palpitations are characterized by the uncomfortable awareness of heartbeats triggered by emotional or physical stressors. They represent a common manifestation of the body's sympathetic nervous system response to stress, with catecholamine surges playing a central role in their development 2.

Pathophysiology

• Elevated plasma catecholamines during stress lead to increased heart rate and contractility
• Supraphysiological elevations of catecholamines can trigger cardiac symptoms 2
• Some individuals may have increased β2-adrenergic receptor density, making them more responsive to sympathetic stimuli 2

Diagnostic Approach

When evaluating stress-induced palpitations, consider:

1. Symptom characteristics:

   • Timing in relation to stressful events
   • Associated symptoms (dizziness, chest pain, syncope, dyspnea)
   • Duration and frequency of episodes

2. Risk stratification:

   • Presence of structural heart disease (increases risk)
   • History of syncope (concerning symptom requiring further evaluation) 2
   • Family history of sudden cardiac death

3. Diagnostic tests to consider:

   • 12-lead ECG (baseline evaluation)
   • 24-48 hour Holter monitoring (if episodes occur daily) 2
   • Event recorder (for sporadic episodes) 2
   • Echocardiography (if structural heart disease is suspected) 2

Treatment Algorithm

First-line approach:

1. Beta-blockers (particularly cardioselective agents like metoprolol):
   • Directly counteract catecholamine effects 1
   • Reduce heart rate and cardiac output at rest and during exercise
   • Inhibit isoproterenol-induced tachycardia
   • Reduce reflex orthostatic tachycardia 1
   • Common side effects include fatigue, dizziness, and cold extremities 1

Non-pharmacological interventions:

1. Relaxation techniques:

   • Progressive muscle relaxation
   • Deep breathing exercises
   • Guided imagery
   • All have demonstrated effectiveness in promoting psychological and physiological states of relaxation 3

2. Lifestyle modifications:

   • Reduce or eliminate stimulants (caffeine, nicotine)
   • Regular exercise (improves stress tolerance)
   • Adequate sleep
   • Stress management techniques

For refractory cases:

1. Consider psychiatric evaluation if symptoms persist despite treatment and no cardiac abnormalities are found 2

   • Individuals who are highly sensitive to bodily sensations and experience frequent daily stressors are more likely to have persistent palpitations 4

2. Consider referral to cardiology if:

   • Symptoms are associated with syncope or presyncope
   • There is evidence of structural heart disease
   • Palpitations occur during exercise
   • There is a family history of sudden cardiac death

Special Considerations

Warning signs requiring urgent evaluation:

• Syncope during palpitations
• Palpitations during exercise
• Palpitations with chest pain or dyspnea
• Family history of sudden cardiac death

Potential complications:

In rare cases, severe stress can trigger stress-induced cardiomyopathy (Tako-tsubo cardiomyopathy), characterized by:

• Transient left ventricular dysfunction
• Apical ballooning pattern on imaging
• Occurs predominantly in postmenopausal women 2, 5
• Management is supportive and focuses on treating heart failure symptoms 2

By following this approach, most patients with stress-induced palpitations can achieve significant symptom improvement and avoid progression to more serious conditions.