How to assess palpitations?

Assessment of Palpitations

A comprehensive evaluation of palpitations requires a systematic approach beginning with detailed patient history, physical examination, and 12-lead ECG, followed by appropriate diagnostic testing based on symptom frequency and severity. 1

Initial Assessment

History

• Obtain specific details about palpitations:
  • Timing and circumstances (position, activity during episodes)
  • Precipitating factors
  • Onset characteristics (sudden vs. gradual)
  • Associated symptoms (syncope, near-syncope, dyspnea, chest pain)
  • Frequency and duration of episodes

Physical Examination

• Assess for:
  • Signs of structural heart disease
  • Irregular cannon A waves or irregular S1 intensity
  • Thyroid abnormalities
  • Lower extremity pulses and vascular examination

Essential Diagnostic Tests

1. 12-lead ECG (Class I, Level B-NR)

   • Essential even if patient is not currently experiencing symptoms
   • Look for pre-excitation patterns and baseline cardiac abnormalities

2. Basic laboratory tests (Class I)

   • Complete blood count
   • Electrolytes
   • Thyroid function tests

Diagnostic Algorithm Based on Symptom Frequency

For Frequent Symptoms (Daily or Almost Daily)

• 24-48 hour Holter monitoring (Class I, Level B-NR)
• Standard upright exercise test if symptoms are exertional

For Less Frequent but Recurrent Symptoms

• Wearable loop recorder or event recorder
• Exercise echocardiography for exertional or postural symptoms

For Rare Symptoms (Less than twice per month)

• Implantable loop recorder (ILR) should be considered
• Particularly useful for patients with recurrent unexplained syncope at low risk of SCD 2

Additional Testing Based on Clinical Suspicion

• Echocardiography (Class I)

  • To exclude structural heart disease
  • Particularly important in patients with sustained SVT

• Exercise stress testing

  • For patients with palpitations during or after physical effort

Special Considerations

Syncope with Palpitations

• Requires thorough evaluation including 12-lead ECG, exercise test, echocardiography, and 48-hour ambulatory ECG monitoring 2
• Syncope during exertion or immediately following palpitation/chest pain suggests cardiac mechanism
• Unexplained non-vasovagal syncope is a risk factor for sudden cardiac death

Atrial Fibrillation

• Immediate electrophysiological evaluation for irregular palpitations suggesting AF in high-risk patients

Management Approach

For Confirmed Arrhythmias

• For patients with LVEF >40%:

  • First-line: Beta-blockers (metoprolol, atenolol)
  • Alternative: Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)
  • Second-line: Digoxin (particularly for nocturnal symptoms)

• For patients with LVEF ≤40%:

  • First-line: Beta-blockers
  • Alternative: Digoxin

Lifestyle Modifications

• Stress management techniques
• Limiting caffeine, alcohol, and nicotine
• Evaluating for sleep apnea in patients with nocturnal symptoms

When to Refer to a Specialist

• Wide complex tachycardia of unknown origin
• Narrow complex tachycardias with drug resistance or intolerance
• Wolff-Parkinson-White syndrome
• Severe symptoms during palpitations
• Palpitations with syncope or presyncope

Common Pitfalls to Avoid

1. Attributing symptoms to anxiety without adequate cardiac evaluation
2. Relying solely on short-term monitoring for infrequent symptoms
3. Overlooking medication side effects
4. Dismissing patient symptoms despite normal initial testing

Dynamic Auscultation for MVP

For patients with suspected mitral valve prolapse, dynamic auscultation can be useful. The midsystolic click may be followed by a late systolic murmur. Changes in LV end-diastolic volume result in changes in the timing of the click-murmur complex - standing decreases volume and moves the complex earlier in systole, while squatting increases volume and moves it later 2.