What is the approach to evaluating and managing new onset palpitations?

Approach to New Onset Palpitations Workup

A systematic diagnostic approach to new onset palpitations should begin with a detailed patient history, targeted physical examination, and 12-lead ECG, followed by appropriate monitoring based on symptom frequency and severity. 1

Initial Assessment

History - Key Elements to Obtain

• Characteristics of palpitations:
  • Onset (sudden vs. gradual)
  • Duration (seconds, minutes, hours)
  • Frequency (daily, weekly, monthly)
  • Regularity or irregularity of heartbeat
  • Description (racing, pounding, skipping, fluttering)
  • Termination pattern (sudden vs. gradual)
• Associated symptoms:
  • Syncope or near-syncope (indicates higher risk)
  • Chest pain
  • Dyspnea
  • Dizziness
• Precipitating factors:
  • Exercise
  • Position changes
  • Emotional stress
  • Caffeine, alcohol, or stimulant use
  • Medication use

Physical Examination - Focus On

• Vital signs (heart rate, blood pressure, respiratory rate)
• Cardiac examination for murmurs, irregular rhythm, extra heart sounds
• Signs of thyroid disease
• Signs of heart failure
• Irregular cannon A waves or irregular S1 intensity

First-Line Diagnostic Testing

1. 12-lead ECG (Class I, Level B-NR) - Essential even if patient is asymptomatic during visit 1

   • Look for:
     • Pre-excitation patterns (WPW syndrome)
     • QT interval abnormalities
     • Conduction abnormalities
     • Chamber enlargement
     • Ischemic changes

2. Laboratory testing (Class I)

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

3. Echocardiography (Class I)

   • Particularly important for patients with sustained SVT or abnormal ECG
   • Evaluates for structural heart disease

Cardiac Monitoring Strategy Based on Symptom Frequency

• For frequent symptoms (daily or almost daily):

  • 24-48 hour Holter monitoring (Class I, Level B-NR) 1

• For less frequent but recurrent symptoms (weekly):

  • Wearable event recorder or loop recorder (14-30 days)

• For infrequent symptoms (less than twice monthly):

  • Implantable loop recorder
  • Consider smartphone-based ECG monitors

• For exercise-induced symptoms:

  • Exercise stress testing

Risk Stratification

High-Risk Features (Require Urgent Evaluation)

• Syncope or pre-syncope with palpitations
• Family history of sudden cardiac death
• Known structural heart disease
• Abnormal ECG findings
• Palpitations associated with severe symptoms

Moderate-Risk Features

• Palpitations lasting >5 minutes
• History of cardiovascular disease
• Age >65 years
• Abnormal physical examination

Low-Risk Features

• Young patient without cardiac history
• Brief, isolated episodes
• Clear triggers (caffeine, stress, exercise)
• Normal physical exam and ECG

Management Approach

For Benign Palpitations

• Lifestyle modifications:
  • Reduce caffeine, alcohol, and nicotine
  • Stress management techniques
  • Regular exercise
  • Adequate sleep

For Supraventricular Tachycardias

• First-line pharmacologic therapy:
  • Beta-blockers (metoprolol, atenolol) for patients with LVEF >40% 1
  • Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) as alternatives
  • Digoxin as second-line option, particularly for nocturnal symptoms

For Patients with Structural Heart Disease

• Beta-blockers are recommended as first-line treatment for patients with LVEF ≤40% 1
• Consider referral to cardiology

For Refractory Cases

• Antiarrhythmic medications (flecainide, propafenone) if beta-blockers and calcium channel blockers are ineffective 2, 3
• Consider catheter ablation for recurrent symptomatic arrhythmias

Indications for Specialist Referral

• Wide complex tachycardia of unknown origin
• Pre-excitation syndromes (WPW)
• Palpitations with syncope or pre-syncope
• Drug-resistant or poorly tolerated narrow complex tachycardias
• Severe symptoms during palpitations
• Structural heart disease with arrhythmias

Common Pitfalls to Avoid

• Attributing all palpitations to anxiety without adequate cardiac evaluation
• Relying solely on short-term monitoring when symptoms are infrequent
• Overlooking medication side effects as potential causes
• Dismissing patient symptoms despite normal initial testing
• Failing to correlate reported symptoms with cardiac rhythm during monitoring

By following this systematic approach, most causes of palpitations can be identified and appropriately managed, reducing morbidity and improving quality of life for patients experiencing this common symptom.