Treatment of GERD-Related Palpitations
For GERD-related palpitations, the first-line treatment is a proton pump inhibitor (PPI) such as omeprazole or lansoprazole taken 30-60 minutes before breakfast for 4-8 weeks, with adjunctive therapy personalized to the specific GERD phenotype. 1, 2
Pharmacological Management
First-Line Therapy
- Proton Pump Inhibitors (PPIs):
Assessment and Dose Adjustment
- Evaluate response after 4-8 weeks 1
- If symptoms persist:
- Assess compliance
- Consider increasing to twice-daily PPI dosing 1
- Or switch to a more effective acid suppressive agent
Adjunctive Medications
Based on GERD phenotype and specific symptoms 1:
- For breakthrough symptoms: Alginate antacids
- For nocturnal symptoms: H2-receptor antagonists (e.g., ranitidine) 5
- For regurgitation or belch-predominant symptoms: Baclofen
- For coexistent gastroparesis: Prokinetics
Diagnostic Confirmation for Persistent Symptoms
If palpitations and other GERD symptoms persist despite PPI therapy:
- Endoscopy to evaluate for erosive esophagitis, hiatal hernia, and Barrett's esophagus 1
- pH monitoring (preferably 96-hour wireless monitoring off medication) if endoscopy is negative for erosive disease 1
- pH-impedance monitoring on PPI to determine the mechanism of persisting symptoms 1
Lifestyle Modifications
Dietary adjustments 6:
- Avoid trigger foods: fatty/fried foods, spicy foods, citrus juices, tomatoes, chocolate, coffee/tea, carbonated beverages
- Avoid eating within 2-3 hours of bedtime
- Smaller, more frequent meals
Other lifestyle changes 2:
- Weight loss for overweight/obese patients
- Elevation of the head of the bed
- Smoking cessation
- Moderate alcohol consumption
Advanced Interventions for Refractory Cases
For patients with proven GERD and persistent symptoms despite optimized medical therapy:
- Surgical options 1, 2:
- Laparoscopic fundoplication
- Magnetic sphincter augmentation
- Endoscopic option 1:
- Transoral incisionless fundoplication in carefully selected patients
- For obese patients 1:
- Roux-en-Y gastric bypass (effective anti-reflux intervention)
Management of Psychological Factors
- Consider pharmacologic neuromodulation and/or referral for behavioral therapy for patients with:
- Functional heartburn
- Esophageal hypervigilance
- Reflux hypersensitivity
- Associated behavioral disorders 1
Monitoring and Follow-up
- If PPI therapy is continued beyond 12 months, evaluate the appropriateness and dosing 1
- Consider reflux testing to determine requirement for lifelong therapy
- Attempt to wean to lowest effective dose or convert to on-demand therapy when possible 1
Pitfalls and Caveats
- Palpitations may be cardiac in origin; ensure cardiac causes have been ruled out before attributing to GERD
- Long-term PPI use requires periodic reassessment for appropriate use and potential adverse effects 2
- Sleeve gastrectomy has potential to worsen GERD and should be avoided in these patients 1
- Ensure proper timing of PPI administration (30-60 minutes before meals) for maximum efficacy 2