What is the best management approach for a patient with symptomatic palpitations and dizziness, with normal Holter monitor and echocardiogram results?

Management of Symptomatic Palpitations with Normal Cardiac Testing

For a patient with symptomatic palpitations and dizziness with normal Holter monitoring and echocardiogram results, beta-blockers are the first-line treatment to reduce symptoms and improve quality of life.

Diagnostic Interpretation

The patient presents with:

• Symptomatic palpitations with dizziness
• Normal 7-day Holter monitoring showing:
  • Predominant sinus rhythm (average HR 89 bpm)
  • No atrial fibrillation or flutter
  • Rare PACs/PVCs
  • One brief episode of SVT (3 beats only)
• Normal echocardiogram (LVEF 56%, no valvular abnormalities)
• Normal tilt table test

These findings suggest that while the patient experiences symptoms, there is minimal evidence of significant arrhythmia on monitoring. The brief 3-beat SVT episode is unlikely to explain persistent symptoms.

Management Approach

First-Line Treatment

1. Beta-blockers (e.g., metoprolol)
   • Recommended as first-line therapy for symptomatic palpitations 1
   • Effective for reducing both the physical symptoms and perception of palpitations
   • Target heart rate <100 bpm or <20% above baseline
   • Particularly effective for patients with mild tachyarrhythmias or increased adrenergic symptoms 2

Alternative Pharmacological Options

If beta-blockers are contraindicated or not tolerated:

1. Calcium channel blockers (diltiazem or verapamil)
   • Effective for rate control in patients with SVT 2
   • Consider in patients who cannot tolerate beta-blockers

Non-Pharmacological Management

1. Lifestyle modifications

   • Reduction or elimination of stimulants:
     • Caffeine
     • Alcohol
     • Nicotine/smoking
   • These modifications alone may be sufficient to control symptoms in many cases 2

2. Anxiety management

   • Consider cognitive behavioral therapy if anxiety is contributing to symptom perception 1
   • Anxiety is a common cause of palpitation perception even with normal cardiac rhythm

Monitoring and Follow-up

1. Follow-up evaluation

   • Schedule follow-up in 2 weeks to assess response to treatment 1
   • Adjust medication doses based on symptom response

2. Extended monitoring

   • If symptoms persist despite treatment, consider:
     • Event monitor for intermittent symptoms
     • Implantable loop recorder for very infrequent but concerning symptoms 2

Special Considerations

When to Consider Further Evaluation

Immediate cardiology referral is warranted if the patient develops:

• Syncope or near-syncope with palpitations
• New or worsening symptoms despite therapy
• Signs of structural heart disease
• Sustained arrhythmias on subsequent monitoring 1

Caution with Beta-Blockers

• Monitor for potential side effects:
  • Fatigue
  • Bradycardia
  • Hypotension
  • Bronchospasm (in patients with asthma)

Conclusion

The patient's normal cardiac testing with minimal arrhythmic findings suggests that symptomatic treatment with beta-blockers is the most appropriate management strategy. This approach addresses the symptoms while avoiding unnecessary invasive procedures or more aggressive antiarrhythmic therapy.