When are palpitations treated?

When to Treat Palpitations

Palpitations should be treated when they are associated with an underlying arrhythmia, structural heart disease, or when they significantly impact a patient's quality of life, even if benign in origin. 1

Diagnostic Approach

Before determining treatment, proper diagnosis is essential:

1. Initial Evaluation:

   • 12-lead ECG (Class I, Level B-NR) - essential even when patient is asymptomatic 1
   • Blood pressure measurement to identify hypertension 1
   • Cardiac auscultation to detect murmurs or abnormal sounds 1

2. Extended Monitoring:

   • For frequent palpitations: 48-hour ambulatory ECG monitoring 2, 1
   • For infrequent palpitations: Implantable loop recorder (ILR) 2, 1
   • For near-daily symptoms: Extended ambulatory monitoring (>24 hours) 1

3. Additional Testing:

   • Echocardiography to exclude structural heart disease (Class I) 1
   • Exercise testing for exertional palpitations 2

Treatment Indications

1. Arrhythmia-Related Palpitations

• Ventricular Arrhythmias:

  • Treat when associated with syncope, near-syncope, or structural heart disease 2
  • Hospitalize patients with documented ventricular arrhythmias causing syncope (Class I, Level B-NR) 2

• Supraventricular Arrhythmias:

  • Treat when persistent or recurrent (atrial flutter, atrial tachycardia, AVNRT) 2
  • Consider electrophysiological studies for ablatable substrates 2

• Atrial Fibrillation:

  • Treat with rate control, rhythm control, or anticoagulation based on patient factors 1

2. Structural Heart Disease

• Hypertrophic Cardiomyopathy:

  • Treat palpitations with beta-blockers, particularly when associated with left ventricular outflow tract obstruction 2
  • Avoid arterial and venous dilators, including nitrates, which can exacerbate symptoms 2

• Mitral Valve Prolapse:

  • Treat with beta-blockers when palpitations are associated with mild tachyarrhythmias or increased adrenergic symptoms 2

3. Non-Cardiac Causes

• Stimulant-Induced:

  • First-line approach: Cessation of caffeine, alcohol, nicotine, and other stimulants 2, 1
  • Only consider medication if symptoms persist after stimulant elimination 1

• Sleep Apnea:

  • Treat with CPAP (Class I, Level B-NR) when palpitations are associated with sleep-disordered breathing 1
  • Consider weight loss as adjunctive therapy 1

• Anxiety-Related:

  • Treat with beta-blockers when palpitations are associated with anxiety or panic attacks 2

4. Quality of Life Impact

• Treat when palpitations significantly affect daily activities, sleep, or emotional well-being, even if the underlying rhythm is benign 1, 3

Treatment Approaches

1. Pharmacological Management:

   • Beta-blockers (e.g., metoprolol): First-line for tachycardia-related palpitations 1
   • Calcium channel blockers (diltiazem, verapamil): For patients who cannot tolerate beta-blockers 1
   • Anti-arrhythmic medications: Use with caution due to proarrhythmic effects 4

2. Non-Pharmacological Approaches:

   • Lifestyle modifications: Reducing caffeine, alcohol, and smoking 2, 1
   • Management of underlying conditions (hypertension, thyroid disorders) 1

High-Risk Features Requiring Urgent Evaluation

• Palpitations with syncope or near-syncope 1
• Family history of sudden cardiac death 1
• Known structural heart disease 1
• Wide complex tachycardia of unknown origin 1
• Irregular palpitations suggesting atrial fibrillation in high-risk patients 1

Follow-Up

• Reassess in 2 weeks to evaluate treatment response 1
• Adjust medication doses based on symptom improvement 1
• Consider cardiology referral for refractory symptoms 1

Caution

When using anti-arrhythmic medications like flecainide, be aware of potential proarrhythmic effects, especially in patients with structural heart disease or sustained ventricular tachycardia 4. These medications should be initiated in a hospital setting with careful monitoring for patients with serious arrhythmias.