What is the management approach for palpitations?

Management Approach for Palpitations

For patients with palpitations, a systematic diagnostic approach starting with 48-hour ambulatory ECG monitoring for frequent palpitations or implantable loop recorder for infrequent episodes is recommended, followed by targeted treatment based on the identified cause. 1

Diagnostic Evaluation

Initial Assessment

• 12-lead ECG: Essential first-line test (Class I) to identify baseline cardiac abnormalities and pre-excitation patterns 1
• Detailed symptom characterization:
  • Frequency, duration, and triggers of episodes
  • Associated symptoms (syncope, chest pain, dyspnea)
  • Regular vs. irregular palpitations (irregular may suggest premature beats, atrial fibrillation) 2
  • Sudden onset/termination suggests paroxysmal supraventricular tachycardia (PSVT) 2

Monitoring Options

• For frequent palpitations: 48-hour ambulatory ECG monitoring (Class I recommendation) 2, 1
• For infrequent episodes: Implantable loop recorder (ILR) (Class IIa recommendation) 2, 1
• For exertional palpitations: Exercise testing 1

Additional Testing

• Echocardiography: Recommended to exclude structural heart disease, particularly in sustained arrhythmias 1
• Electrophysiological studies (EPS): Not routinely recommended but indicated for persistent/recurrent supraventricular tachycardia or when non-invasive tests suggest sino-atrial disease or AV block 2

Treatment Approach

General Principles

1. Identify and treat underlying cause
2. Eliminate triggers when possible
3. Provide symptom relief
4. Prevent complications

Specific Treatments Based on Diagnosis

Supraventricular Tachycardias (SVT)

• First-line: Beta-blockers (e.g., metoprolol) with target heart rate <100 bpm 1
• Alternative: Calcium channel blockers (diltiazem, verapamil) for patients who cannot tolerate beta-blockers 1
• For paroxysmal SVT: Flecainide starting at 50 mg every 12 hours, may increase in 50 mg increments every 4 days to maximum 300 mg/day 3
  • Caution: Monitor plasma levels in patients with renal impairment, hepatic disease, or concurrent amiodarone therapy 3

Ventricular Arrhythmias

• Treatment indicated when associated with syncope, near-syncope, or structural heart disease 1
• For sustained ventricular tachycardia: Flecainide starting at 100 mg every 12 hours, initiated in-hospital with rhythm monitoring 3

Special Populations

• Hypertrophic cardiomyopathy: Beta-blockers recommended; avoid arterial and venous dilators including nitrates 1
• Mitral valve prolapse: Beta-blockers for mild tachyarrhythmias 1
• Anxiety-related palpitations: Beta-blockers may be beneficial 1

Lifestyle Modifications

• Reduce or eliminate caffeine, alcohol, and nicotine 1
• Smoking cessation strongly recommended 1
• For sleep-related palpitations: Evaluate for sleep apnea and consider CPAP if diagnosed 1

Follow-up and Referral

Follow-up

• Reassess in 2 weeks to evaluate treatment response and adjust medications as needed 1

Indications for Specialist Referral

• Wide complex tachycardia of unknown origin
• Narrow complex tachycardias with drug resistance/intolerance
• Wolff-Parkinson-White syndrome
• Severe symptoms during palpitations
• Irregular palpitations suggesting atrial fibrillation in high-risk patients
• Syncope or near-syncope with palpitations
• Family history of sudden cardiac death
• Known structural heart disease 1

Common Pitfalls to Avoid

• Dismissing palpitations without adequate evaluation
• Failing to correlate symptoms with cardiac rhythm through appropriate monitoring
• Overlooking non-cardiac causes (thyroid disease, anemia, anxiety)
• Initiating antiarrhythmic therapy without confirming diagnosis
• Using flecainide in patients with structural heart disease or heart failure 3
• Inadequate follow-up after initiating treatment