What is the medical plan for a patient presenting with palpitations?

Medical Plan for Patient with Palpitations

For patients presenting with palpitations, a systematic diagnostic approach is recommended, starting with a 48-hour ambulatory ECG monitoring to identify the likely cause of the arrhythmia, followed by appropriate treatment based on the specific underlying mechanism.

Initial Evaluation

• Obtain a detailed history focusing on the nature of palpitations (regular vs. irregular, onset/offset pattern, duration), associated symptoms (syncope, chest pain, dyspnea), and potential triggers (exercise, stress, caffeine, medications) 1
• Perform a 12-lead ECG during the initial evaluation to identify any baseline abnormalities or capture the arrhythmia if present during the visit 1
• Assess for signs of hemodynamic instability (hypotension, altered mental status) which would require immediate intervention 1
• Document any symptoms that may suggest serious underlying conditions: syncope, near-syncope, dyspnea, or chest pain occurring with palpitations 1

Diagnostic Testing

• For patients with frequent or sustained palpitations, 48-hour ambulatory ECG monitoring is recommended as the first-line diagnostic test 1
• For patients with less frequent episodes (less than daily), consider:
  • Event recorder or wearable loop recorder for palpitations occurring weekly 1
  • Implantable loop recorder (ILR) for very infrequent but concerning episodes 1
• Echocardiography should be performed to exclude structural heart disease, especially in patients with sustained palpitations or concerning associated symptoms 1
• Exercise testing should be considered for patients with exertional palpitations 1

Management Based on Diagnosis

Supraventricular Tachycardia (SVT)

• For patients with documented SVT, guideline-directed medical therapy (GDMT) is recommended 1
• Initial treatment options include:
  • Teaching patients to perform vagal maneuvers for acute termination 1
  • Beta-blockers may be prescribed empirically provided significant bradycardia (<50 bpm) has been excluded 1
  • For patients with drug resistance or intolerance, referral to an electrophysiologist for catheter ablation should be considered 1

Atrial Fibrillation (AF)

• Patients with AF require appropriate management with either rate control or rhythm control strategies 1
• Assess stroke risk and initiate anticoagulation if indicated 1

Ventricular Arrhythmias

• All patients with ventricular arrhythmias causing palpitations should receive guideline-directed medical therapy 1
• Patients with sustained ventricular tachycardia require hospitalization for initiation of antiarrhythmic therapy 2
• For patients with ventricular rates ≥200 bpm, recognize the high risk of syncope (65%) 1

Sinus Tachycardia

• Identify and treat underlying causes (fever, anemia, hypotension, hyperthyroidism, etc.) 1
• Avoid treating compensatory tachycardias when cardiac function is poor, as cardiac output may be dependent on the rapid heart rate 1

Special Considerations

• Patients with palpitations and syncope require more urgent evaluation, including 12-lead ECG, exercise testing, and 48-hour ambulatory ECG monitoring 1
• Patients with Wolff-Parkinson-White syndrome (pre-excitation on ECG) with palpitations should be referred for electrophysiology evaluation regardless of symptom frequency 1
• Antiarrhythmic medications (Class I or III) should not be initiated without documentation of the arrhythmia 1
• For patients with palpitations associated with severe symptoms (syncope, dyspnea), prompt referral to an arrhythmia specialist is indicated 1

Follow-up Recommendations

• Patients with benign causes of palpitations (e.g., premature beats) should be counseled to eliminate precipitating factors such as caffeine, alcohol, nicotine, and recreational drugs 1
• For patients on antiarrhythmic medications, appropriate monitoring should be implemented based on the specific medication (e.g., flecainide requires monitoring of plasma levels in certain populations) 2
• Patients with recurrent, unexplained palpitations despite initial evaluation may require electrophysiological studies, particularly if symptoms are associated with hemodynamic compromise 1

Indications for Referral to Cardiology/Electrophysiology

• Palpitations with syncope or pre-syncope 1
• Evidence of structural heart disease 1
• Documented complex arrhythmias (sustained ventricular tachycardia, atrial fibrillation with rapid ventricular response) 1
• Patients with drug-resistant symptoms or those who desire to be free of drug therapy 1
• Patients with pre-excitation (WPW) pattern on ECG 1