What medications are used to treat palpitations?

Medications for Palpitations

Beta-blockers, calcium channel blockers (diltiazem, verapamil), and digoxin are the first-line medications for treating palpitations, with the specific choice depending on the underlying cause and patient characteristics. 1

First-Line Medications Based on Underlying Condition

For Atrial Fibrillation/Flutter

• Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs in patients with preserved left ventricular ejection fraction (LVEF >40%) 1
• Beta-blockers and/or digoxin are recommended in patients with reduced ejection fraction (LVEF ≤40%) 1
• For lenient rate control (resting heart rate <110 beats per minute), these medications are typically sufficient 1

For Supraventricular Tachycardia (SVT)

• Adenosine is the drug of choice for acute termination of regular narrow-complex tachycardias in a monitored setting 1
• Verapamil (5-10 mg IV over 60 seconds) can be used for definite SVT but is contraindicated if beta-blockers have been taken due to risk of profound bradycardia 1
• Beta-blockers are particularly effective for adrenergically mediated SVT 1

For Ventricular Arrhythmias

• Beta-blockers are first-line therapy for symptomatic ventricular premature contractions (PVCs) 1
• Nondihydropyridine calcium channel blockers may relieve symptoms of palpitations from PVCs 1

Second-Line Medications

For Atrial Fibrillation/Flutter

• Amiodarone may be considered for patients with AF who have hemodynamic instability or severely depressed LVEF to achieve acute control of heart rate 1
• Combination rate control therapy should be considered if a single drug fails to control symptoms or heart rate 1

For Paroxysmal Atrial Fibrillation

• Flecainide, propafenone, and sotalol are recommended as initial antiarrhythmic therapy for patients with minimal heart disease 1
• The "pill-in-the-pocket" approach using propafenone may be feasible for selected patients with infrequent episodes 1
• Amiodarone, dofetilide, disopyramide, procainamide, and quinidine are considered second or third-line choices due to greater potential for adverse reactions 1

For Specific Patient Populations

• For patients with heart failure: amiodarone or dofetilide are preferred for rhythm control 1
• For patients with coronary artery disease: sotalol is considered first-line, with amiodarone and dofetilide as secondary agents 1
• For patients with hypertension without LV hypertrophy: flecainide and propafenone are recommended first 1
• For patients with LV hypertrophy: amiodarone is suggested as first-line therapy due to relative safety 1

Important Considerations and Precautions

• Propafenone carries a risk of proarrhythmic effects (4.7% of patients may have new or worsened ventricular arrhythmia) 2
• Class IC antiarrhythmics (like propafenone) should be avoided in patients with structural heart disease due to increased mortality risk 2
• Amiodarone can be associated with bradycardia requiring permanent pacemaker implantation, more commonly in women 1
• When starting antiarrhythmic drugs, ECG monitoring is essential to assess PR interval, QRS duration, and QT interval depending on the medication 1
• Concomitant drug therapies should be monitored closely, particularly digoxin and warfarin doses which typically need reduction when starting amiodarone 1

Treatment Algorithm

1. Identify the underlying cause of palpitations (atrial fibrillation, SVT, PVCs, etc.)
2. Assess cardiac function (preserved vs. reduced ejection fraction)
3. Select appropriate medication:
   • For AF with preserved EF: Beta-blockers, diltiazem, verapamil, or digoxin 1
   • For AF with reduced EF: Beta-blockers and/or digoxin 1
   • For SVT: Beta-blockers or calcium channel blockers 1
   • For PVCs: Beta-blockers 1
4. Monitor response and adjust therapy as needed, considering combination therapy if single agents fail 1
5. Consider second-line agents if first-line medications are ineffective or contraindicated 1

Common Pitfalls to Avoid

• Using AV nodal blocking agents (adenosine, calcium blockers, beta-blockers, digoxin) in pre-excited atrial fibrillation, which may accelerate ventricular response 1
• Combining AV nodal blocking agents with longer duration of action, which can lead to profound bradycardia 1
• Starting antiarrhythmic drugs without appropriate ECG monitoring 1
• Using propafenone in patients with vagally mediated AF due to its weak beta-blocking activity which may aggravate the condition 1
• Failing to reduce doses of digoxin and warfarin when initiating amiodarone therapy 1