What is the workup for a child reporting palpitations with exercise during a sports physical?

Workup for a Child Reporting Palpitations with Exercise During a Sports Physical

The workup for a child reporting palpitations with exercise should include a comprehensive cardiac evaluation with 12-lead ECG, echocardiography, and exercise testing to rule out potentially life-threatening cardiac conditions.

Initial Evaluation

• Complete history focusing on:

  • Timing of palpitations in relation to exercise (during or after) 1
  • Associated symptoms such as syncope, presyncope, chest pain, or sudden-onset exercise intolerance (high-risk features) 1
  • Family history of collapse, syncope, sudden cardiac death, or cardiomyopathy 1
  • Frequency, duration, and pattern of palpitations 2
  • Presence of palpitations with specific triggers (e.g., emotional stress, caffeine) 1

• Physical examination with emphasis on:

  • Cardiac auscultation for murmurs, gallops, or irregular rhythms 1
  • Blood pressure measurement in recumbent and standing positions 1
  • Assessment for signs of structural heart disease 1

• 12-lead ECG to identify:

  • Abnormal ECG findings requiring further evaluation 1
  • Pre-excitation patterns (WPW syndrome) 1
  • QT interval abnormalities 1
  • Bundle branch blocks 1

Further Diagnostic Testing

• Exercise testing (maximal-effort) to:

  • Assess for arrhythmias during exercise 1
  • Evaluate if palpitations can be reproduced during testing 1
  • Observe for suppression or emergence of PVCs with exercise 1
  • Monitor for symptoms of sudden-onset exercise intolerance 1

• Echocardiography to assess:

  • Cardiac structure and function 1
  • Presence of cardiomyopathy or congenital heart disease 1
  • Wall thickness or ventricular dilation 1

• 24-48 hour Holter monitoring or extended ambulatory rhythm monitoring to:

  • Capture arrhythmias during daily activities and exercise 1, 3
  • Quantify PVC burden (>8000 in 24h is considered high burden) 1
  • Correlate symptoms with rhythm disturbances 2

High-Risk Features Requiring Urgent Evaluation

• Palpitations associated with syncope or presyncope 1
• Palpitations occurring specifically during (not after) exercise 1
• Family history of sudden cardiac death or inherited cardiac conditions 1
• Abnormal ECG findings 1
• Palpitations with chest pain or excessive dyspnea 1
• History suggestive of sustained or frequent rapid palpitations 1

Specific Cardiac Conditions to Consider

• Supraventricular tachycardia (SVT) 1
• Ventricular tachycardia (VT) 1
• Wolff-Parkinson-White (WPW) syndrome 1
• Long QT syndrome (LQTS) 1
• Catecholaminergic polymorphic ventricular tachycardia (CPVT) 1
• Hypertrophic cardiomyopathy 1
• Coronary artery anomalies 1

Referral Considerations

• Immediate cardiology referral is indicated for:

  • Abnormal ECG findings 1, 4
  • Palpitations with syncope or near-syncope 1
  • Palpitations specifically during exercise (not post-exercise) 1
  • Concerning family history 1, 4
  • Abnormal cardiac examination 4

• Electrophysiology study consideration for:

  • Recurrent, symptomatic palpitations despite initial evaluation 1
  • Suspected accessory pathway conduction 1
  • Complex PVCs in endurance athletes 1

Management Approach

• Temporary cessation of competitive sports participation during evaluation if high-risk features are present 1
• Shared decision-making with athlete and family after risk assessment 1
• For benign causes (e.g., sinus tachycardia), reassurance and education 2
• For identified arrhythmias, specific treatment based on the underlying condition 1
• For channelopathies, assessment by a pediatric or adult cardiologist with expertise in cardiac channelopathies 1

Important Pitfalls to Avoid

• Dismissing palpitations with exercise as benign without proper evaluation 1
• Failing to recognize that palpitations during (not after) exercise may indicate serious cardiac conditions 1
• Missing the association between syncope and exercise, which is an ominous sign 1
• Overlooking the importance of family history in pediatric cardiac evaluation 1
• Inadequate monitoring duration that fails to capture intermittent arrhythmias 2