What is the appropriate workup for a patient presenting with palpitations?

Workup for Patients Presenting with Palpitations

The appropriate workup for a patient presenting with palpitations should begin with a 12-lead ECG, detailed history, and 48-hour ambulatory ECG monitoring to identify the likely cause. 1

Initial Evaluation

• 12-lead ECG: Essential first step for all patients with palpitations to identify baseline abnormalities and potential causes 1

• Detailed history: Focus on specific characteristics of palpitations:

  • Onset and termination (sudden or gradual) 1
  • Duration and frequency of episodes 1
  • Associated symptoms (syncope, dyspnea, chest pain) 1
  • Precipitating factors (exertion, position changes, stress) 1
  • Pattern of palpitations (regular, irregular, fast, strong) 1

• Physical examination: Assess for signs of structural heart disease or thyroid dysfunction 1

Diagnostic Testing

First-line Testing:

• 48-hour ambulatory ECG monitoring: Recommended for patients with frequent or sustained palpitations to identify the likely cause 1
• Echocardiography: Should be considered in patients with documented sustained palpitations to exclude structural heart disease 1

Extended Monitoring Based on Frequency:

• For frequent episodes (several per week): 24-48 hour Holter monitoring 1
• For less frequent episodes: Event recorder or wearable loop recorder 1
• For rare episodes (fewer than two per month): Implantable loop recorder (ILR) may be considered 1

Additional Testing Based on Clinical Suspicion

• Exercise testing: Consider when palpitations are triggered by exertion 1
• Extended monitoring (>24 hours): Recommended for patients who develop palpitations or lightheadedness 1
• Laboratory tests: Only indicated if volume depletion or metabolic causes are suspected 1

Special Considerations

• Pre-excitation on resting ECG: If present with history of paroxysmal regular palpitations, presumptive diagnosis of AVRT can be made; referral to electrophysiology is indicated 1
• Patients with structural heart disease: Require more intensive evaluation including echocardiography, prolonged ECG monitoring, and possibly electrophysiological studies 1

Indications for Specialist Referral

• Wide complex tachycardia of unknown origin 1
• Narrow complex tachycardia with drug resistance or intolerance 1
• Wolff-Parkinson-White syndrome (pre-excitation with arrhythmias) 1
• Severe symptoms during palpitations (syncope, dyspnea) 1
• Suspected structural heart disease based on initial evaluation 1

Common Pitfalls to Avoid

• Inadequate monitoring duration: Match monitoring strategy to symptom frequency 1
• Missing pre-excitation: Careful examination of the 12-lead ECG is essential 1
• Relying on automatic ECG interpretation: These systems are unreliable and often suggest incorrect arrhythmia diagnoses 1
• Failure to obtain ECG during symptoms: Patients should be encouraged to have at least one 12-lead ECG during an episode of palpitations 1

Follow-up Recommendations

• Patients with HCM and palpitations should have 12-lead ECG and 24-48 hour ambulatory monitoring every 1-2 years 1
• For patients with frequent palpitations where no cause is identified after prolonged ECG monitoring, an implantable loop recorder may be considered 1