What is the first-line drug for treating palpitations?

First-Line Drug for Palpitations

Beta-blockers are the first-line drug treatment for palpitations, particularly when associated with supraventricular tachycardias or atrial fibrillation. 1, 2

Treatment Algorithm Based on Underlying Cause

For Supraventricular Tachycardia (SVT)

• For acute termination of SVT episodes:

  • Vagal maneuvers should be attempted first 3
  • Adenosine is the first-line drug for acute termination when vagal maneuvers fail (6mg IV rapid bolus, followed by up to two 12mg doses if needed) 3
  • Beta-blockers (IV metoprolol or propranolol) are reasonable when adenosine is ineffective or contraindicated 3
  • Verapamil may be considered when adenosine and beta-blockers are ineffective or contraindicated 3

• For chronic prevention of recurrent SVT:

  • Beta-blockers are considered first-line therapy for prevention of recurrent episodes 3, 1
  • Newer guidelines have downgraded recommendations for verapamil/diltiazem in chronic AVNRT management 3

For Atrial Fibrillation (AF)

• Beta-blockers are first-line agents for rate control and maintenance of sinus rhythm, especially in patients with:

  • History of myocardial infarction 3
  • Heart failure 3
  • Hypertension 3
  • Adrenergically-mediated AF 3

• For patients with AF and structural heart disease:

  • Beta-blockers remain first-line therapy 3
  • Amiodarone or dofetilide may be considered in patients with heart failure when beta-blockers are ineffective 3

For Palpitations Without Structural Heart Disease

• In patients with lone AF or paroxysmal AF without structural heart disease:
  • Beta-blockers are first-line therapy 3, 1
  • Flecainide, propafenone, or sotalol may be considered as alternatives 3, 4
  • For vagally-mediated AF, anticholinergic agents like disopyramide may be preferred 3

Special Populations

Pregnant Patients

• Beta-blockers (particularly beta-1-selective agents) are considered first-line for arrhythmias in pregnancy due to extensive safety data 3
• Adenosine is recommended for acute treatment of SVT in pregnant patients 3
• Many antiarrhythmic drugs have been downgraded or are no longer recommended during pregnancy, including propranolol, procainamide, quinidine, and sotalol 3

Monitoring and Precautions

• When using beta-blockers for palpitations:

  • Monitor heart rate and blood pressure 2
  • Be aware that beta-blockers may be ineffective in some patients with premature ventricular contractions (PVCs), with "good" response seen in only 11-16% of patients 5
  • Patients with higher baseline heart rates may have better response to beta-blockers 5

• For class IC agents (flecainide, propafenone):

  • Avoid in patients with structural heart disease 4
  • QRS widening should not exceed 50% of the pretreatment QRS duration 3
  • Propafenone is contraindicated for controlling ventricular rate during AF 4

Common Pitfalls

• Failure to identify the underlying cause of palpitations before initiating therapy 6, 7
• Using class IC agents (flecainide, propafenone) in patients with coronary artery disease or structural heart disease 3, 4
• Not recognizing that palpitations may be due to non-cardiac causes (hyperthyroidism, anxiety, stimulant use) 6
• Treating palpitations without documenting the underlying rhythm through appropriate monitoring 6