What is the initial management for a patient complaining of palpitations?

Initial Management of Palpitations

The initial management for a patient complaining of palpitations should include a 12-lead ECG, detailed symptom characterization, and 48-hour ambulatory ECG monitoring for patients with frequent or sustained palpitations. 1, 2

Initial Assessment

• Obtain a detailed symptom characterization including frequency, duration, onset/offset patterns, and associated symptoms such as dizziness, chest pain, or syncope 1, 2
• Assess for precipitating factors such as caffeine, alcohol, exercise, stress, or medications 2
• Evaluate for signs of hemodynamic instability which would require immediate intervention 1
• Note the timing of symptoms - nocturnal or postprandial palpitations may suggest vagally-mediated arrhythmias, while daytime episodes during activity may indicate adrenergically-mediated arrhythmias 2

Diagnostic Testing

First-Line Investigations

• Perform a 12-lead ECG during the initial evaluation to identify baseline abnormalities or capture arrhythmias if present during the visit 1, 2
• Conduct 48-hour ambulatory ECG monitoring for patients with frequent or sustained palpitations 3, 1
• Order basic laboratory tests including complete blood count, electrolytes, and thyroid function tests to rule out metabolic causes 2

Second-Line Investigations

• Consider an event recorder or wearable loop recorder for patients with less frequent episodes 1
• Perform echocardiography to exclude structural heart disease, especially in patients with sustained palpitations or concerning associated symptoms 1, 2
• Consider an implantable loop recorder (ILR) for patients with recurrent episodes of unexplained palpitations who are at low risk of sudden cardiac death 3
• Exercise ECG testing is particularly useful if palpitations are exercise-induced 2

Risk Stratification

• Palpitations associated with syncope, pre-syncope, or chest pain require more urgent evaluation 1, 2
• Classify patients based on hemodynamic stability: asymptomatic, minimal symptoms, presyncope, or syncope 3
• Patients with palpitations and syncope require more urgent evaluation including 12-lead ECG, exercise testing, and 48-hour ambulatory ECG monitoring 1

Management Based on Diagnosis

• For supraventricular tachycardia (SVT), consider vagal maneuvers, beta-blockers, or referral for catheter ablation 1
• For atrial fibrillation, implement appropriate rate control or rhythm control strategies and assess stroke risk 1
• For ventricular arrhythmias, provide guideline-directed medical therapy; patients with sustained ventricular tachycardia require hospitalization 1
• For patients with vagally-mediated AF, avoid adrenergic blocking drugs or digitalis as they may worsen symptoms 3
• For adrenergically-induced AF, beta-blockers are the initial treatment of choice 3

Indications for Specialist Referral

• Refer to cardiology/electrophysiology for patients with palpitations associated with severe symptoms such as syncope or dyspnea 1
• Consider electrophysiology study for patients with recurrent, troublesome palpitations when non-invasive testing is inconclusive 2
• Immediate cardiology referral is necessary if palpitations are associated with syncope, pre-syncope, or chest pain 2

Common Pitfalls to Avoid

• Do not assume all palpitations are benign; up to 16% of patients may have no identifiable cause 4
• Avoid using calcium channel blockers such as verapamil and diltiazem to terminate wide-QRS-complex tachycardia of unknown origin, especially in patients with myocardial dysfunction 3
• Don't overlook the possibility of non-cardiac causes of palpitations such as hyperthyroidism, stimulant use, or anxiety 5, 4
• Remember that many patients with arrhythmias do not complain of palpitations but may present with other manifestations such as syncope or chest pain 6