What are the treatment options for heart palpitations?

Treatment Options for Heart Palpitations

Beta blockers are the first-line treatment for symptomatic palpitations, particularly when associated with mild tachyarrhythmias or increased adrenergic symptoms. 1

Initial Evaluation

• Determine if palpitations are associated with hemodynamic compromise (hypotension, dizziness, syncope) which may require urgent treatment 1, 2
• Identify potential triggers: caffeine, alcohol, cigarettes, stimulant medications, and electrolyte abnormalities 1
• Obtain 12-lead ECG during symptoms when possible to identify underlying rhythm 2, 3
• Consider ambulatory ECG monitoring (Holter monitor for daily symptoms, event recorder for less frequent episodes) to correlate symptoms with cardiac rhythm 1, 3

Treatment Based on Underlying Cause

For Benign Palpitations or Mild Arrhythmias:

• Eliminate triggers: discontinue caffeine, alcohol, and cigarettes 1
• Beta blockers (e.g., metoprolol, atenolol) are effective for symptomatic palpitations, especially with evidence of increased adrenergic tone 1
  • In a randomized controlled trial, atenolol significantly decreased symptom frequency and premature ventricular contraction count compared to placebo 1
• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) are effective alternatives for patients who cannot tolerate beta blockers 1
  • Only use in patients with preserved left ventricular function (LVEF >40%) 1

For Supraventricular Tachycardias:

• Adenosine (3-12 mg IV) is the drug of choice for terminating AV nodal re-entrant tachyarrhythmias 1
  • Contraindicated in asthmatic patients due to risk of bronchospasm 1
• Verapamil (5-10 mg IV over 60 seconds) can be effective for definite SVT 1
  • Contraindicated if beta blockers have been taken due to risk of profound bradycardia 1
  • Avoid in patients with Wolff-Parkinson-White syndrome 1

For Atrial Fibrillation with Rapid Ventricular Response:

• If hemodynamically unstable: IV amiodarone (150 mg IV over 10 minutes) is recommended due to better hemodynamic profile 4
• For rate control in stable patients: beta blockers, non-dihydropyridine calcium channel blockers, or digoxin 1
• For rhythm control: consider antiarrhythmic drugs or cardioversion after appropriate anticoagulation 1

For Ventricular Arrhythmias:

• Beta blockers are first-line therapy for symptomatic PVCs in structurally normal hearts 1
• If beta blockers are ineffective, Class I antiarrhythmic medications (e.g., propafenone) can be considered 1, 5
  • In clinical trials, propafenone significantly reduced the rate of paroxysmal arrhythmias compared to placebo 5
• For sustained ventricular tachycardia with hemodynamic compromise: immediate defibrillation 1

Special Considerations

• For orthostatic symptoms with palpitations: volume expansion through liberal fluid and salt intake; support stockings may be beneficial 1
• For patients with mitral valve prolapse and palpitations: beta blockers are often effective 1
• For palpitations associated with panic attacks or anxiety: consider beta blockers and address underlying psychological factors 1, 3

When to Refer to Cardiology

• Palpitations with syncope, pre-syncope, or severe symptoms 2, 3
• Evidence of structural heart disease on initial evaluation 3
• Sustained ventricular arrhythmias 1
• Failed response to initial therapy 3, 6
• Consideration for electrophysiologic testing or catheter ablation for recurrent symptomatic arrhythmias 1

Monitoring and Follow-up

• Reassess symptoms and response to therapy at regular intervals 3
• Consider wearable ECG monitoring devices for patients with infrequent but concerning symptoms 6
• For patients with frequent PVCs, periodic reassessment of ventricular function may be warranted 1

Remember that while most palpitations are benign, identifying and treating the underlying cause is essential for symptom relief and preventing potential complications 2, 6.