Treatment Options for Palpitations
The first-line approach to treating palpitations should be a thorough diagnostic evaluation with 48-hour ambulatory ECG monitoring to identify the underlying cause, followed by targeted therapy based on the specific diagnosis. 1, 2
Diagnostic Approach
- Obtain a detailed history focusing on the nature of palpitations (regular vs. irregular), associated symptoms, and potential triggers 2, 3
- Perform a 12-lead ECG during the initial evaluation to identify baseline abnormalities or capture arrhythmias if present during the visit 2, 3
- For patients with frequent or sustained palpitations, 48-hour ambulatory ECG monitoring is recommended as the first-line diagnostic test 1, 2
- For patients with less frequent episodes, an event recorder or wearable loop recorder should be considered 2, 3
- An implantable loop recorder (ILR) may be considered for patients with recurrent episodes of unexplained palpitations when no cause is identified following prolonged ECG monitoring 1
- Echocardiography should be performed to exclude structural heart disease, especially in patients with sustained palpitations or concerning associated symptoms 2, 3
Treatment Based on Specific Diagnoses
Supraventricular Tachycardia (SVT)
- Vagal maneuvers can be effective for acute termination of SVT episodes 2, 3
- Beta-blockers like metoprolol are first-line pharmacological therapy for prevention of recurrent episodes 3, 4
- Catheter ablation should be considered for patients with recurrent, symptomatic SVT 2, 3
Atrial Fibrillation
- Implement appropriate rate control (beta-blockers, calcium channel blockers) or rhythm control strategies based on symptom severity 2, 3
- For 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, 4
Premature Beats (PACs/PVCs)
- Reassurance is often sufficient for patients with benign premature beats 2, 5
- Avoidance of triggers such as caffeine, alcohol, and stimulants 3, 6
- Beta-blockers may be effective for symptomatic patients 4, 5
Anxiety-Related Palpitations
- Address underlying anxiety with cognitive behavioral therapy and relaxation techniques 7, 6
- Alprazolam may be considered for short-term management of anxiety-related palpitations, particularly when associated with generalized anxiety disorder 7
- Beta-blockers can be effective for both the physical symptoms of anxiety and the palpitations 4, 8
Management Based on Severity
Mild, Infrequent Palpitations
- Lifestyle modifications: reduce caffeine, alcohol, and stimulant intake 3, 6
- Avoid medications that can trigger palpitations (decongestants, stimulants) 2, 6
- Stress management techniques and regular exercise 3, 5
Moderate, Recurrent Palpitations
- Beta-blockers (e.g., metoprolol) for symptom control 3, 4
- Targeted therapy based on specific arrhythmia diagnosis 2, 3
- Consider referral to cardiology if symptoms persist despite initial management 2, 9
Severe or Concerning Palpitations
- Immediate evaluation for patients with palpitations associated with syncope, pre-syncope, or chest pain 2, 3
- Electrophysiology study for patients with recurrent, troublesome palpitations when non-invasive testing is inconclusive 1, 2
- Hospitalization for patients with sustained ventricular tachycardia 3, 9
Common Pitfalls to Avoid
- Don't use calcium channel blockers such as verapamil and diltiazem to terminate wide-QRS-complex tachycardia of unknown origin 3
- Avoid dismissing palpitations as "just anxiety" without appropriate cardiac evaluation 6, 5
- Don't overlook non-cardiac causes of palpitations such as hyperthyroidism, anemia, or medication side effects 3, 6
- Remember that not all patients with arrhythmias experience palpitations, and not all palpitations are due to arrhythmias 6, 5