Management of Stable, Unchanged Palpitations
Stable, unchanged palpitations do not require a thorough workup if there are no concerning features. 1
Initial Assessment
- Determine if the palpitations are causing hemodynamic instability (altered mental status, chest discomfort, heart failure, hypotension, or shock) - if present, immediate intervention is required 2
- For stable patients with palpitations, assess if the palpitations are unchanged from previous episodes and if they have been previously evaluated 1
- Compare current ECG with previous ECGs - patients with an unchanged ECG have a reduced risk of myocardial infarction and very low risk of in-hospital life-threatening complications 1
When Further Workup IS NOT Required
- Palpitations that are stable, unchanged from previous episodes, and previously evaluated 1
- Palpitations with normal physical examination and normal 12-lead ECG that match previously documented episodes 1, 3
- Palpitations associated with known triggers such as caffeine, stress, or exercise without other concerning features 4
- Palpitations documented to be due to extracardiac causes (e.g., hyperthyroidism) that are being appropriately managed 1
When Further Workup IS Required
- New-onset palpitations or change in pattern/frequency of palpitations 1, 3
- Palpitations associated with syncope, presyncope, or chest pain 1, 2
- Palpitations in patients with structural heart disease or family history of sudden cardiac death 1
- Palpitations preceding a syncopal episode 1
- Palpitations with abnormal ECG findings 1
- Palpitations occurring during exertion 1
Appropriate Workup When Indicated
- 12-lead ECG to define the rhythm if not already obtained 2
- 48-hour ambulatory ECG monitoring for patients with frequent or sustained palpitations to identify the cause 1, 3
- Exercise testing for patients with exertional palpitations 1
- Echocardiography if structural heart disease is suspected 1, 3
- Implantable loop recorder may be considered for patients with recurrent unexplained palpitations who are at low risk of sudden cardiac death 1
Common Pitfalls to Avoid
- Overinvestigating benign palpitations that are stable and unchanged, leading to unnecessary anxiety and healthcare costs 3, 5
- Failing to recognize warning signs that require further evaluation (syncope, chest pain, exertional symptoms) 1, 2
- Using AV nodal blocking agents in pre-excited atrial fibrillation/flutter which can accelerate ventricular response 2
- Normalizing heart rate in compensatory tachycardias where cardiac output depends on rapid rate 2
Conclusion
Most palpitations are benign, particularly when stable and unchanged from previous episodes 3, 5. The decision to pursue further workup should be based on the presence of concerning features rather than the mere presence of palpitations 1. Patients with stable, unchanged palpitations without concerning features can be reassured without extensive testing 1, 3.