What medication can be used to treat palpitations without causing hypotension?

Beta-Blockers are the First-Line Treatment for Palpitations Without Causing Hypotension

Beta-blockers are the most appropriate medication for treating palpitations without causing hypotension, particularly metoprolol, atenolol, or propranolol. 1

Mechanism and Efficacy

• Beta-blockers effectively control heart rate and reduce palpitations by antagonizing the effects of increased sympathetic tone, making them ideal first-line agents for symptomatic palpitations 1
• They can significantly reduce premature ventricular beats by up to 60%, with even greater reductions in couplets (84%) and ventricular tachycardia (94%), addressing the underlying causes of many palpitations 2
• Beta-blockers are particularly effective for palpitations associated with mild tachyarrhythmias or increased adrenergic symptoms 1

Advantages for Blood Pressure Management

• Unlike calcium channel blockers (diltiazem, verapamil) which can cause significant hypotension, beta-blockers can be titrated to control heart rate with minimal impact on blood pressure in normotensive patients 1
• For patients with palpitations who also have hypertension, beta-blockers provide dual benefit of treating both conditions simultaneously 1
• Selective beta-1 blockers (metoprolol, atenolol) may have less impact on peripheral vascular resistance than non-selective agents, making them particularly suitable when hypotension is a concern 1

Patient Selection

• Beta-blockers are especially effective for:
  • Patients with palpitations associated with anxiety or increased adrenergic tone 1
  • Those with exercise-induced palpitations 2
  • Patients with supraventricular arrhythmias causing symptomatic palpitations 1
  • Individuals with a hyperkinetic heart syndrome 1

Dosing Considerations

• Start with low doses and titrate gradually to minimize side effects:
  • Metoprolol: Start with 25mg twice daily, titrate up to 50-100mg twice daily 1
  • Atenolol: Start with 25mg daily, titrate up to 50-100mg daily 1
  • Propranolol: Start with 10-20mg three times daily, titrate as needed 1

Alternative Options

• If beta-blockers are contraindicated or ineffective, consider:
  • Flecainide or propafenone for patients with no structural heart disease 1, 3, 4
  • Low-dose amiodarone for refractory cases, though this carries more side effects 1

Precautions and Contraindications

• Avoid beta-blockers in patients with:
  • Severe bradycardia or high-degree AV block 1
  • Decompensated heart failure (though they may be beneficial in stable heart failure) 1
  • Severe reactive airway disease 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with:
  • Heart failure with reduced ejection fraction 5
  • Hypotension or cardiogenic shock 1
  • WPW syndrome with atrial fibrillation 1

Diagnostic Workup Before Treatment

• For patients with recurrent palpitations, continuous or event-activated ambulatory ECG recordings should be performed to identify the underlying rhythm disturbance 1
• Evaluate for structural heart disease with echocardiography before starting antiarrhythmic therapy 1
• Assess for potential triggers such as caffeine, alcohol, and cigarettes, as cessation may be sufficient to control symptoms in some cases 1

Treatment Algorithm

1. First-line: Beta-blockers (metoprolol, atenolol, or propranolol) 1
2. Second-line (if no structural heart disease): Flecainide or propafenone 1
3. Third-line: Amiodarone for refractory cases 1
4. Consider non-pharmacological approaches (e.g., catheter ablation) for drug-refractory cases 1

Remember that lifestyle modifications (reducing caffeine, alcohol, and cigarettes) should be implemented alongside pharmacological treatment for optimal results 1.