From the Guidelines
The primary care workup for palpitations should begin with a thorough history and physical examination to identify potential causes and risk factors, followed by a 12-lead ECG and basic laboratory tests, as recommended by the most recent guidelines 1. The initial evaluation should include:
- A thorough history to identify potential causes and risk factors, such as timing, duration, and associated symptoms of palpitations, as well as triggers like caffeine, alcohol, or stress 1
- A physical examination to identify signs of structural heart disease, such as irregular pulse, irregular jugular venous pulsations, and variation in the intensity of the first heart sound or absence of a fourth sound heard previously during sinus rhythm 1
- Vital signs, including blood pressure and heart rate, and a cardiovascular examination
- Initial testing should include a 12-lead ECG to identify arrhythmias, structural abnormalities, or conduction disorders
- Basic laboratory tests are recommended, including complete blood count, electrolytes (particularly potassium, magnesium, and calcium), thyroid function tests, and possibly cardiac biomarkers if cardiac injury is suspected For intermittent palpitations, ambulatory cardiac monitoring is valuable, with options including:
- 24-48 hour Holter monitoring for frequent symptoms
- Event monitors for less frequent episodes (worn for 2-4 weeks)
- Implantable loop recorders for very infrequent episodes 1 Additional testing may include:
- Echocardiography if structural heart disease is suspected, as recommended by the European Heart Journal 1
- Exercise stress testing if symptoms are exercise-related
- Possibly referral for electrophysiology studies in complex cases Red flags warranting urgent referral include:
- Syncope
- Chest pain
- Dyspnea
- Family history of sudden cardiac death
- Abnormal ECG findings Management depends on the underlying cause, ranging from lifestyle modifications (reducing caffeine, alcohol, and stress) to medication (beta-blockers like metoprolol 25-100mg twice daily) or referral to cardiology for more complex arrhythmias.
From the Research
Initial Evaluation
- A detailed history, physical examination, and electrocardiogram (ECG) are essential in the initial evaluation of patients presenting with palpitations in a primary care setting 2.
- The patient's history, physical examination, and noninvasive testing can, in most cases, distinguish benign from pathologic causes of palpitations 3.
- A 12-lead electrocardiogram is a crucial part of the initial evaluation, which can yield a probable diagnosis and provide prognostic stratification of the patients 4.
Diagnostic Testing
- Limited laboratory testing may be indicated in some cases, and ambulatory ECG monitoring can be useful in diagnosing the cause of palpitations 2.
- Various outpatient options are available for the evaluation of palpitations, including Holter monitor, event monitor, transtelephonic electrocardiographic monitor, treadmill exercise stress test, echocardiography, and electrophysiologic studies 5.
- Extended electrocardiogram monitoring tools, such as 24-hour Holter monitoring, 30-day external continuous monitoring, and implantable loop recorders, can be used to document arrhythmias in patients with infrequent symptoms 6.
Special Considerations
- Most patients with palpitations can be evaluated as outpatients, but some may require admission to an inpatient setting if they are hemodynamically compromised or have a high probability of an arrhythmic origin 5, 4.
- The choice of diagnostic tests and the need for cardiology referral depend on the patient's symptoms, medical history, and the results of the initial evaluation 2, 4.