What is the initial management for patients experiencing palpitations?

Initial Management of Palpitations

Begin with a 12-lead ECG immediately upon presentation, as this is the gold standard for diagnosis and may capture the arrhythmia in real-time or identify baseline abnormalities that guide further management. 1, 2

Immediate Clinical Assessment

Symptom Characterization

• Document the specific pattern of palpitations: regular versus irregular, sudden onset/offset (suggesting reentrant tachycardias like AVNRT) versus gradual onset (suggesting sinus tachycardia or non-paroxysmal mechanisms) 1, 3
• Identify frequency and duration of episodes, as this determines the appropriate monitoring strategy 1
• Assess for associated red flag symptoms including syncope, pre-syncope, chest pain, or dyspnea—these require urgent evaluation and immediate cardiology referral 1, 2
• Evaluate hemodynamic stability at presentation, as unstable patients require immediate intervention 1

Precipitating Factors and Triggers

• Screen for stimulant use: caffeine, alcohol, nicotine, recreational drugs, and medications (including over-the-counter sympathomimetics) 1
• Determine timing patterns: nocturnal or postprandial palpitations suggest vagally-mediated arrhythmias, while daytime episodes during activity indicate adrenergically-mediated arrhythmias 1
• Identify exercise-induced palpitations, which are particularly concerning and warrant stress testing 1, 2

Physical Examination Findings

• Look for irregular cannon A waves and irregular variation in S1 intensity, which strongly suggest ventricular origin of a regular tachycardia 4
• Assess for signs of structural heart disease that may not be apparent on ECG alone 4

Diagnostic Testing Algorithm

First-Line Investigations (All Patients)

• 12-lead ECG during initial visit is mandatory—automatic analysis systems are unreliable and should not be trusted for diagnosis 4, 1
• Basic laboratory tests: complete blood count, electrolytes, and thyroid function tests to exclude metabolic causes like hyperthyroidism 1
• Pre-excitation on resting ECG in a patient with paroxysmal regular palpitations is sufficient for presumptive diagnosis of AVRT and warrants immediate referral to electrophysiology without further documentation attempts 4

Ambulatory Monitoring Selection (Based on Symptom Frequency)

• 48-hour ambulatory ECG monitoring for patients with frequent (several episodes per week) or sustained palpitations 1, 2
• Event recorder or wearable loop recorder for less frequent arrhythmias (less than daily but more than monthly) 4, 1
• Implantable loop recorder (ILR) for rare symptoms (fewer than two episodes per month) associated with severe symptoms or hemodynamic instability 4, 1
• 24-hour Holter monitoring has limited utility and should only be used for daily symptoms 4

Second-Line Investigations

• Echocardiography should be performed in all patients with documented sustained SVT to exclude structural heart disease, which cannot be reliably detected by physical examination or ECG alone 4, 1, 2
• Exercise stress testing is indicated specifically when palpitations are clearly triggered by exertion or occur during/immediately after physical activity 4, 1, 2

Conservative Management Before Pharmacotherapy

Lifestyle Modifications (First-Line Treatment)

• Eliminate all stimulants: complete cessation of caffeine consumption, alcohol intake, and cigarette smoking is often sufficient to control symptoms before considering pharmacological therapy 1
• Discontinue oral contraceptives in appropriate patients, as they may exacerbate palpitations 1
• Address physical inactivity: gradual increase in physical activity may reduce symptoms in sedentary patients, as physical inactivity is a predictor of palpitations in men 1

Management of Orthostatic Symptoms

• Liberalize fluid and salt intake as the preferred initial approach for palpitations associated with postural hypotension and tachycardia 1
• Use support stockings to improve venous return and reduce orthostatic symptoms 1

Psychological Factors

• Screen for and address depression, anxiety, and panic disorder, as 45% of patients with panic disorder have mitral valve prolapse, and psychological comorbidities are significant predictors of palpitations 1

Management Based on Specific Diagnosis

Benign Extrasystoles

• If surface ECG is normal and history suggests premature extra beats, eliminate precipitating factors (caffeine, alcohol, nicotine, recreational drugs, hyperthyroidism) 4
• Benign extrasystoles manifest at rest and become less common with exercise—this pattern helps distinguish them from pathological arrhythmias 4

Supraventricular Tachycardia

• Consider vagal maneuvers, beta-blockers, or referral for catheter ablation 1
• Termination with vagal maneuvers suggests AV nodal tissue involvement 3

Atrial Fibrillation

• Implement rate control or rhythm control strategies and assess stroke risk 1, 2
• For vagally-mediated AF, avoid adrenergic blocking drugs or digitalis as they may worsen symptoms 1
• For adrenergically-induced AF, beta-blockers are the initial treatment of choice 1

Ventricular Arrhythmias

• Provide guideline-directed medical therapy; patients with sustained ventricular tachycardia require hospitalization 1, 2
• Very frequent PVCs (>10,000-20,000/day) can lead to PVC-induced cardiomyopathy, which is reversible with control of the PVCs 3

Mandatory Referral Criteria

Immediate Electrophysiology Referral

• All patients with Wolff-Parkinson-White syndrome (pre-excitation combined with arrhythmias) due to potential for lethal arrhythmias 4
• Clinical history of irregular and paroxysmal palpitations with baseline pre-excitation strongly suggests episodes of AF, requiring immediate evaluation due to risk of significant morbidity and sudden death 4
• Palpitations associated with syncope, pre-syncope, or chest pain 1, 2
• Wide complex tachycardia of unknown origin 4

Cardiology Referral Indications

• Severe symptoms such as syncope or dyspnea during palpitations 4, 1
• Narrow complex tachycardias with drug resistance or intolerance 4
• Patients desiring to be free of drug therapy 4
• Evidence of structural heart disease or documented complex arrhythmias 2

Invasive Electrophysiological Study Consideration

• Patients with clear history of paroxysmal regular palpitations may proceed directly to invasive electrophysiological investigation with subsequent catheter ablation for diagnosis and therapy, without extensive non-invasive testing 4
• Recurrent, troublesome palpitations when non-invasive testing is inconclusive 1

Critical Pitfalls to Avoid

• Never use calcium channel blockers (verapamil, diltiazem) to terminate wide-QRS-complex tachycardia of unknown origin, especially in patients with myocardial dysfunction 1
• Do not rely on automatic ECG analysis systems—they are unreliable and commonly suggest incorrect arrhythmia diagnoses 4
• Do not overlook non-cardiac causes such as hyperthyroidism, stimulant use, or anxiety disorders 1
• Do not perform esophageal stimulation if invasive electrophysiological investigation is already planned 4
• Recognize that many patients have no arrhythmias on continuous ambulatory ECG recordings at the time of symptoms, highlighting the importance of proper diagnostic evaluation and not dismissing symptoms based on negative monitoring 1