What are the treatment options for palpitations and dizziness?

Treatment of Palpitations and Dizziness

For patients presenting with palpitations and dizziness, immediate assessment of hemodynamic stability is critical, followed by a 12-lead ECG to identify the underlying rhythm disturbance, with treatment directed at the specific arrhythmia identified. 1

Immediate Assessment and Risk Stratification

Evaluate hemodynamic stability first - patients with palpitations and dizziness accompanied by hypotension, chest pain, or syncope require immediate intervention and are at higher risk for serious cardiac causes. 1, 2

Key features requiring urgent evaluation include:

• Syncope or pre-syncope - indicates potentially life-threatening arrhythmia 1, 3
• Chest pain - suggests possible myocardial ischemia 1
• Severe dyspnea - may indicate heart failure or hemodynamic compromise 4
• Hemodynamic instability - requires immediate stabilization before diagnostic workup 1, 2

Diagnostic Approach

Obtain a 12-lead ECG immediately during the initial evaluation to capture the rhythm if present or identify baseline abnormalities. 1, 2

For frequent symptoms: Order 48-hour ambulatory ECG monitoring to correlate symptoms with actual arrhythmias. 1

For infrequent symptoms: Consider event recorders or wearable loop recorders to capture episodic events. 1

Laboratory testing: Check complete blood count, electrolytes (particularly potassium and magnesium), and thyroid function to exclude metabolic causes. 1

Echocardiography should be performed in patients with sustained palpitations or concerning associated symptoms to exclude structural heart disease. 1

Treatment Based on Specific Arrhythmia

Supraventricular Tachycardia (SVT/AVNRT)

For acute termination in hemodynamically stable patients:

• First-line: Vagal maneuvers - Valsalva maneuver (bearing down against closed glottis for 10-30 seconds at 30-40 mmHg pressure) or carotid sinus massage (after confirming absence of bruit, apply steady pressure for 5-10 seconds). 4

• Second-line: Adenosine - terminates AVNRT in approximately 95% of patients and serves as both therapeutic and diagnostic agent. 4

• Third-line: IV beta-blockers, diltiazem, or verapamil - reasonable if adenosine and vagal maneuvers fail. 4

• If medications ineffective: IV amiodarone may be considered. 4

For hemodynamically unstable patients: Synchronized cardioversion is indicated when adenosine and vagal maneuvers fail or are not feasible. 4

For chronic management: Beta-blockers are the preferred agents for ongoing suppression of recurrent symptomatic SVT. 4

Atrial Fibrillation

For adrenergically-induced AF: Beta-blockers are the initial treatment of choice. 1

For vagally-mediated AF: Avoid adrenergic blocking drugs or digitalis as they may worsen symptoms. 1

Implement appropriate rate control or rhythm control strategies and assess stroke risk according to standard AF guidelines. 1

Multifocal Atrial Tachycardia (MAT)

Metoprolol is reasonable for ongoing management in patients with recurrent symptomatic MAT, particularly after correction of hypoxia or acute decompensation. 4

Beta-blockers should be avoided in severe bronchospastic pulmonary disease, acute decompensated heart failure, or severe conduction abnormalities. 4

Ventricular Arrhythmias

Provide guideline-directed medical therapy - patients with sustained ventricular tachycardia require immediate hospitalization. 1

Conservative Management

Before initiating pharmacological therapy, eliminate stimulants:

• Discontinue caffeine consumption completely 1
• Stop alcohol intake 1
• Cease cigarette smoking 1
• Consider discontinuing oral contraceptives in appropriate patients 1

For orthostatic symptoms (dizziness with palpitations):

• Liberalize fluid and salt intake as the preferred initial approach 1
• Use support stockings to improve venous return 1

Address physical inactivity: Gradual increase in physical activity may reduce symptoms in sedentary patients, as physical inactivity is a predictor of palpitations. 1

Manage psychological comorbidities: Depression, anxiety, and poor self-rated health are significant predictors of palpitations and should be addressed as part of comprehensive management. 1

Critical Warnings and Drug Considerations

Beta-blocker precautions (metoprolol):

• May mask tachycardia occurring with hypoglycemia, though dizziness and sweating remain 5
• Can cause bradycardia, including sinus pause, heart block, and cardiac arrest - monitor heart rate and rhythm closely 5
• May precipitate heart failure and cardiogenic shock by depressing myocardial contractility 5
• Should not be abruptly discontinued in patients with coronary artery disease due to risk of severe angina exacerbation, myocardial infarction, and ventricular arrhythmias 5

Avoid calcium channel blockers (verapamil/diltiazem) for terminating wide-QRS-complex tachycardia of unknown origin, especially in patients with myocardial dysfunction. 1

Indications for Specialist Referral

Immediate cardiology referral required for:

• Palpitations with syncope, pre-syncope, or chest pain 1
• Severe symptoms such as dyspnea 1
• Hemodynamic instability 1

Consider electrophysiology study for patients with recurrent, troublesome palpitations when non-invasive testing is inconclusive. 1

Common Pitfalls

• Don't overlook non-cardiac causes such as hyperthyroidism, stimulant use, anxiety, or panic disorder (45% of patients with panic disorder have mitral valve prolapse). 1, 3
• Don't assume all palpitations represent arrhythmias - many patients have no arrhythmias on continuous ambulatory ECG recordings at the time of symptoms. 1
• Don't use first-generation antihistamines (diphenhydramine) for infusion reactions as they can exacerbate hypotension, tachycardia, and dizziness. 4