What is the recommended treatment for heart palpitations?

Treatment of Heart Palpitations

The recommended treatment for heart palpitations depends critically on whether an arrhythmia is documented and the patient's hemodynamic stability, with lifestyle modifications as first-line therapy for benign cases and immediate intervention required for life-threatening arrhythmias. 1, 2

Initial Assessment and Risk Stratification

The first priority is determining hemodynamic stability and identifying life-threatening conditions 1, 2:

• Immediate intervention is required if palpitations are accompanied by syncope, pre-syncope, chest pain, hypotension (systolic BP ≤90 mmHg), heart failure, or heart rate ≥150 beats/min 3, 1
• Obtain a 12-lead ECG immediately during the initial evaluation to capture any arrhythmia present and identify baseline abnormalities 1, 4
• Assess for precipitating factors including caffeine, alcohol, exercise, stress, or medications 2

Conservative Management for Benign Palpitations

For hemodynamically stable patients without documented dangerous arrhythmias, lifestyle modifications should be the first-line approach before considering pharmacological therapy: 2

• Eliminate all stimulants: Stop caffeine consumption, discontinue alcohol intake, and cease cigarette smoking 2
• Liberalize fluid and salt intake for patients with orthostatic symptoms 2
• Use support stockings to improve venous return in patients with postural symptoms 2
• Gradually increase physical activity in sedentary patients, as physical inactivity predicts palpitations 2
• Address psychological comorbidities including depression and anxiety, which are significant predictors of palpitations 2

Treatment Based on Documented Arrhythmia Type

Ventricular Tachycardia (VT)

For sustained VT with hemodynamic compromise: 3

• Beta-blockers are first-line therapy unless contraindicated 3
• Lidocaine (lignocaine) is the drug of first choice if beta-blockers fail or high risk of recurrent ventricular fibrillation: 1 mg/kg IV bolus, may repeat half-dose every 8-10 minutes to maximum 4 mg/kg, followed by infusion of 1-3 mg/min 3
• Amiodarone may be superior for recurrent sustained VT requiring cardioversion: 5 mg/kg (300 mg) IV over 1 hour, followed by 900-1200 mg over 24 hours 3
• Synchronized DC cardioversion (100J, 200J, 360J) if hemodynamically significant VT persists 3
• Hospitalization is required for patients with sustained VT to initiate antiarrhythmic therapy 1, 2

Ventricular Fibrillation

Immediate defibrillation is the priority - pharmacological treatment is secondary to early defibrillation 3

• Magnesium may be effective, particularly with acute myocardial infarction: 8 mmol bolus followed by 2.5 mmol/h infusion 3

Supraventricular Tachycardia (SVT)

Management depends on hemodynamic stability: 1, 2

• Vagal maneuvers should be attempted first in stable patients 1, 2
• Beta-blockers are effective for rate control and rhythm conversion 3, 1
• Catheter ablation should be considered for recurrent episodes 1, 2

Atrial Fibrillation

Implement either rate control or rhythm control strategies with stroke risk assessment: 3, 1, 2

• Beta-blockers and digoxin are effective for rate control in many cases 3
• Amiodarone may be more efficacious for terminating the arrhythmia 3
• For vagally-mediated AF: Avoid adrenergic blocking drugs or digitalis as they may worsen symptoms 2
• For adrenergically-induced AF: Beta-blockers are the initial treatment of choice 2
• Cardioversion may be used but should only be employed if mandatory, as recurrences are common 3

Diagnostic Testing to Guide Treatment

When the arrhythmia is not captured on initial ECG: 1, 4

• 48-hour ambulatory ECG monitoring is first-line for frequent or sustained palpitations 1, 4
• Event recorder or wearable loop recorder for less frequent episodes 1, 4
• Implantable loop recorder for rare episodes in low-risk patients 2, 4
• Echocardiography to exclude structural heart disease, especially with sustained palpitations or concerning symptoms 1, 4
• Exercise stress testing when palpitations are triggered by exertion 4

Indications for Specialist Referral

Immediate cardiology/electrophysiology referral is necessary for: 1, 2, 4

• Palpitations with syncope, pre-syncope, or dyspnea 1, 2
• Evidence of structural heart disease 1, 4
• Documented complex arrhythmias 1
• Wide complex tachycardia of unknown origin 4
• Pre-excitation on resting ECG with history of paroxysmal regular palpitations 4
• Wolff-Parkinson-White syndrome 4

Critical Pitfalls to Avoid

• Never use calcium channel blockers (verapamil, diltiazem) to terminate wide-QRS-complex tachycardia of unknown origin, especially with myocardial dysfunction 2
• Do not overlook non-cardiac causes such as hyperthyroidism, stimulant use, or anxiety 2
• Recognize that many patients with palpitations have no arrhythmias on ambulatory ECG at the time of symptoms, highlighting the importance of proper diagnostic correlation 2