What are the treatment options for palpitations and skipped beats?

Treatment Options for Palpitations and Skipped Beats

For most patients with palpitations and skipped beats, treatment begins with reassurance and lifestyle modifications after excluding serious underlying arrhythmias, with beta-blockers as first-line pharmacotherapy when symptoms are bothersome enough to warrant medication. 1, 2

Initial Risk Stratification

The first critical step is determining whether palpitations represent a benign or potentially life-threatening condition:

• Immediate hospitalization is required if palpitations are associated with documented ventricular arrhythmia, syncope, or suspected serious arrhythmia 1
• Red flag symptoms requiring urgent evaluation include syncope, near-syncope, chest pain, dyspnea, or palpitations during exertion, as these suggest hemodynamically significant arrhythmias 1, 3
• Benign palpitations are typically isolated premature ventricular contractions (PVCs) that are suppressed with exercise and occur without structural heart disease 3

Diagnostic Workup Before Treatment

Before initiating treatment, establish the underlying rhythm:

• 12-lead ECG should be obtained during initial evaluation to identify baseline abnormalities or capture the arrhythmia if present 2
• 48-hour ambulatory ECG monitoring is the first-line diagnostic test for frequent or sustained palpitations 2
• Event recorders or loop recorders are appropriate for infrequent episodes 2
• Echocardiography should be performed to exclude structural heart disease, especially with sustained palpitations or concerning symptoms 2

Treatment Based on Etiology

For Benign Premature Beats (PVCs/PACs)

Reassurance and observation is the primary treatment for isolated premature beats without structural heart disease 1, 3:

• Educate patients that these are typically benign and do not increase mortality risk 3
• Identify and eliminate triggers: caffeine, alcohol, nicotine, stress, sleep deprivation 4, 5
• Beta-blockers (such as metoprolol) are first-line when symptoms are bothersome enough to warrant medication 1, 2

For Supraventricular Tachycardia (SVT)

Guideline-directed medical therapy includes 2:

• Vagal maneuvers as initial acute management 1, 2
• Beta-blockers for rate control and prevention 2
• Catheter ablation should be considered for recurrent symptomatic episodes, as it offers definitive cure 2

For Atrial Fibrillation

Rate control or rhythm control strategies with stroke risk assessment 2:

• Rate control with beta-blockers or calcium channel blockers
• Anticoagulation based on CHA₂DS₂-VASc score
• Consider rhythm control with antiarrhythmic drugs or ablation for symptomatic patients

For Ventricular Arrhythmias

Hospitalization and specialist management is required 2:

• Patients with sustained ventricular tachycardia require immediate hospitalization for antiarrhythmic therapy initiation 2
• Ventricular tachycardia is particularly concerning in patients with structural heart disease and may present with palpitations, dyspnea, chest pain, or syncope 3
• Implantable cardioverter-defibrillator (ICD) consideration for high-risk patients 1

Pharmacologic Treatment Options

Beta-Blockers (First-Line)

• Metoprolol is commonly used for symptomatic palpitations 1, 2, 6
• Effective for both supraventricular and ventricular ectopy
• Generally well-tolerated with manageable side effects

Antiarrhythmic Drugs (Specialist-Directed)

Critical warning about Class IC agents (flecainide): The CAST trial demonstrated increased mortality in patients with structural heart disease or prior myocardial infarction treated with flecainide 7. Flecainide is contraindicated in patients with chronic atrial fibrillation and should only be used in structurally normal hearts 7.

Special Populations

Pregnancy

• Palpitations are extremely common due to physiologic increases in blood volume and heart rate 3
• SVT symptoms increase during pregnancy 3
• Consider postpartum cardiomyopathy in women with new-onset palpitations in the last 6 weeks of pregnancy or early postpartum 3

Patients with Structural Heart Disease

• Require more aggressive evaluation and treatment 1, 3
• Higher risk of life-threatening arrhythmias
• Prompt referral to cardiology/electrophysiology is indicated 2

When to Refer to Cardiology/Electrophysiology

Immediate referral is indicated for 2:

• Palpitations with syncope or severe symptoms
• Evidence of structural heart disease on echocardiography
• Documented complex arrhythmias (sustained VT, symptomatic SVT)
• Palpitations during exertion with concerning features

Common Pitfalls to Avoid

• Do not dismiss palpitations with syncope as benign without thorough evaluation—these require hospitalization 1
• Do not use Class IC antiarrhythmics (flecainide) in patients with structural heart disease or prior MI due to increased mortality risk 7
• Do not overlook non-cardiac causes: hyperthyroidism, electrolyte abnormalities (hypokalemia, hypomagnesemia), and QT-prolonging medications can all cause palpitations 3
• Do not assume all irregular palpitations are benign: atrial fibrillation requires stroke risk assessment and anticoagulation consideration 2, 3

Treatment Algorithm Summary

1. Assess for red flags (syncope, chest pain, dyspnea, exertional symptoms) → If present, hospitalize 1
2. Obtain 12-lead ECG and consider 48-hour monitoring 2
3. Perform echocardiography if sustained symptoms or concerning features 2
4. For benign ectopy: Reassurance, trigger avoidance, beta-blockers if symptomatic 1, 2, 3
5. For documented arrhythmias: Guideline-directed therapy specific to arrhythmia type 2
6. Refer to cardiology for complex arrhythmias, structural disease, or refractory symptoms 2