From the Guidelines
For a 47-year-old male with undiagnosed hypertension and hyperlipidemia complaining of heart palpitations for 3 days following a night of staying up all night, I strongly recommend a comprehensive evaluation including an ECG, basic metabolic panel, complete blood count, thyroid function tests, and cardiac enzymes to rule out any underlying cardiac conditions, as hypertension precedes the development of heart failure in approximately 90% of patients and increases risk for heart failure by 2- to 3-fold 1.
Given the patient's symptoms of heart palpitations, fatigue, and undiagnosed hypertension, it is crucial to establish a diagnosis of hypertension through multiple blood pressure measurements at different visits. The patient's presentation of heart palpitations after a night of sleep deprivation may be related to the activation of neurohormonal systems, such as the sympathetic nervous system, which can lead to abnormal ventricular remodeling and reduced cardiac contractility 1.
The patient should be monitored for 24-48 hours with a Holter monitor to capture any arrhythmias, and immediate management should include avoidance of caffeine, alcohol, and stimulants, maintenance of adequate hydration, establishment of regular sleep patterns, and practice of stress reduction techniques. If palpitations persist or worsen, he should seek immediate medical attention.
Key aspects of the evaluation and management plan include:
- Comprehensive diagnostic testing to rule out underlying cardiac conditions
- Establishment of a hypertension diagnosis through multiple blood pressure measurements
- Monitoring for arrhythmias with a Holter monitor
- Lifestyle modifications to manage symptoms and reduce cardiovascular risk
- Consideration of medication therapy for hypertension and hyperlipidemia if lifestyle modifications are insufficient, with a focus on evidence-based treatments such as ACEIs, BBs, and diuretics, which have been shown to reduce morbidity and mortality in patients with heart failure 1.
From the Research
Evaluation of Palpitations
The patient's complaint of heart palpitations for 3 days following a night of staying up all night, without chest pain or shortness of breath, but with fatigue, requires a thorough evaluation. According to 2, palpitations can be a symptom of many cardiac and noncardiac conditions, and a detailed history, physical examination, and basic electrocardiogram are essential in evaluating palpitations.
Diagnostic Approach
The diagnostic approach for palpitations includes:
- Detailed history and physical examination
- Electrocardiogram (ECG)
- Limited laboratory testing
- Ambulatory ECG monitoring
- Cardiology referral, as indicated 3
- The use of tools such as Holter monitor, event monitor, transtelephonic electrocardiographic monitor, treadmill exercise stress test, echocardiography, and electrophysiologic studies may be necessary to evaluate palpitations caused by a presumed cardiogenic cause 2
Role of ECG
The ECG is a crucial tool in the diagnosis and initial management of patients presenting with symptoms compatible with acute coronary syndrome 4. It can help identify ST segment elevation or depression, which may indicate acute occlusion of an epicardial artery or subendocardial ischemia. However, the ECG should be interpreted in the context of the patient's clinical scenario and compared to previous ECGs.
Monitoring Options
For patients with infrequent symptoms, extended electrocardiogram monitoring may be necessary to document arrhythmias. Options include:
- 24-hour Holter monitoring
- 30-day external continuous monitoring
- Implantable loop recorders 5
- Portable ECG signal recording in smart devices and wearables, which may also be used to monitor blood pressure and identify hypertension 6
Considerations for Hypertension
Given the patient's undiagnosed hypertension, it is essential to consider the potential relationship between hypertension and palpitations. While ECG wave morphology may be promising for monitoring blood pressure and identifying hypertension, further research is needed to confirm its effectiveness 6.