What are the treatment options for chest palpitations?

Treatment Options for Chest Palpitations

Immediate Risk Stratification and Triage

Patients with palpitations accompanied by syncope, presyncope, severe dyspnea, or chest pain require immediate emergency department referral and should be transported by emergency medical services when available. 1, 2

• Assess hemodynamic stability first: check for hypotension, altered mental status, or signs of shock 2, 3
• Patients with severe symptoms (syncope, dyspnea, chest pain) need immediate ED evaluation 1, 2
• Less severe symptoms may be evaluated in outpatient settings or chest pain units 1

Initial Diagnostic Approach

Obtain a 12-lead ECG immediately during the initial visit to identify baseline abnormalities or capture arrhythmias if present. 2, 4

• Perform 48-hour ambulatory ECG monitoring for frequent or sustained palpitations 2
• Order basic laboratory tests: complete blood count, electrolytes, and thyroid function tests to exclude metabolic causes 2
• Consider event recorders or wearable loop monitors for infrequent episodes 2, 5
• Echocardiography is indicated for sustained palpitations or concerning associated symptoms to exclude structural heart disease 2

Conservative Management (First-Line for Stable Patients)

Eliminating stimulants—caffeine, alcohol, and cigarettes—is often sufficient to control symptoms before considering pharmacological therapy. 2

Lifestyle Modifications

• Cessation of caffeine consumption, alcohol intake, and cigarette smoking 2
• Avoid oral contraceptives in appropriate patients 2
• Gradual increase in physical activity for sedentary patients, as physical inactivity predicts palpitations 2

Management of Orthostatic Symptoms

• Liberalize fluid and salt intake for palpitations associated with postural hypotension and tachycardia 2
• Use support stockings to improve venous return 2

Psychological Factors

• Address depression, anxiety, and panic disorder, which are significant predictors of palpitations 2
• Recognize that 45% of patients with panic disorder have mitral valve prolapse 2

Pharmacological Treatment Based on Arrhythmia Type

Supraventricular Tachycardia (SVT)

• Consider vagal maneuvers as initial intervention 2
• Beta-blockers are first-line pharmacological therapy 2, 6
• Refer for catheter ablation if recurrent or refractory 2

Atrial Fibrillation

• Beta-blockers are the initial treatment of choice for adrenergically-induced AF 2
• Avoid adrenergic blocking drugs or digitalis for vagally-mediated AF as they may worsen symptoms 2
• Implement appropriate rate control or rhythm control strategies and assess stroke risk 2

Ventricular Arrhythmias

• Oral beta-blockers should be considered during hospital stay and continued thereafter in all acute coronary syndrome patients without contraindications 1
• Correction of electrolyte imbalances is recommended in patients with recurrent VT or VF 1
• Intravenous amiodarone (150-300 mg bolus) should be considered for recurrent hemodynamically relevant ventricular arrhythmias 1
• Intravenous lidocaine may be considered for recurrent sustained VT or VF not responding to beta-blockers or amiodarone 1
• Prophylactic treatment with anti-arrhythmic drugs (other than beta-blockers) is not recommended 1

Emergency Interventions for Hemodynamically Unstable Patients

Immediate synchronized cardioversion is indicated for tachycardic patients who are unstable with severe signs and symptoms, including hypotension or shock. 3

• Sedate the patient if conscious, but do not delay cardioversion if extremely unstable 3
• Do not delay cardioversion to obtain a 12-lead ECG in unstable patients 3
• For wide-complex tachycardia in an unstable patient, presume ventricular tachycardia and cardiovert immediately 3
• After successful cardioversion, consider antiarrhythmic prophylaxis with amiodarone to prevent recurrence 3

Bradycardia Management (if palpitations associated with bradycardia)

• For hemodynamically unstable bradycardia (heart rate <60 bpm with symptoms), administer atropine 0.5-1 mg IV as first-line treatment, repeatable every 3-5 minutes (maximum 3 mg) 7
• If unresponsive to atropine, consider IV infusion of dopamine or epinephrine 7
• Initiate transcutaneous pacing if patient remains unstable despite medication 7

Advanced Interventions

Catheter Ablation

• Radiofrequency catheter ablation at a specialized center followed by ICD implantation should be considered for recurrent VT, VF, or electrical storms despite optimal medical treatment 1
• Very effective for recurrent VT or VF triggered by premature ventricular complexes arising from partially injured Purkinje fibers 1

Revascularization

• In acute coronary syndrome patients with recurrent polymorphic VT or VF, immediate coronary angiography should be considered as incomplete reperfusion may be the cause 1

Specialist Referral Indications

Immediate cardiology referral is necessary if palpitations are associated with syncope, presyncope, or chest pain. 2

• Refer to cardiology/electrophysiology for severe symptoms such as syncope or dyspnea 2
• Consider electrophysiology study for recurrent, troublesome palpitations when non-invasive testing is inconclusive 2

Critical Pitfalls to Avoid

• Avoid calcium channel blockers (verapamil, diltiazem) for wide-QRS-complex tachycardia of unknown origin, especially with myocardial dysfunction 2
• Don't overlook non-cardiac causes: hyperthyroidism, stimulant use, or anxiety 2
• Adenosine is not recommended for patients with hypotension due to risk of worsening hemodynamic status 3
• Beta-blockers are contraindicated in hemodynamically unstable tachycardia due to negative inotropic effects 3