What is the initial approach to managing heart palpitations?

Initial Management of Heart Palpitations

Begin with a 12-lead ECG immediately during the initial visit, obtain detailed symptom characterization including frequency, duration, onset/offset patterns, and assess for hemodynamic instability requiring urgent intervention. 1

Immediate Assessment

Symptom Characterization

• Document the pattern of palpitations: frequency, duration, mode of onset (sudden vs. gradual), and offset (sudden vs. gradual) 1
• Identify associated symptoms that indicate serious pathology: dizziness, chest pain, syncope, pre-syncope, or dyspnea—these require urgent evaluation 2, 1
• Assess hemodynamic stability: check for hypotension, altered mental status, acute heart failure, or ongoing chest pain, which mandate immediate electrical cardioversion if arrhythmia is present 3, 4

Precipitating Factors

• Screen for triggers: caffeine, alcohol, exercise, stress, medications (prescription and over-the-counter), illicit drugs, and stimulants 1, 5
• Note timing patterns: nocturnal or postprandial palpitations suggest vagally-mediated arrhythmias, while daytime episodes during activity indicate adrenergically-mediated arrhythmias 1

Critical Red Flags

• Palpitations with syncope or pre-syncope require urgent evaluation with 12-lead ECG, exercise testing, and 48-hour ambulatory monitoring 2, 1
• Wide-complex tachycardia of unknown origin mandates immediate referral to cardiac electrophysiology 2
• Pre-excitation on baseline ECG (delta waves suggesting Wolff-Parkinson-White syndrome) in a patient with palpitations requires immediate electrophysiology referral due to risk of sudden death 2, 3

First-Line Diagnostic Testing

Mandatory Initial Tests

• 12-lead ECG during the initial visit to identify baseline abnormalities, pre-excitation, or capture arrhythmias if present during symptoms 2, 1
• Basic laboratory tests: complete blood count, electrolytes (potassium, magnesium, calcium), and thyroid function tests to exclude metabolic causes 1, 5

Ambulatory Monitoring Strategy

• For frequent palpitations (several episodes per week): 48-hour ambulatory ECG monitoring is first-line 1
• For less frequent episodes: event recorder or wearable loop recorder is more cost-effective than Holter monitoring 2, 1, 5
• For rare but severe symptoms (fewer than two episodes per month): implantable loop recorder may be necessary 2, 1

Additional Testing Based on Clinical Context

• Echocardiography to exclude structural heart disease, especially in patients with sustained palpitations, concerning symptoms, or abnormal ECG findings 2, 1
• Exercise ECG testing if palpitations are clearly triggered by exertion 2, 1

Conservative Management Approach

Lifestyle Modifications (First-Line for Benign Palpitations)

• Eliminate stimulants completely: caffeine, alcohol, and cigarettes—this alone is often sufficient to control symptoms before considering pharmacological therapy 1
• Discontinue oral contraceptives in appropriate patients, as they may exacerbate palpitations 1
• Address orthostatic symptoms: liberalize fluid and salt intake for palpitations associated with postural hypotension and tachycardia; use support stockings to improve venous return 1

Physical Activity Modification

• Gradually increase physical activity in sedentary patients, as physical inactivity is a predictor of palpitations 1

Psychological Factors

• Screen for and address anxiety, depression, and panic disorder: 45% of patients with panic disorder have mitral valve prolapse, and psychological comorbidities are significant predictors of palpitations 1, 5

Management Based on Identified Arrhythmia

Supraventricular Tachycardia (SVT)

• Acute management: vagal maneuvers, followed by beta-blockers if unsuccessful 1
• Long-term: consider catheter ablation for recurrent symptomatic episodes 1

Atrial Fibrillation with Rapid Ventricular Response

• Rate control first-line for stable patients: IV beta-blockers (metoprolol 2.5-5 mg IV over 2 minutes or esmolol infusion) or diltiazem IV, targeting heart rate <110 bpm 3, 4
• Anticoagulation assessment: calculate CHA₂DS₂-VASc score immediately; initiate direct oral anticoagulants (DOACs) if score ≥2 in men or ≥3 in women 3, 4
• Rhythm control consideration: for younger patients with paroxysmal AF, rhythm control is preferred long-term to prevent tachycardia-induced cardiomyopathy 3, 4

Ventricular Arrhythmias

• Provide guideline-directed medical therapy 1
• Sustained ventricular tachycardia requires hospitalization 1

Critical Pitfalls to Avoid

Medication Errors

• Never use AV nodal blockers (beta-blockers, calcium channel blockers, digoxin) in pre-excited atrial fibrillation (WPW syndrome): this can precipitate ventricular fibrillation by allowing rapid conduction down the accessory pathway 3, 4
• Avoid calcium channel blockers (verapamil, diltiazem) in patients with reduced ejection fraction (<40%) or decompensated heart failure: use beta-blockers and/or digoxin instead 2, 3, 4
• Do not use digoxin as monotherapy in active patients: it only controls rate at rest and is ineffective during exercise 4

Diagnostic Errors

• Do not overlook non-cardiac causes: hyperthyroidism, stimulant use, anxiety, and medications are common culprits 1, 5
• Do not assume psychiatric etiology even if anxiety is present: always exclude cardiac causes first, as psychiatric comorbidity does not rule out cardiac etiology 6
• Monitor for tachycardia-induced cardiomyopathy: sustained rapid ventricular response can cause reversible left ventricular dysfunction that improves within 6 months of adequate rate or rhythm control 3

Indications for Specialist Referral

Immediate Cardiology/Electrophysiology Referral

• Palpitations with syncope, pre-syncope, or chest pain 2, 1
• Pre-excitation (WPW syndrome) on baseline ECG due to risk of sudden death 2, 3
• Wide-complex tachycardia of unknown origin 2

Elective Referral

• Drug-resistant or drug-intolerant patients with documented arrhythmias 2
• Patients desiring to be free of drug therapy 2
• Recurrent troublesome palpitations when non-invasive testing is inconclusive: consider electrophysiology study 1