What is the next step in managing a patient with a history of anxiety and palpitations, who developed palpitations after consuming caffeine, with a previously negative cardiac workup including electrocardiogram (EKG) and echocardiogram (echo)?

Management of Caffeine-Induced Palpitations with Prior Negative Cardiac Workup

Immediately eliminate all caffeine intake (coffee, matcha, energy drinks) and reassess symptoms over 2-4 weeks, as caffeine cessation alone is often sufficient to control palpitations in patients with anxiety and a negative cardiac workup. 1, 2, 3

Immediate Management Steps

Caffeine Elimination (First-Line Intervention)

• Stop all caffeine consumption immediately including coffee, matcha, tea, energy drinks, and caffeine-containing medications or supplements. 1, 2, 3
• Caffeine is a well-established trigger for tachyarrhythmias, particularly in young adults and those with anxiety disorders. 2, 4
• In patients with panic disorder (45% have mitral valve prolapse), caffeine produces significantly greater increases in anxiety, nervousness, fear, palpitations, and tremors compared to healthy subjects. 1, 5
• Energy drinks are particularly problematic as they contain high caffeine loads plus other cardiac stimulants and have been associated with arrhythmias and even sudden death. 2, 4

Additional Lifestyle Modifications

• Eliminate alcohol and cigarettes, as cessation of these stimulants is often sufficient to control symptoms before considering pharmacological therapy. 1, 3
• Address physical inactivity, as it is a significant predictor of palpitations in men. 1, 3
• Liberalize fluid and salt intake if orthostatic symptoms are present. 1, 3

Diagnostic Workup During This Episode

Essential Testing

• Obtain a 12-lead ECG now to capture the arrhythmia during symptoms if palpitations are still present. 1, 2, 3
• Look specifically for pre-excitation (delta waves) on the resting ECG, as this indicates Wolff-Parkinson-White syndrome and requires immediate electrophysiology referral due to risk of sudden death. 1, 2
• Review the baseline ECG for QRS morphology and P-wave characteristics. 2

Ambulatory Monitoring Strategy

• Use a 24-hour Holter monitor if palpitations occur daily or several times per week. 1, 3
• Use an event recorder or wearable loop recorder if episodes are less frequent (less than daily). 1, 2, 3
• Continuous or event-activated ambulatory ECG recordings help correlate symptoms with actual arrhythmias, though many patients with palpitations show no arrhythmias at the time of symptoms. 1, 3

Management Algorithm After Caffeine Elimination

If Symptoms Resolve (Most Likely Scenario)

• No further cardiac workup is needed beyond what has already been completed. 1, 3
• Address underlying anxiety disorder, as depression, poor self-rated health, and anxiety are significant predictors of palpitations. 1, 3
• Counsel permanent avoidance of caffeine, alcohol, and cigarettes. 1, 3

If Symptoms Persist Despite Caffeine Elimination

• Teach vagal maneuvers (Valsalva, carotid massage) to help terminate episodes and confirm re-entrant tachycardia involving AV nodal tissue. 2, 3
• Consider empiric beta-blocker therapy if significant bradycardia (<50 bpm) has been excluded, as beta-blockers are effective for patients with palpitations, mild tachyarrhythmias, or increased adrenergic symptoms. 1, 2
• Do NOT start Class I or III antiarrhythmic drugs without documented arrhythmia due to significant proarrhythmic risk. 2

Mandatory Specialist Referral Criteria

Refer immediately to cardiac electrophysiology if: 1, 2, 3

• Pre-excitation is present on ECG (WPW syndrome)
• Severe symptoms occur during palpitations (syncope, dyspnea, chest pain)
• Wide complex tachycardia of unknown origin is documented
• Symptoms persist despite caffeine elimination and beta-blocker therapy
• Patient desires definitive therapy (catheter ablation) rather than chronic medication

Critical Pitfalls to Avoid

• Do not dismiss the caffeine connection: While older literature suggested caffeine doesn't cause arrhythmias, this patient consumed both coffee AND matcha (double caffeine load), and energy drinks specifically are well-documented triggers. 2, 4
• Do not overlook anxiety as a comorbid condition: 71% of patients with mitral valve prolapse report that caffeine effects are similar to panic attacks, and addressing psychological comorbidities is essential. 1, 3, 5
• Do not use calcium channel blockers (verapamil, diltiazem) to terminate wide-QRS-complex tachycardia of unknown origin. 3
• Do not assume benign etiology without capturing the arrhythmia: Always attempt to document the rhythm with ECG during symptoms before concluding the workup. 1, 2