What is the management for palpitations?

Management of Palpitations

Immediate Assessment and Risk Stratification

Patients presenting with palpitations require immediate evaluation for hemodynamic instability and high-risk features that determine the urgency and setting of management. 1, 2

High-Risk Features Requiring Hospitalization or Urgent Referral:

• Syncope or near-syncope during palpitations – these patients should be hospitalized for evaluation, monitoring, and management when ventricular arrhythmia is documented or suspected 1
• Pre-excitation (delta waves) on resting ECG – indicates Wolff-Parkinson-White syndrome and requires immediate electrophysiology referral due to sudden death risk, particularly if irregular palpitations suggest atrial fibrillation 1, 3
• Wide complex tachycardia of unknown origin – mandates immediate specialist referral 1, 3
• Sustained ventricular arrhythmias – require hospitalization for initiation of antiarrhythmic therapy 1, 4
• Associated chest pain, dyspnea, or severe symptoms – warrant urgent evaluation for structural heart disease 1, 3, 4

Initial Diagnostic Workup:

• Obtain 12-lead ECG immediately – this is the gold standard initial test and may capture the arrhythmia if symptoms are present 1, 4, 5
• Assess for structural heart disease with echocardiography – particularly important in patients with sustained palpitations or concerning symptoms 1, 4
• Review medications and triggers – identify caffeine, alcohol, nicotine, stimulant medications (including energy drinks), recreational drugs, over-the-counter medications, and check for electrolyte abnormalities and thyroid disease 1, 2, 3

Diagnostic Strategy Based on Symptom Frequency

For Daily or Frequent Palpitations:

• 24-48 hour Holter monitoring is the appropriate first-line ambulatory monitoring strategy 4, 6

For Less Frequent Episodes (Less Than Daily):

• Event recorder or wearable loop recorder is more effective and cost-effective than Holter monitoring 3, 4, 6
• Two-week continuous closed-loop event recording is indicated when palpitations occur unpredictably 6

For Exercise-Related Palpitations:

• Exercise stress testing in a controlled environment with advanced life support should be performed to reproduce symptoms and correlate with ECG findings 4

Management Based on Etiology

Benign Palpitations (Normal ECG, No Structural Disease):

Eliminate precipitating factors first – caffeine cessation alone is often sufficient to control palpitations in patients with anxiety and negative cardiac workup 3

• Remove all caffeine sources including coffee, matcha, energy drinks, and caffeine-containing medications or supplements 3
• Address anxiety disorders – depression, poor self-rated health, and anxiety are significant predictors of palpitations 3
• Teach vagal maneuvers (Valsalva, carotid massage) to help terminate episodes and confirm re-entrant tachycardia 1, 3

If symptoms persist after trigger elimination, initiate beta-blocker therapy – this is first-line pharmacologic treatment for symptomatic palpitations, particularly when associated with mild tachyarrhythmias or increased adrenergic symptoms (Class I recommendation) 2

• Ensure significant bradycardia (<50 bpm) has been excluded before starting beta-blockers 1, 3
• Do NOT initiate Class I or Class III antiarrhythmic drugs without documented arrhythmia due to proarrhythmia risk 1

Alternative Pharmacologic Options:

• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) are effective alternatives for patients who cannot tolerate beta-blockers (Class IIa recommendation) 2
• Beta-blockers are specifically recommended for mitral valve prolapse with palpitations (Class IIa recommendation) 2

Documented Supraventricular Tachycardia:

Adenosine is the drug of choice for terminating AV nodal re-entrant tachycardia (Class I recommendation) 2

For paroxysmal supraventricular arrhythmias requiring chronic suppression:

• Flecainide starting dose: 50 mg every 12 hours, may increase by 50 mg twice daily every 4 days until efficacy achieved, maximum 300 mg/day 7
• Propafenone reduces attack rates significantly – in controlled trials, 53-67% of PAF patients and 38-47% of PSVT patients remained attack-free versus 13-22% and 7-16% on placebo respectively 8
• These agents should be initiated in-hospital for sustained ventricular tachycardia due to proarrhythmic risk 7

Special Populations:

For orthostatic palpitations:

• Volume expansion through liberal fluid and salt intake, plus support stockings may be beneficial 2

For frequent premature ventricular contractions:

• Periodic reassessment of ventricular function is recommended (Class IIa) 2

Mandatory Cardiology/Electrophysiology Referral Criteria

Refer immediately for:

• Pre-excitation on ECG (Wolff-Parkinson-White syndrome) 1, 3
• Syncope or severe symptoms during palpitations 1, 3, 4
• Wide complex tachycardia of unknown origin 1, 3
• Evidence of structural heart disease 4
• Documented complex or sustained ventricular arrhythmias 1, 4
• Symptoms persisting despite caffeine elimination and beta-blocker therapy 3
• Patient desires definitive therapy (catheter ablation) rather than chronic medication 1, 3
• Drug resistance or intolerance in patients with documented arrhythmias 1

Consider electrophysiologic testing or catheter ablation for recurrent symptomatic arrhythmias (Class IIb recommendation) 2

Common Pitfalls to Avoid

• Never rely on automatic ECG interpretation systems – they are unreliable and commonly suggest incorrect arrhythmia diagnoses 1
• Do not delay obtaining 12-lead ECG during tachycardia – encourage patients to seek immediate evaluation during episodes to capture the arrhythmia 1
• Avoid empiric antiarrhythmic therapy without documented arrhythmia – Class I and III agents carry significant proarrhythmia risk 1
• Do not assume benign etiology in patients with irregular palpitations and pre-excitation – this suggests atrial fibrillation in WPW syndrome, which carries sudden death risk 1
• Recognize that palpitations frequently occur during normal rhythm – symptom-rhythm correlation through ambulatory monitoring is essential 1