What is the best course of action for a patient with a history of hypertension, arrhythmia, or anxiety disorder who experiences chest pain and palpitations after consuming caffeine?

Management of Caffeine-Induced Chest Pain and Palpitations

For patients with hypertension, arrhythmia, or anxiety who experience chest pain and palpitations after caffeine consumption, immediate evaluation with 12-lead ECG and cardiac monitoring is mandatory to exclude life-threatening arrhythmias, followed by caffeine reduction or elimination only in those with uncontrolled hypertension or documented arrhythmia triggers. 1, 2, 3

Immediate Assessment Required

Any patient presenting with chest pain and palpitations requires urgent evaluation regardless of suspected caffeine trigger. 3

• Obtain 12-lead ECG within 10 minutes to identify STEMI, pre-excitation (WPW syndrome), QT prolongation, or active arrhythmias 2, 3
• Place patient on continuous cardiac monitoring with defibrillator readily available 3
• Measure cardiac troponin immediately if acute coronary syndrome is suspected 3
• Check vital signs including blood pressure, as caffeine can significantly elevate pressures in hypertensive patients 1, 4

Red Flag Symptoms Requiring Hospitalization

The following features mandate immediate hospital admission with continuous monitoring: 2, 3

• Syncope or pre-syncope accompanying palpitations 2
• Pre-excitation (delta waves) on ECG suggesting WPW syndrome with sudden death risk 2
• Wide complex tachycardia of unknown origin 2
• Hemodynamic instability or acute orthopnea suggesting heart failure decompensation 2
• Documented sustained ventricular arrhythmias 2

Risk Stratification by Underlying Condition

Patients with Hypertension

Caffeine should be limited to less than 300 mg daily (approximately 3 cups of coffee) in hypertensive patients, and avoided entirely in those with uncontrolled hypertension. 1

• Caffeine acutely raises blood pressure by elevating vascular resistance, with larger and more prolonged effects in hypertensive versus normotensive patients 4
• The pressor response occurs equally at rest and under stress, potentially leading to dangerously high pressures when combined 4
• Coffee use in controlled hypertension is not associated with increased cardiovascular disease long-term, but acute increases in blood pressure do occur 1
• Pharmacologic tolerance to caffeine is incomplete with daily intake, so effects persist 4

Patients with Arrhythmias

Moderate caffeine consumption (3-5 cups daily) does not increase arrhythmia risk in most patients and may actually reduce atrial fibrillation recurrence. 5, 6, 7

• The most recent high-quality evidence from the 2025 DECAF randomized trial showed that caffeinated coffee consumption (averaging 1 cup daily) resulted in 39% lower hazard of atrial fibrillation recurrence compared to abstinence (HR 0.61,95% CI 0.42-0.89, P=.01) 7
• Large epidemiologic studies have failed to find a connection between coffee/caffeine amount and arrhythmia development 6
• Patients with myocardial infarction do not have increased ventricular or other arrhythmias after ingesting several cups of coffee 6
• There is no real benefit to having patients with palpitations, paroxysmal atrial fibrillation, or supraventricular tachycardia abstain from caffeine 6

However, energy drinks must be avoided entirely in patients with arrhythmias. 6

• Energy drinks contain high caffeine loads plus sugar and other cardiac stimulants 6
• Increasing case reports describe arrhythmias or sudden death triggered by exercise plus energy drink use 6

Patients with Anxiety Disorders

Recognize that 45% of patients with panic disorder have mitral valve prolapse, requiring echocardiography to exclude structural heart disease. 2

• Many patients report palpitations when continuous ambulatory ECG shows no arrhythmias, but this does not exclude serious underlying pathology 2
• Psychological factors (depression, anxiety, panic disorder) are common comorbidities 2

Diagnostic Workup Algorithm

After excluding acute life-threatening conditions: 8, 2

1. Laboratory evaluation: TSH, electrolytes, complete blood count, and BNP to assess for heart failure 8
2. Transthoracic echocardiography to evaluate for structural heart disease, left ventricular function, mitral valve prolapse, or congenital lesions 8
3. Consider ambulatory ECG monitoring if symptoms are recurrent but ECG is normal during evaluation 2

Treatment Recommendations

For Documented Arrhythmias During Symptoms

• Supraventricular tachycardia: vagal maneuvers first-line, followed by adenosine if needed 8
• Hemodynamically unstable arrhythmias: immediate electrical cardioversion 1
• Refer to electrophysiology for catheter ablation consideration 8

Caffeine Management Strategy

The evidence supports a nuanced approach rather than blanket caffeine restriction: 1, 5, 6, 7

• Uncontrolled hypertension: Avoid caffeine entirely until blood pressure is controlled 1, 9
• Controlled hypertension: Limit to <300 mg daily (approximately 3 cups coffee) 1
• Documented arrhythmias: Moderate consumption (3-5 cups daily) is safe and may be beneficial 5, 7
• All patients: Completely avoid energy drinks 6
• Healthy individuals: 3-5 cups daily associated with 15% reduction in cardiovascular disease risk 9

Critical Pitfalls to Avoid

• Never assume benign etiology without obtaining ECG during or immediately after symptoms 2, 3
• Do not use nitroglycerin response as diagnostic criterion for cardiac ischemia, as other conditions may respond similarly 3
• Avoid empiric antiarrhythmic therapy without documented arrhythmia due to proarrhythmia risk 2
• Do not overlook structural heart disease evaluation with echocardiography, especially in patients with anxiety disorders 8, 2
• Never delay evaluation of syncope or pre-syncope with palpitations, as this indicates high sudden death risk 2

Indications for Cardiology/Electrophysiology Referral

Immediate specialist referral required for: 8, 2

• Pre-excitation on ECG (WPW syndrome) 2
• Syncope or near-syncope with palpitations 2
• Structural heart disease on echocardiography 8
• Severe symptoms during palpitations 8
• Documented sustained ventricular arrhythmia 2