What's the next step in managing my palpitations now that all my tests, including heart tests, are normal?

Management of Palpitations with Normal Testing

Reassure the patient and initiate empiric beta-blocker therapy while arranging ambulatory ECG monitoring with an event or loop recorder to capture the arrhythmia during symptoms. 1

Immediate Next Steps

Stop all potential triggers before proceeding with further evaluation:

• Eliminate caffeine, alcohol, and nicotine completely 1
• Review all medications for arrhythmogenic potential 1
• Assess for recreational drug use 1

Teach vagal maneuvers (Valsalva and carotid massage) to perform during episodes, as termination with these maneuvers suggests re-entrant tachycardia involving AV nodal tissue 1

Ambulatory Monitoring Strategy

The critical error is assuming normal initial tests rule out arrhythmia—monitoring must continue until symptoms occur while wearing the device. 1

Choose the Right Monitor Based on Symptom Frequency:

• Daily palpitations: 24-48 hour Holter monitoring 1
• Several times per week: Event or loop recorders (superior diagnostic yield and more cost-effective than Holter) 1, 2
• Less than 2 episodes per month with severe symptoms: Consider implantable loop recorder 1

Event recorders are specifically recommended for "less frequent arrhythmias" rather than daily Holter monitoring and have proven superior cost-effectiveness for intermittent symptoms. 1

Empiric Medical Therapy

Beta-blockers may be prescribed empirically while awaiting monitoring results, but only after excluding significant bradycardia (<50 bpm). 1, 3

Critical Contraindications to Beta-Blockers:

• Baseline heart rate <50 bpm 1
• Severe congestive heart failure 3
• Certain conduction defects 3
• Asthma or severe reactive airway disease 3

Never start Class I or III antiarrhythmic drugs without documented arrhythmia due to significant proarrhythmic risk. 1

Additional Workup Considerations

Order echocardiography if:

• Sustained SVT is eventually documented 1
• Clinical suspicion exists for structural abnormalities (valvular aortic stenosis, hypertrophic cardiomyopathy, tachycardia-mediated cardiomyopathy) 1
• Physical examination suggests structural disease 1

Consider exercise testing if palpitations are clearly triggered by exertion. 1

Pattern Recognition During Monitoring

When arrhythmia is captured, the rhythm characteristics determine management:

Regular Rhythm with Sudden Onset/Offset:

• Suggests AVNRT or AVRT 1
• Particularly common in younger patients 1
• Warrants electrophysiology referral for potential ablation 1

Irregular Rhythm:

• Most commonly atrial fibrillation 1
• Requires anticoagulation assessment and rate/rhythm control strategy 1

Wide Complex Tachycardia:

• Refer immediately to cardiac electrophysiology as this may represent ventricular tachycardia or SVT with aberrancy 1
• Look for AV dissociation or fusion complexes diagnostic of VT 1

Mandatory Immediate Specialist Referral

Refer to cardiac electrophysiology immediately for: 1

• Wolff-Parkinson-White syndrome (pre-excitation with irregular palpitations suggests atrial fibrillation with accessory pathway—risk of sudden death)
• Wide complex tachycardia of unknown origin documented on any rhythm strip
• Severe symptoms during palpitations (syncope, presyncope, dyspnea)
• Drug resistance or intolerance in documented narrow complex tachycardia
• Patients desiring to be free of drug therapy with documented arrhythmia

Common Pitfalls to Avoid

Do not rely on automatic ECG analysis systems—they are unreliable and commonly suggest incorrect diagnoses. 1

Do not dismiss syncope occurring with palpitations—this combination warrants aggressive evaluation including possible implantable loop recorder. 1

Do not order comprehensive laboratory panels routinely—thyroid function testing is reasonable given hyperthyroidism as a common non-cardiac cause, but extensive metabolic workup is low yield. 1, 2

Do not conclude the evaluation is complete with non-diagnostic monitoring—continue monitoring until symptoms are captured. 1

Special Consideration: Tachycardia-Mediated Cardiomyopathy

SVT persisting for weeks to months with fast ventricular response can cause reversible cardiomyopathy, emphasizing the importance of timely diagnosis and treatment even when initial cardiac testing appears normal. 1