Management of Palpitations with Normal EKG, Small Hiatal Hernia, and Anxiety
Your palpitations are most likely benign and related to anxiety, but you must immediately eliminate all caffeine sources (coffee, energy drinks, matcha, caffeine-containing medications) as this single intervention often completely resolves symptoms in patients with your presentation. 1, 2
Immediate Action Steps
Eliminate all caffeine immediately - this includes coffee, tea, energy drinks, matcha, caffeinated sodas, and any supplements or medications containing caffeine. 1, 2 Caffeine is a well-established trigger for palpitations, particularly in patients with anxiety disorders, and cessation alone is often sufficient to control symptoms when cardiac workup is negative. 2
Address your anxiety disorder directly - depression, poor self-rated health, and anxiety are significant predictors of palpitations. 1, 2 Patients with panic disorder experience significantly greater increases in anxiety, nervousness, fear, palpitations, and tremors with caffeine consumption. 2
Learn vagal maneuvers - practice the Valsalva maneuver and carotid massage techniques. 1, 3 These can help terminate episodes if they occur and provide reassurance that you have control over the symptoms. 1
Understanding Your Hiatal Hernia Connection
While your small hiatal hernia is unlikely to be the primary cause, larger hiatal hernias can trigger cardiac arrhythmias including premature ventricular contractions, atrial fibrillation, and supraventricular tachycardia. 4, 5 However, these cardiac complications are typically associated with large or giant hiatal hernias that cause mechanical compression of cardiac structures. 6, 5, 7 Since yours is described as small and your 12-lead EKG is normal, the hernia is probably not contributing significantly to your symptoms. 4
Next Steps If Symptoms Persist After Caffeine Elimination
If palpitations continue after 2 weeks of complete caffeine elimination:
Start a beta-blocker - this is the recommended empiric therapy for persistent palpitations after trigger elimination, particularly when associated with anxiety. 1, 3 However, this should only be prescribed after ensuring you don't have significant bradycardia (heart rate <50 bpm). 1, 3
Consider extended monitoring - if symptoms occur less than daily, an event recorder or wearable loop recorder is more appropriate than a 24-hour Holter monitor. 3, 2 The monitoring must continue until symptoms occur while wearing the device - non-diagnostic monitoring should not be considered conclusive. 3
When You MUST See a Cardiologist Immediately
Seek immediate cardiology/electrophysiology referral if you experience: 1, 3, 2
- Syncope (fainting) or near-syncope during palpitations
- Severe chest pain, shortness of breath, or lightheadedness with episodes
- Palpitations that persist despite complete caffeine elimination and beta-blocker therapy
- Any irregular palpitations (as opposed to regular fast heartbeat)
Critical Reassurance
Your normal 12-lead EKG is highly reassuring. 1, 3 It rules out pre-excitation (Wolff-Parkinson-White syndrome), which would require immediate specialist referral due to sudden death risk. 1, 3, 2 The combination of normal EKG, small (not large) hiatal hernia, and active anxiety strongly suggests your symptoms are benign and will respond to caffeine elimination and anxiety management. 1, 2
Common Pitfalls to Avoid
Do not start antiarrhythmic medications (Class I or III drugs) without documented arrhythmia, as these carry significant proarrhythmia risk. 1, 3 Your normal EKG means you should not be on these medications. 1
Do not assume you need extensive cardiac workup - if symptoms resolve with caffeine elimination, no further cardiac evaluation is needed beyond what you've already completed. 2 Focus instead on treating the underlying anxiety disorder. 1, 2
Do not dismiss the power of lifestyle modification - also eliminate alcohol and nicotine, review all medications for cardiac stimulants, and ensure adequate hydration. 1, 3