What are the evaluation and treatment options for a patient experiencing palpitations that feel like a kick, potentially related to underlying conditions such as hypertension, heart failure, or arrhythmias like Premature Ventricular Contractions (PVCs) or Premature Atrial Contractions (PACs)?

Palpitations That Feel Like a Kick

Palpitations described as a "kick" sensation most commonly represent premature ventricular contractions (PVCs) or premature atrial contractions (PACs), where the patient feels the forceful compensatory beat following the premature beat rather than the premature beat itself. 1

What You're Actually Feeling

The "kick" sensation occurs because:

• The premature beat creates a pause, allowing the ventricle to fill with more blood than usual 1
• The next normal beat contracts against this increased volume, producing a forceful sensation 1
• This is typically benign but requires systematic evaluation to exclude dangerous underlying conditions 1, 2

Immediate Assessment Required

Critical Red Flags Requiring Hospitalization

• Syncope or near-syncope with palpitations mandates immediate hospitalization 1
• Chest pain, dyspnea, or hemodynamic instability during episodes 1, 2
• Family history of sudden cardiac death in first-degree relatives 1

Essential Initial Workup

Obtain a 12-lead ECG immediately to: 2, 3

• Look for pre-excitation (delta waves) indicating Wolff-Parkinson-White syndrome—this requires immediate electrophysiology referral due to sudden death risk 2, 3
• Identify baseline QT prolongation (risk for torsades de pointes) 1
• Detect evidence of prior myocardial infarction or structural heart disease 1, 2
• Capture the arrhythmia if occurring during the visit 3

Pattern characterization is crucial: 2, 3

• Frequency and duration of episodes 2
• Triggers: exercise, caffeine, alcohol, stress, or positional changes 1, 2
• Associated symptoms: polyuria occurs in ~15% of SVT patients 2
• Response to maneuvers: does coughing or bearing down stop the episodes? 3

Diagnostic Strategy Based on Symptom Frequency

For Daily Palpitations

Use 24-48 hour Holter monitoring 2, 3

For Weekly Episodes

Event recorders have superior diagnostic yield and are more cost-effective than Holter monitoring 2

For Monthly or Less Frequent Episodes

Consider implantable loop recorder if symptoms are severe or associated with hemodynamic instability 2, 3

Critical pitfall to avoid: Do not consider non-diagnostic monitoring conclusive—monitoring must continue until symptoms occur while wearing the device 2

Exclude Reversible Triggers First

Before extensive cardiac workup, eliminate: 2, 4

• All caffeine (coffee, energy drinks, matcha, supplements)—caffeine cessation alone often controls palpitations 4
• Alcohol—a well-established trigger for atrial fibrillation 2, 4
• Nicotine and recreational drugs (cocaine, amphetamines) 1, 2
• Review all medications for QT-prolonging drugs 1

Check thyroid function tests to exclude hyperthyroidism 2

When to Order Echocardiography

Obtain echocardiography if: 2, 3

• Sustained palpitations are documented on any monitoring 2
• Clinical suspicion of structural heart disease (murmur, abnormal ECG, heart failure symptoms) 2, 3
• Hypertrophic cardiomyopathy suspected (family history, exertional symptoms) 2

Exercise Stress Testing Indications

Order exercise testing only if: 3

• Palpitations occur primarily during or immediately after physical exertion 3
• Syncope or presyncope occurs with exertion—must be performed in controlled environment with advanced life support available 3

Empiric Medical Therapy

After excluding significant bradycardia (<50 bpm), a beta-blocker may be prescribed empirically while awaiting monitoring results 2

Critical warning: Never start Class I or III antiarrhythmic drugs without documented arrhythmia due to significant proarrhythmic risk 2

Mandatory Immediate Electrophysiology Referral

Refer immediately to cardiac electrophysiology for: 2, 3

• Any pre-excitation on ECG (Wolff-Parkinson-White syndrome) 2, 3
• Wide complex tachycardia documented on any rhythm strip 2
• Severe symptoms during palpitations (syncope, dyspnea, chest pain) 2, 3
• Palpitations with syncope 3
• Drug resistance or intolerance to beta-blockers 2
• Patient desires definitive therapy (catheter ablation) rather than chronic medication 2

Special Consideration for Hypertrophic Cardiomyopathy

Patients with hypertrophic cardiomyopathy require 24-48 hour ambulatory monitoring every 1-2 years, with extended monitoring if additional atrial fibrillation risk factors present (left atrial dilatation, advanced age, NYHA class III-IV) 2

If Symptoms Resolve With Trigger Elimination

If palpitations resolve after eliminating caffeine/alcohol and addressing anxiety, no further cardiac workup is needed beyond initial ECG and history 4

Depression, poor self-rated health, and anxiety are significant predictors of palpitations—addressing underlying anxiety disorder is essential 4

Teaching Vagal Maneuvers

Instruct patients in Valsalva maneuver and carotid massage to perform during episodes 2, 3

• Termination with vagal maneuvers confirms re-entrant tachycardia involving AV nodal tissue 2
• This helps differentiate SVT from other arrhythmias and provides immediate symptom relief 3