What is the management approach for a patient experiencing palpitations, with or without a history of anxiety or cardiac conditions?

Management of Palpitations

Initial Evaluation and Risk Stratification

Obtain a 12-lead ECG immediately in all patients presenting with palpitations, as this is the gold standard initial test and may capture the arrhythmia if symptoms are present. 1, 2

Immediate High-Risk Features Requiring Hospitalization

• Syncope or near-syncope during palpitations mandates immediate hospitalization for continuous monitoring when ventricular arrhythmia is documented or suspected. 2, 3
• Pre-excitation (delta waves) on ECG indicates Wolff-Parkinson-White syndrome and requires immediate electrophysiology referral due to sudden death risk, particularly if irregular palpitations suggest atrial fibrillation. 2, 3
• Wide complex tachycardia of unknown origin requires immediate specialist referral. 2, 3
• Documented sustained ventricular arrhythmias require hospitalization for initiation of antiarrhythmic therapy. 2, 3
• Associated chest pain, dyspnea, or severe symptoms warrant urgent evaluation for structural heart disease. 1, 2, 3

Detailed Symptom Characterization

Obtain specific details about the palpitations to guide diagnosis and management:

• Frequency, duration, onset/offset patterns (sudden vs. gradual), and associated symptoms such as dizziness, chest pain, or syncope. 1
• Timing of symptoms: Nocturnal or postprandial palpitations suggest vagally-mediated arrhythmias, while daytime episodes during activity indicate adrenergically-mediated arrhythmias. 1, 3
• Precipitating factors: caffeine, alcohol, exercise, stress, medications, or illicit drugs. 1
• Hemodynamic stability: Assess for signs requiring immediate intervention. 1

Diagnostic Testing Algorithm

First-Line Investigations

• Perform 48-hour ambulatory ECG monitoring for patients with frequent or sustained palpitations. 4, 1
• Order basic laboratory tests including complete blood count, electrolytes, and thyroid function tests to rule out metabolic causes. 1

Second-Line Investigations

• Consider an event recorder or wearable loop recorder for patients with less frequent episodes (occurring less than daily). 1, 5
• Perform echocardiography to exclude structural heart disease, especially in patients with sustained palpitations or concerning associated symptoms. 1
• An implantable loop recorder (ILR) should be considered for patients with recurrent episodes of unexplained palpitations who are at low risk of sudden cardiac death. 4, 1
• Exercise ECG testing is particularly useful if palpitations are exercise-induced. 1

Role of Electrophysiological Studies

• Electrophysiological studies are not routinely recommended for patients with palpitations. 4
• EPS are indicated when ECG recordings fail to document the cause of palpitations in patients with clinically significant symptoms suspected to be of cardiac origin, or when palpitations precede a syncopal episode. 4

Management Based on Etiology

Conservative Management (First-Line for Benign Palpitations)

Eliminating stimulants such as caffeine, alcohol, and cigarettes is often sufficient to control symptoms before considering pharmacological therapy. 4, 1, 2

• Remove all caffeine sources including coffee, matcha, energy drinks, and caffeine-containing medications or supplements. 2
• Discontinue cigarette smoking and alcohol intake. 4, 1
• Avoid oral contraceptives in appropriate patients, as they may exacerbate palpitations. 1
• Address psychological factors: Depression, poor self-rated health, and anxiety are significant predictors of palpitations. 1, 3

Pharmacological Management

If symptoms persist after trigger elimination, initiate beta-blocker therapy, particularly when associated with mild tachyarrhythmias or increased adrenergic symptoms. 4, 2

• Ensure significant bradycardia (<50 bpm) has been excluded before starting beta-blockers. 2
• Non-dihydropyridine calcium channel blockers (verapamil or diltiazem) are effective alternatives for patients who cannot tolerate beta-blockers. 2
• Teach vagal maneuvers (Valsalva and carotid massage) to help terminate episodes and confirm re-entrant tachycardia. 2

Specific Arrhythmia Management

• For supraventricular tachycardia (SVT): Adenosine is the drug of choice for terminating AV nodal re-entrant tachycardia; consider vagal maneuvers, beta-blockers, or referral for catheter ablation. 1, 2
• For atrial fibrillation: Implement appropriate rate control or rhythm control strategies and assess stroke risk. 1
• For vagally-mediated AF: Avoid adrenergic blocking drugs or digitalis as they may worsen symptoms. 1
• For adrenergically-induced AF: Beta-blockers are the initial treatment of choice. 1
• For ventricular arrhythmias: Provide guideline-directed medical therapy; patients with sustained ventricular tachycardia require hospitalization. 1

Management of Orthostatic Symptoms

• Liberalize fluid and salt intake as the preferred initial approach for palpitations associated with postural hypotension and tachycardia. 1
• Use support stockings to improve venous return and reduce orthostatic symptoms. 1
• Mineralocorticoid therapy or clonidine may be needed in severe cases. 4

Mandatory Cardiology/Electrophysiology Referral Criteria

Refer immediately for:

• Pre-excitation on ECG (Wolff-Parkinson-White syndrome). 2, 3
• Syncope or severe symptoms during palpitations. 2, 3
• Wide complex tachycardia of unknown origin. 2, 3
• Evidence of structural heart disease. 2
• Documented complex or sustained ventricular arrhythmias. 2, 3
• Symptoms persisting despite caffeine elimination and beta-blocker therapy. 2
• Patient desires definitive therapy (catheter ablation) rather than chronic medication. 2
• Drug resistance or intolerance in patients with documented arrhythmias. 2

Critical Pitfalls to Avoid

• Never rely on automatic ECG interpretation systems, as they are unreliable and commonly suggest incorrect arrhythmia diagnoses. 2
• Do not delay obtaining 12-lead ECG during tachycardia; encourage patients to seek immediate evaluation during episodes to capture the arrhythmia. 2, 3
• Avoid empiric antiarrhythmic therapy without documented arrhythmia, as Class I and III agents carry significant proarrhythmia risk. 2, 3, 6
• Do not assume benign etiology in patients with irregular palpitations and pre-excitation, as this suggests atrial fibrillation in WPW syndrome, which carries sudden death risk. 2, 3
• Avoid using calcium channel blockers (verapamil and diltiazem) to terminate wide-QRS-complex tachycardia of unknown origin, especially in patients with myocardial dysfunction. 1
• Recognize that many patients report palpitations when continuous ambulatory ECG shows no arrhythmias at the time of symptoms, but this does not exclude serious underlying pathology. 4, 3
• Don't overlook non-cardiac causes such as hyperthyroidism, stimulant use, or anxiety disorders. 2
• Physical inactivity is a predictor of palpitations in men; gradual increase in physical activity may help reduce symptoms in sedentary patients. 1