What is the appropriate evaluation and management of a patient experiencing palpitations?

Evaluation and Management of Palpitations

Initial Assessment

Obtain a 12-lead ECG immediately and characterize whether the rhythm is regular or irregular, as this distinction fundamentally changes the entire diagnostic approach. 1

Critical History Elements

• Onset and termination pattern: Sudden onset/offset with paroxysmal nature strongly suggests AVNRT or AVRT, while gradual acceleration/deceleration indicates sinus tachycardia triggered by stressors like infection, volume loss, caffeine, or medications 2, 1

• Rhythm regularity: Regular palpitations suggest PSVT, atrial flutter, or ventricular tachycardia; irregular palpitations indicate atrial fibrillation, premature contractions, or multifocal atrial tachycardia 2, 1

• Response to vagal maneuvers: Termination by Valsalva or coughing confirms re-entrant tachycardia involving AV nodal tissue (AVNRT or AVRT) 2, 3

• Associated symptoms: Syncope occurs in approximately 15% of SVT patients and suggests either rapid SVT onset, prolonged post-termination pause, or concomitant structural disease like aortic stenosis or hypertrophic cardiomyopathy 2, 1

• Polyuria: Release of atrial natriuretic peptide from atrial contraction against closed AV valves is pathognomonic for SVT 2, 1

ECG Interpretation Priorities

• Pre-excitation (delta waves) with regular palpitations: Presumptive AVRT requiring immediate electrophysiology referral 1

• Pre-excitation with irregular palpitations: Strongly suggests atrial fibrillation with accessory pathway—immediate electrophysiology evaluation mandatory due to sudden death risk 1

• Wide complex tachycardia: Look for AV dissociation or fusion complexes diagnostic of ventricular tachycardia; refer immediately to electrophysiology 1, 3

Ambulatory Monitoring Strategy

For patients with frequent or sustained palpitations, 48-hour ambulatory ECG monitoring is the first-line diagnostic test. 2

Monitoring Selection Algorithm

• Daily palpitations: 24-48 hour Holter monitoring 1, 4

• Several times per week: Event recorders have superior diagnostic yield and cost-effectiveness compared to Holter monitoring 1, 4

• Less than 2 episodes per month with severe symptoms: Consider implantable loop recorder 2, 1

• Monitoring must continue until symptoms occur while wearing the device—non-diagnostic monitoring should not be considered conclusive 1

Common Pitfall to Avoid

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

Echocardiography Indications

• Documented sustained SVT: Order echocardiography to exclude structural heart disease, which usually cannot be detected by physical examination alone 1

• Clinical suspicion of structural abnormalities: Valvular aortic stenosis, hypertrophic cardiomyopathy, or tachycardia-mediated cardiomyopathy (which can develop from SVT persisting weeks to months with fast ventricular response) 2, 1

Exercise Stress Testing

• Exertional palpitations: Exercise testing reproduces symptoms during controlled exercise to correlate with ECG findings and identify ischemia-driven arrhythmias 3

• Exertional syncope/presyncope: Perform in controlled environment with advanced life support available 3

Mandatory Immediate Electrophysiology Referral

• All patients with Wolff-Parkinson-White syndrome due to potential for lethal arrhythmias 1, 5

• Severe symptoms during palpitations (syncope, dyspnea, chest pain) 1, 3

• Wide complex tachycardia of unknown origin documented on any rhythm strip 1

• Drug resistance or intolerance in narrow complex tachycardia 1

• Patient desires definitive therapy (catheter ablation) rather than chronic medication 1, 5

Initial Management Approach

Lifestyle Modifications

• Immediately eliminate all caffeine intake including coffee, matcha, energy drinks, and caffeine-containing medications, as caffeine cessation alone is often sufficient to control palpitations in patients with anxiety and negative cardiac workup 5

• Stop alcohol, nicotine, and review all medications that may trigger arrhythmias 1

• Assess for recreational drug use 1

Acute Management

• Teach vagal maneuvers (Valsalva, carotid massage) as first-line acute management for SVT 2, 3

• Empiric beta-blocker therapy may be prescribed while awaiting monitoring results, but only after excluding significant bradycardia (<50 bpm) 1, 5

Critical Pitfall to Avoid

Never start Class I or III antiarrhythmic drugs without documented arrhythmia due to significant proarrhythmic risk 1, 5

Special Populations

Hypertrophic Cardiomyopathy

• 48-hour ambulatory monitoring every 1-2 years as part of periodic follow-up 1

• Extended monitoring if additional AF risk factors present (left atrial dilatation, advanced age, NYHA class III-IV) 1

• Exercise echocardiography for exertional or postural syncope to detect provocable LVOTO 2

Unexplained Syncope with Palpitations

• 12-lead ECG, upright exercise test, and 48-hour ambulatory ECG monitoring are mandatory 2

• Implantable loop recorder should be considered in patients with recurrent unexplained syncope at low risk of sudden cardiac death 2

• Do not dismiss syncope with palpitations—unexplained non-vasovagal syncope is a risk factor for sudden cardiac death, particularly in young patients 2, 1