Should I be concerned about palpitations during a cold, especially with a history of heart conditions?

Palpitations During a Cold: Clinical Assessment and Management

Palpitations during a cold are usually benign and result from sinus tachycardia triggered by infection-related stressors (fever, dehydration, increased metabolic demand), but patients with pre-existing heart conditions require careful evaluation to exclude arrhythmias or worsening cardiac function. 1

Understanding the Mechanism

During acute viral infections like the common cold, several physiologic stressors can trigger palpitations:

• Sinus tachycardia is the most common cause, accelerating and terminating gradually in response to infection, fever, dehydration, or increased sympathetic tone 1
• The body's compensatory response to volume loss from decreased oral intake or fever-related fluid losses can precipitate tachycardia 2
• Increased adrenergic tone from the stress response to illness naturally elevates heart rate 3

When to Be Concerned: Red Flag Features

You should be more concerned if palpitations are accompanied by any of the following symptoms, which suggest a potentially serious arrhythmia rather than simple sinus tachycardia: 1, 2

• Syncope or presyncope (loss of consciousness or near-fainting)
• Chest pain or pressure
• Severe dyspnea (shortness of breath out of proportion to the cold symptoms)
• Sudden onset and sudden termination of palpitations (suggests AVNRT or AVRT rather than sinus tachycardia) 1, 2
• Irregular palpitations (may indicate atrial fibrillation, especially concerning in patients with structural heart disease) 1

Special Considerations for Patients with Heart Conditions

If you have a history of heart disease, the threshold for evaluation should be lower: 1

• Patients with structural heart disease (valvular disease, cardiomyopathy, prior MI) are at higher risk for clinically significant arrhythmias during physiologic stress 1
• Those with known arrhythmia history may experience recurrence triggered by the metabolic stress of infection 1
• Tachycardia-mediated cardiomyopathy can develop if SVT persists for weeks to months with fast ventricular response, making timely evaluation important 1, 2

Immediate Assessment Steps

Characterize the palpitation pattern, as this fundamentally changes the diagnostic approach: 2

• Regular vs. irregular rhythm is the most important distinction 2
• Sudden onset/termination suggests AVNRT or AVRT 2, 4
• Gradual acceleration/deceleration suggests sinus tachycardia 1, 2
• Response to coughing or Valsalva maneuver (if palpitations stop) suggests re-entrant SVT involving AV nodal tissue 1, 4

When to Seek Medical Evaluation

Obtain a 12-lead ECG if: 2, 5

• Palpitations persist beyond resolution of cold symptoms
• Any red flag symptoms are present (syncope, chest pain, severe dyspnea)
• You have known structural heart disease or prior arrhythmias
• Palpitations are irregular or have sudden onset/termination pattern

The 12-lead ECG should be obtained to identify the rhythm, look for pre-excitation, and determine if the tachycardia is regular or irregular. 2

Diagnostic Workup for Persistent Symptoms

If palpitations continue after the acute illness resolves:

• 24-48 hour Holter monitoring is appropriate for daily palpitations 2, 5
• Event recorders or loop recorders are more effective and cost-effective for less frequent episodes (several times per week or less) 2, 6
• Targeted laboratory testing based on clinical suspicion: complete blood count (anemia), thyroid function (hyperthyroidism), electrolytes (hypokalemia, hypomagnesemia) 2, 5

Avoid ordering comprehensive laboratory panels routinely, as they have low diagnostic yield; instead, order targeted tests based on specific clinical suspicion from history and physical examination. 5

Management Approach

For simple sinus tachycardia during a cold: 1, 2

• Address underlying stressors: ensure adequate hydration, control fever with antipyretics, rest
• Avoid caffeine, nicotine, decongestants containing pseudoephedrine or phenylephrine (which increase adrenergic tone) 3
• Symptoms should resolve as the infection clears

For patients with pre-existing heart conditions experiencing palpitations during illness: 1, 2

• Continue baseline cardiac medications unless contraindicated
• Consider empiric beta-blocker therapy (after excluding significant bradycardia <50 bpm) while awaiting monitoring results 2
• Never start Class I or III antiarrhythmic drugs without documented arrhythmia due to significant proarrhythmic risk 2

Mandatory Specialist Referral Criteria

Immediate referral to cardiac electrophysiology is required for: 2

• Wolff-Parkinson-White syndrome (pre-excitation on ECG with palpitations) due to risk of sudden death
• Wide complex tachycardia documented on any rhythm strip
• Severe symptoms during palpitations (syncope, severe dyspnea)
• Pre-excitation with irregular palpitations (suggests atrial fibrillation with accessory pathway)

Common Pitfalls to Avoid

• Do not dismiss syncope occurring with palpitations as vasovagal—this requires thorough arrhythmia evaluation 2
• Do not rely on automatic ECG interpretation systems, as they frequently suggest incorrect diagnoses 2
• Do not assume all palpitations during illness are benign sinus tachycardia without proper rhythm documentation, especially in patients with structural heart disease 1
• Do not order Holter monitoring for infrequent symptoms—event recorders have superior diagnostic yield for episodes occurring less than daily 2, 6

Post-COVID Considerations

If the "cold" is actually COVID-19 or recent COVID-19 infection, additional considerations apply: 1

• Post-acute sequelae of SARS-CoV-2 (PASC) can cause persistent tachycardia and palpitations through autonomic dysfunction
• Consider 10-minute active stand test to evaluate for postural orthostatic tachycardia syndrome (POTS), defined as heart rate increase >30 bpm in adults ≥19 years or >40 bpm in those <19 years 1
• Ambulatory rhythm monitoring should exclude arrhythmia and define the pattern of heart rate elevation 1