What should a patient with a sensation of a heavy heartbeat, or palpitations, do to evaluate and manage their symptoms, especially if they have a history of anxiety or stress?

Evaluation and Management of Heavy Heartbeat Sensation (Palpitations)

For patients experiencing a sensation of heavy heartbeat or palpitations, especially with anxiety or stress history, the first priority is to identify warning signs requiring urgent evaluation: syncope/presyncope, chest pain, severe dyspnea, or palpitations during exercise—any of these mandate immediate cardiac assessment with ECG and possible monitoring. 1

Initial Assessment: Red Flags vs. Benign Features

Warning Signs Requiring Urgent Evaluation

• Syncope or presyncope (dizziness/lightheadedness) accompanying palpitations 1, 2
• Chest pain or pressure during episodes 1, 2
• Palpitations occurring during exercise 1
• Severe dyspnea 2
• Sudden onset and termination (suggests reentrant arrhythmias like AVNRT rather than benign causes) 1, 2

Likely Benign Features

• Gradual onset and offset suggests sinus tachycardia, particularly if triggered by identifiable stressors like fever, dehydration, caffeine, or anxiety 1, 2
• Palpitations that terminate with vagal maneuvers (bearing down, coughing) suggest AV nodal involvement but still warrant evaluation 1

Understanding the Anxiety-Palpitation Connection

In patients with anxiety or stress history, palpitations often represent heightened awareness of normal cardiac activity or sinus tachycardia from increased sympathetic tone rather than true arrhythmia. 3 However, this remains a diagnosis of exclusion after cardiac causes are ruled out.

• Depression, poor self-rated health, alcohol use (in women), and heavy coffee drinking with physical inactivity (in men) are significant predictors of palpitations in anxiety-prone patients 4
• Up to 45% of patients with panic disorder have mitral valve prolapse, though most palpitations in these patients occur when ambulatory ECG shows no arrhythmias 4

Diagnostic Approach

Step 1: Immediate Evaluation (All Patients)

• 12-lead ECG at presentation is the gold standard initial test 5, 6
• Detailed symptom characterization: regular vs. irregular, sudden vs. gradual onset/offset, duration, frequency 1, 5
• Identify triggers: caffeine, alcohol, nicotine, medications (adrenergic or anticholinergic drugs), exercise, stress 3, 5
• Screen for systemic causes: fever, dehydration, hyperthyroidism, anemia, hypoglycemia 5

Step 2: Risk Stratification

Patients with structural heart disease or known arrhythmia history require more aggressive evaluation, as physiologic stress can trigger clinically significant arrhythmias. 2

Step 3: Ambulatory Monitoring (When Initial ECG Non-Diagnostic)

• For daily palpitations: 24-48 hour Holter monitoring 2, 5
• For less frequent episodes: Event recorders or loop recorders are more effective and cost-effective than Holter monitors 2, 5
• For very infrequent episodes: Initial two-week course of continuous closed-loop event recording 5

Management Strategy

For Benign Sinus Tachycardia (Most Common in Anxiety/Stress)

Eliminate stimulants first—cessation of caffeine, alcohol, and cigarettes may be sufficient to control symptoms without medication. 4

• Address underlying stressors: ensure adequate hydration, control fever if present, encourage rest 2
• Volume expansion for orthostatic symptoms: liberalize fluid and salt intake 4
• Support stockings may help orthostatic tachycardia 4

When Medication Is Needed

Beta-blockers are the first-line pharmacologic treatment for palpitations associated with mild tachyarrhythmias, increased adrenergic symptoms, chest pain, anxiety, or fatigue. 4

• Continue baseline cardiac medications unless contraindicated 2
• Consider empiric beta-blocker therapy while awaiting monitoring results in patients with pre-existing heart conditions 2

For Patients with Structural Heart Disease

• Echocardiography and prolonged ECG monitoring are recommended as first evaluation steps 4
• Electrophysiological studies if non-diagnostic 4

Special Considerations

Post-Viral Illness

Consider post-acute sequelae of SARS-CoV-2 (PASC) causing persistent tachycardia through autonomic dysfunction, particularly postural orthostatic tachycardia syndrome (POTS). 2

• Use 10-minute active stand test to evaluate for POTS 2

Psychiatric Assessment

Psychiatric evaluation is recommended for patients with frequent recurrent syncope who have multiple other somatic complaints when initial evaluation raises concerns for stress, anxiety, or other psychiatric disorders. 4

Common Pitfalls to Avoid

• Don't assume anxiety is the cause without ECG documentation—cardiac arrhythmias can coexist with anxiety disorders 5
• Don't overlook very frequent PVCs (>10,000-20,000/day), which can lead to reversible PVC-induced cardiomyopathy 1
• Don't use rate alone to determine urgency—with heart rates <150 bpm and no ventricular dysfunction, tachycardia is more likely secondary to underlying conditions rather than the primary problem 4
• Don't "normalize" compensatory tachycardia in patients with poor cardiac function, as cardiac output may be rate-dependent 4