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

Evaluation and Management of Palpitations

Initial Assessment

Obtain a 12-lead ECG immediately to identify the rhythm, look for pre-excitation (delta waves indicating Wolff-Parkinson-White syndrome), and determine if the tachycardia is regular or irregular. 1, 2

The most critical distinction in evaluating palpitations is whether the rhythm is regular versus irregular, as this fundamentally changes the entire diagnostic approach and differential diagnosis. 1

Key History Elements to Obtain

• Onset and termination pattern: Sudden onset/offset with paroxysmal nature strongly suggests AVNRT or AVRT, while gradual acceleration/deceleration indicates sinus tachycardia. 3, 1
• Regularity: Regular palpitations suggest PSVT, atrial flutter, or VT; irregular palpitations suggest atrial fibrillation, premature contractions, or multifocal atrial tachycardia. 3, 1
• Response to vagal maneuvers: Termination by coughing, Valsalva, or carotid massage confirms re-entrant tachycardia involving AV nodal tissue (AVNRT or AVRT). 3, 1, 2
• Associated symptoms: Syncope occurs in ~15% of SVT patients and may indicate rapid conduction over an accessory pathway, structural abnormalities (valvular stenosis, hypertrophic cardiomyopathy), or ventricular arrhythmias. 3, 1
• Polyuria: Suggests SVT due to atrial natriuretic peptide release from atrial contraction against closed AV valves. 3, 1
• Triggers: Identify caffeine, alcohol, nicotine, medications, recreational drugs, exertion, infection, or volume loss. 1, 4

Physical Examination Findings

• Irregular cannon A waves and irregular variation in S1 intensity during tachycardia strongly suggests ventricular origin. 1
• Assess for hemodynamic instability requiring immediate intervention. 2

Immediate Management Based on ECG Findings

If Pre-excitation (Delta Waves) Present

Refer immediately to cardiac electrophysiology due to risk of sudden death, particularly if irregular palpitations suggest atrial fibrillation with accessory pathway conduction. 1, 4

If Hemodynamically Unstable

Perform DC cardioversion immediately. 1

If Wide Complex Tachycardia Documented

Refer immediately to cardiac electrophysiology, as this may represent ventricular tachycardia or SVT with aberrancy; look for AV dissociation or fusion complexes diagnostic of VT. 1, 4

Ambulatory Monitoring Strategy

The choice of monitoring must match symptom frequency:

• Daily palpitations: 24-48 hour Holter monitoring. 1, 2
• Several times per week: Event recorders have superior diagnostic yield and cost-effectiveness compared to Holter monitoring. 1
• Less than twice monthly with severe symptoms: Consider implantable loop recorder. 1, 2
• Exertional palpitations: Exercise stress testing in controlled environment with advanced life support available. 1, 2

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

Lifestyle Modifications Before Further Workup

Immediately eliminate all caffeine intake (coffee, matcha, energy drinks, caffeine-containing medications), alcohol, and nicotine, as caffeine cessation alone is often sufficient to control palpitations in patients with anxiety and negative cardiac workup. 1, 4

Assess for recreational drug use. 1

Echocardiography Indications

Order echocardiography when:

• Documented sustained SVT to exclude structural heart disease. 1
• Clinical suspicion of valvular aortic stenosis, hypertrophic cardiomyopathy, or tachycardia-mediated cardiomyopathy. 1, 2

Empiric Medical Therapy

A beta-blocker may be prescribed empirically while awaiting monitoring results, but only after excluding significant bradycardia (<50 bpm). 1, 4

Critical pitfall: Never start Class I or III antiarrhythmic drugs without documented arrhythmia due to significant proarrhythmic risk. 1

Teach Vagal Maneuvers

Instruct patients in Valsalva maneuver and carotid massage to perform during episodes, as this helps terminate re-entrant tachycardias and confirms diagnosis. 1, 2, 4

Mandatory Specialist Referral Criteria

Refer immediately to cardiac electrophysiology for:

• All patients with Wolff-Parkinson-White syndrome (pre-excitation on ECG) due to potential for lethal arrhythmias. 1, 4
• Severe symptoms during palpitations (syncope, dyspnea, chest pain). 1, 4
• Wide complex tachycardia of unknown origin documented on any rhythm strip. 1, 4
• Drug resistance or intolerance in narrow complex tachycardia. 1
• Patients desiring curative therapy rather than lifelong medication, as catheter ablation has high success rate with <5% recurrence and <1% risk of heart block. 1

Special Considerations

Documented SVT Management

Patients with documented SVT, despite normal structural evaluation, require referral to cardiac electrophysiology for consideration of catheter ablation, as documented SVT episodes are real and require treatment regardless of whether all symptomatic episodes correlate with arrhythmia. 1

Tachycardia-Mediated Cardiomyopathy

SVT persisting for weeks to months with fast ventricular response can lead to tachycardia-mediated cardiomyopathy, emphasizing the importance of timely diagnosis and treatment. 3, 1

Hypertrophic Cardiomyopathy

Patients require 24-48 hour ambulatory monitoring every 1-2 years as part of periodic follow-up, with extended monitoring if additional AF risk factors present (left atrial dilatation, advanced age, NYHA class III-IV). 1

Critical Pitfalls to Avoid

• Do not rely on automatic ECG analysis systems, as they are unreliable and commonly suggest incorrect diagnoses. 1
• Do not order comprehensive laboratory panels routinely; limit testing to thyroid function if clinically indicated. 1
• Do not dismiss syncope with palpitations, as this warrants urgent evaluation. 1