What is the next step in managing a patient with dizziness, who has a 7-day monitor report showing sinus rhythm with occasional supraventricular ectopy (SVT) and no significant ventricular ectopy, with a history of dizziness and no known underlying cardiac conditions?

Management of Dizziness with Occasional Supraventricular Ectopy on 7-Day Monitor

In this patient with dizziness and a 7-day monitor showing only occasional supraventricular ectopy (4.4% burden) without any sustained arrhythmias, the next step is to exclude structural heart disease with an echocardiogram and then provide reassurance, as the findings do not explain the symptoms and no specific antiarrhythmic treatment is indicated. 1

Key Monitor Findings Analysis

The monitor report reveals several reassuring features:

• Normal sinus rhythm predominates with appropriate heart rate range (59-119 bpm, average 67 bpm) 1
• Rare ventricular ectopy (<1%) is benign and requires no intervention in the absence of structural heart disease 1, 2
• Occasional supraventricular ectopy (4.4%) represents premature atrial contractions, which are common and typically benign 1
• No sustained arrhythmias were captured—no SVT runs, no ventricular tachycardia, no pauses >3 seconds, and no AV block 1
• The patient-triggered event showed sinus rhythm following frequent PVCs, demonstrating that the ectopy suppressed with increased heart rate, which is characteristic of benign automaticity-driven ectopy 2

Critical Diagnostic Step: Exclude Structural Heart Disease

Obtain an echocardiogram to evaluate for structural abnormalities, as this fundamentally changes risk stratification and management. 1, 2 The ACC/AHA guidelines emphasize that the presence of associated heart disease should always be sought in patients with supraventricular arrhythmias, and an echocardiogram may be helpful. 1

Specifically assess for:

• Valvular abnormalities (aortic stenosis, mitral valve disease) that could cause syncope or dizziness 1
• Cardiomyopathy (hypertrophic, dilated) that may predispose to arrhythmias 1
• Left ventricular function to exclude tachycardia-mediated cardiomyopathy 1
• Structural congenital abnormalities if clinically suggested 1

Symptom-Arrhythmia Correlation Assessment

The lack of correlation between symptoms and documented arrhythmias is crucial. 3 The patient had dizziness as the indication, yet:

• No diary entries were recorded during the monitoring period 3
• The single patient-triggered event showed benign findings (sinus rhythm following PVCs) 2
• No significant arrhythmias occurred that would explain dizziness 1, 3

Research demonstrates that in patients referred for dizziness/syncope, only 2% show temporal correlation between symptoms and arrhythmias on ambulatory monitoring. 3 This suggests the dizziness likely has a non-cardiac etiology.

Management Algorithm

If Echocardiogram is Normal:

Provide reassurance that the cardiac findings are benign. 2, 4 The ACC/AHA guidelines state that simple ventricular ectopy in the absence of heart disease has not been demonstrated to have adverse prognostic significance, and the same applies to occasional supraventricular ectopy. 1, 2

• No antiarrhythmic therapy is indicated, as treatment of asymptomatic ectopy has not been shown to improve survival and may be hazardous 4
• Pursue alternative explanations for dizziness: orthostatic hypotension, vestibular disorders, medication side effects, dehydration, or neurological causes 1
• No further cardiac monitoring is needed unless symptoms clearly suggest paroxysmal arrhythmia 1

If Echocardiogram Shows Structural Abnormalities:

Refer to cardiology for risk stratification and management of the underlying cardiac condition. 1 The presence of structural heart disease changes the significance of even benign-appearing ectopy. 1, 4

Common Pitfalls to Avoid

Do not treat the ectopy with antiarrhythmic drugs. 1, 4 The guidelines are clear that asymptomatic premature ventricular contractions and supraventricular ectopy generally do not require perioperative therapy or further evaluation. 1 Antiarrhythmic therapy has not been shown to improve survival in patients without sustained arrhythmias and may cause harm. 4

Do not order additional prolonged monitoring without clear indication. 3 The 7-day monitor was adequate to capture the patient's rhythm profile. Further monitoring is only warranted if there is high clinical suspicion for paroxysmal sustained arrhythmias based on symptom characteristics (sudden onset/offset, palpitations, presyncope during episodes). 1

Do not assume the ectopy explains the dizziness. 3 The burden of supraventricular ectopy (4.4%) and ventricular ectopy (<1%) is insufficient to cause hemodynamic symptoms, and no temporal correlation was documented. 3

When to Consider Electrophysiology Referral

Referral to an arrhythmia specialist is not indicated in this case, but would be appropriate if: 1

• Sustained SVT or VT is documented on monitoring 1
• Pre-excitation (WPW pattern) is present on baseline ECG with history of palpitations 1
• Recurrent symptoms clearly correlate with arrhythmia on monitoring 1
• Structural heart disease is present with concerning arrhythmias 1