What is the best course of action for a patient with palpitations?

Management of Palpitations

The best course of action for a patient with palpitations is to immediately obtain a 12-lead ECG to identify the rhythm and look for pre-excitation, followed by determining whether the palpitations are regular or irregular, as this distinction fundamentally changes the entire diagnostic and therapeutic approach. 1

Immediate Assessment and Risk Stratification

Critical First Steps

• Obtain a 12-lead ECG immediately to capture the arrhythmia if symptoms are present, identify pre-excitation (delta waves indicating Wolff-Parkinson-White syndrome), and determine if the rhythm is regular or irregular 1, 2
• Assess hemodynamic stability—patients who are unstable require immediate DC cardioversion 1
• Look specifically for pre-excitation with a history of paroxysmal regular palpitations, which suggests AVRT and requires immediate electrophysiology referral due to sudden death risk 1, 2
• Pre-excitation with irregular palpitations strongly suggests atrial fibrillation with an accessory pathway—this is a medical emergency requiring immediate electrophysiological evaluation 1

Pattern Characterization (Most Critical Diagnostic Step)

The distinction between regular and irregular palpitations is the single most important factor in diagnosis 1:

Regular palpitations with sudden onset/termination suggest:

• AVNRT or AVRT (most common in younger patients) 1
• Ventricular tachycardia (may be associated with presyncope or syncope) 1
• Atrial flutter with regular ventricular response 1

Irregular palpitations suggest:

• Atrial fibrillation 1
• Premature atrial or ventricular contractions 3
• Multifocal atrial tachycardia (most common in patients with pulmonary disease) 3

Associated Symptoms That Demand Urgent Evaluation

• Syncope or presyncope (occurs in approximately 15% of SVT patients) 3, 1
• Chest discomfort or dyspnea 1
• Polyuria (caused by atrial natriuretic peptide release, suggests SVT) 3, 1
• Symptoms during exertion 1

Diagnostic Workup Strategy

History Elements That Guide Diagnosis

• Number of episodes, duration, frequency, mode of onset, and triggers are crucial for clinical decision-making 3, 1
• Response to vagal maneuvers (Valsalva, coughing, carotid massage)—termination by these maneuvers confirms re-entrant tachycardia involving AV nodal tissue 3, 1, 4
• Gradual onset and termination suggests sinus tachycardia, which requires evaluation for stressors like infection, volume loss, caffeine, nicotine, or medications 1

Eliminate Common Triggers Before Extensive Testing

• Stop all caffeine (including coffee, matcha, energy drinks), alcohol, nicotine, and review medications that may trigger arrhythmias 1, 2
• Caffeine cessation alone is often sufficient to control palpitations in patients with anxiety and a negative cardiac workup 2
• Energy drinks are particularly problematic as they contain high caffeine loads plus other cardiac stimulants 2
• Assess for recreational drug use 1

Ambulatory ECG Monitoring Selection

The choice of monitoring must match symptom frequency 1:

• Daily palpitations: 24-48 hour Holter monitoring 1, 4
• Several times per week: Event recorders have superior diagnostic yield and are more cost-effective than Holter monitoring 1
• Less frequent arrhythmias (less than daily): Event or loop recorders 1, 4
• Less than 2 episodes per month with severe symptoms: Consider implantable loop recorder 1, 4

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

Additional Diagnostic Testing

• Echocardiography is indicated when:

  • Sustained SVT is documented (to exclude structural heart disease that cannot be detected by physical examination alone) 1
  • Clinical suspicion of structural abnormalities like valvular aortic stenosis, hypertrophic cardiomyopathy, or tachycardia-mediated cardiomyopathy exists 1

• Exercise stress testing is indicated when:

  • Palpitations are clearly triggered by exertion 1, 4
  • Palpitations occur primarily during or immediately after physical exertion 4
  • Must be performed in a controlled environment with proper advanced life support 4

• Laboratory testing:

  • Thyroid function tests to exclude hyperthyroidism (a common non-cardiac cause) 1
  • Assess renal function (creatinine, GFR) as baseline for medication decisions 1
  • Monitor electrolytes, particularly potassium, which affects arrhythmia risk 1

Management Based on Diagnosis

Acute Management of Documented SVT

For stable patients with documented SVT:

• Teach vagal maneuvers (Valsalva, carotid massage) as first-line acute management 1, 4
• Beta-blocker therapy may be prescribed empirically after excluding significant bradycardia (<50 bpm) 1, 2
• Do NOT start Class I or III antiarrhythmic drugs without documented arrhythmia due to significant proarrhythmic risk 1

Definitive Treatment Considerations

• Patients with documented SVT, despite normal structural evaluation, require referral to a cardiac electrophysiologist for consideration of catheter ablation 1
• Catheter ablation has a high success rate with <5% recurrence and <1% risk of heart block, and is potentially curative 1
• A young patient with documented SVT and a normal structural heart is a good candidate for curative therapy rather than lifelong medication 1

Special Populations

Hyperthyroidism with palpitations:

• Restoration of euthyroid state is the primary goal—this usually results in spontaneous resolution of arrhythmias 1
• Atrial fibrillation occurs in 5-15% of hyperthyroid patients, more common in those over 60 years 1
• Beta-blockers are the preferred initial agent for rate control, but use with extreme caution 1
• If beta-blockers are contraindicated or cardiac function is impaired, use a nondihydropyridine calcium channel blocker 1
• Assess stroke risk using CHA₂DS₂-VASc score if atrial fibrillation is documented 1
• Do NOT abruptly withdraw beta-blockers once started, as this can precipitate thyroid storm 1

Hypertrophic cardiomyopathy:

• Requires 24-48 hour ambulatory monitoring every 1-2 years as part of periodic follow-up 1
• Extended monitoring is recommended for those with additional AF risk factors (left atrial dilatation, advanced age, NYHA class III-IV heart failure) 1

Mandatory Immediate Specialist Referral Criteria

Refer immediately to cardiac electrophysiology for: 1, 2, 4

• All patients with Wolff-Parkinson-White syndrome (pre-excitation on ECG) due to potential for lethal arrhythmias
• Wide complex tachycardia of unknown origin documented on any rhythm strip
• Severe symptoms during palpitations (syncope, dyspnea, chest pain)
• Drug resistance or intolerance in patients with narrow complex tachycardia
• Patients desiring definitive therapy (catheter ablation) rather than chronic medication
• Palpitations with syncope and evidence of structural heart disease
• Documented complex arrhythmias or sustained ventricular tachycardia

Critical Pitfalls to Avoid

• Do NOT rely on automatic ECG analysis systems—they are unreliable and commonly suggest incorrect diagnoses 1
• Do NOT start Class I or III antiarrhythmics empirically without documented arrhythmia 1
• Do NOT order comprehensive laboratory panels routinely 1
• Do NOT dismiss syncope with palpitations—this warrants urgent evaluation 1
• Do NOT consider non-diagnostic monitoring as conclusive—monitoring must capture symptomatic episodes 1

When Symptoms Resolve with Conservative Measures

• If symptoms resolve after caffeine elimination and addressing anxiety, no further cardiac workup is needed beyond what has already been completed 2
• Addressing underlying anxiety disorder is essential, as depression, poor self-rated health, and anxiety are significant predictors of palpitations 2
• 45% of patients with panic disorder have mitral valve prolapse and experience significantly greater increases in anxiety, nervousness, fear, palpitations, and tremors with caffeine 2