What is the appropriate evaluation and management of a patient presenting with palpitations?

Evaluation and Management of Palpitations

Immediate Risk Stratification

All patients presenting with palpitations require immediate 12-lead ECG and assessment for high-risk features that determine whether hospitalization, urgent specialist referral, or outpatient management is appropriate. 1

Mandatory Immediate Hospitalization or Specialist Referral

• Syncope or near-syncope during palpitations requires hospitalization when ventricular arrhythmia is documented or suspected 1
• Pre-excitation (delta waves) on ECG indicates Wolff-Parkinson-White syndrome and demands immediate electrophysiology referral due to sudden death risk, particularly if irregular palpitations suggest atrial fibrillation 1, 2
• Wide complex tachycardia of unknown origin mandates immediate specialist referral 1, 2
• Sustained ventricular arrhythmias require hospitalization for antiarrhythmic therapy initiation 1
• Associated chest pain, dyspnea, or severe symptoms warrant urgent evaluation for structural heart disease 1, 3

Initial Diagnostic Approach

Step 1: Obtain 12-Lead ECG Immediately

The 12-lead ECG is the gold standard initial test and may capture the arrhythmia if symptoms are present. 1, 2

Look for:

• Pre-excitation patterns (delta waves) 2
• QT interval abnormalities 3
• Evidence of structural disease 2
• Rhythm during symptomatic episodes 1

Critical pitfall: Never rely on automatic ECG interpretation systems—they are unreliable and commonly suggest incorrect arrhythmia diagnoses. 1, 2

Step 2: Characterize the Pattern

The most important distinction is regular versus irregular rhythm, as this fundamentally changes the diagnostic approach 2

Document:

• Onset and termination pattern: Sudden onset/offset suggests AVNRT or AVRT; gradual acceleration suggests sinus tachycardia 2, 3
• Duration and frequency of episodes 2
• Response to vagal maneuvers: Termination confirms re-entrant tachycardia involving AV nodal tissue 1, 2
• Triggers: Caffeine, alcohol, nicotine, medications, exertion 1, 2
• Associated symptoms: Syncope, presyncope, chest pain, dyspnea, or polyuria (occurs in ~15% of SVT patients) 2, 3

Step 3: Physical Examination

• Look for irregular cannon A waves and irregular variation in S1 intensity during tachycardia, which strongly suggests ventricular origin 2
• Document vital signs including orthostatic measurements 3

Ambulatory Monitoring Strategy

The choice of monitoring depends on symptom frequency:

• Daily palpitations: 24-48 hour Holter monitoring 2
• Several times per week: Event recorders have superior diagnostic yield and are more cost-effective than Holter monitoring 2
• Less than twice monthly with severe features: Consider implantable loop recorder 2

Monitoring must continue until symptoms occur while wearing the device—non-diagnostic monitoring should not be considered conclusive. 2

Echocardiography Indications

Order echocardiography when:

• Documented sustained SVT to exclude structural heart disease 2
• Clinical suspicion of structural abnormalities (valvular disease, hypertrophic cardiomyopathy, tachycardia-mediated cardiomyopathy) 2
• Sustained palpitations or concerning symptoms 1

Initial Management Based on Etiology

First-Line: Eliminate Precipitating Factors

Caffeine cessation alone is often sufficient to control palpitations in patients with anxiety and negative cardiac workup. 1

• Remove all caffeine sources: coffee, matcha, energy drinks, caffeine-containing medications or supplements 1
• Eliminate alcohol, nicotine, and review medications that may trigger arrhythmias 1, 2
• Assess for recreational drug use 2
• Address underlying anxiety disorders 1

Second-Line: Teach Vagal Maneuvers

Instruct patients in Valsalva maneuver and carotid massage to perform during episodes—this can terminate episodes and confirm re-entrant tachycardia 1, 2

Third-Line: Beta-Blocker Therapy

If symptoms persist after trigger elimination, initiate beta-blocker therapy (Class I recommendation), particularly when associated with mild tachyarrhythmias or increased adrenergic symptoms. 1

Critical requirement: Ensure significant bradycardia (<50 bpm) has been excluded before starting beta-blockers. 1, 2

• Alternative: Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) are effective for patients who cannot tolerate beta-blockers (Class IIa recommendation) 1

Acute Termination of SVT

Adenosine is the drug of choice for terminating AV nodal re-entrant tachycardia (Class I recommendation). 1

Special Considerations

Hyperthyroidism

Patients with overt hyperthyroidism must be treated urgently—restoration of euthyroid state is the primary goal, as this usually results in spontaneous resolution of arrhythmias. 2

• Atrial fibrillation occurs in 5-15% of hyperthyroid patients, more commonly in those over 60 years 2
• Beta-blockers are the preferred initial agent for rate control, but use with extreme caution 2
• If beta-blockers are contraindicated or cardiac function is impaired, use nondihydropyridine calcium channel blockers 2
• Assess stroke risk using CHA₂DS₂-VASc score if atrial fibrillation is documented 2
• Never abruptly withdraw beta-blockers once started, as this can precipitate thyroid storm 2

Documented SVT

Patients with documented SVT, despite normal structural evaluation, require referral to cardiac electrophysiology for consideration of catheter ablation. 2

• Catheter ablation has a high success rate with <5% recurrence and <1% risk of heart block 2
• Young patients with documented SVT and normal structural hearts are good candidates for curative therapy rather than lifelong medication 2

Critical Pitfalls to Avoid

• Never start Class I or III antiarrhythmic drugs empirically without documented arrhythmia—these agents carry significant proarrhythmia risk 1, 2
• Do not delay obtaining 12-lead ECG during tachycardia—encourage patients to seek immediate evaluation during episodes to capture the arrhythmia 1
• Do not assume benign etiology in patients with irregular palpitations and pre-excitation—this suggests atrial fibrillation in WPW syndrome, which carries sudden death risk 1
• Recognize that palpitations frequently occur during normal rhythm—symptom-rhythm correlation through ambulatory monitoring is essential 1
• Do not dismiss syncope with palpitations—this warrants urgent evaluation 2, 3