What is the approach to palpitations in asymptomatic patients in an urgent care setting?

From the Guidelines

For asymptomatic patients presenting with palpitations in the urgent care setting, the initial approach should focus on risk stratification and basic evaluation, prioritizing a thorough history and physical examination, including vital signs and a 12-lead ECG, as recommended by the guidelines 1. The approach to palpitations in asymptomatic patients in the urgent care setting involves several key steps.

• A thorough history and physical examination are crucial, including vital signs with particular attention to heart rate and rhythm, blood pressure, and oxygen saturation, to identify any potential underlying conditions that may be contributing to the palpitations.
• Obtaining a 12-lead ECG is essential to identify any arrhythmias, conduction abnormalities, or structural heart disease indicators, as noted in the guidelines 1.
• Basic laboratory tests should include electrolytes (particularly potassium, magnesium, and calcium), thyroid function tests, and a complete blood count, to rule out any underlying electrolyte imbalances or thyroid disorders that may be causing the palpitations.
• If the patient is truly asymptomatic at presentation with normal vital signs and a normal ECG, they can typically be discharged with outpatient follow-up within 1-2 weeks, as suggested by the guidelines 1.
• Patients should be instructed to avoid potential triggers such as caffeine, alcohol, and stimulants, and educated about red flag symptoms that warrant immediate return, including syncope, pre-syncope, chest pain, shortness of breath, or palpitations with severe symptoms.
• For those with frequent palpitations, consider providing a heart monitor for home use or scheduling Holter monitoring as an outpatient, to further evaluate the palpitations and determine the underlying cause. The underlying mechanism for most benign palpitations involves premature atrial or ventricular contractions, which are often harmless but can be perceived as skipped or extra beats by patients, as noted in the guidelines 1. More concerning arrhythmias typically present with symptoms and would require more urgent intervention, emphasizing the importance of a thorough initial evaluation and risk stratification.

From the Research

Evaluation of Palpitations in Asymptomatic Patients

The approach to evaluating palpitations in asymptomatic patients in an urgent care setting involves several steps, including:

• Taking a thorough patient history to identify potential causes of palpitations 2, 3
• Performing a physical examination to look for signs of underlying cardiac or noncardiac conditions 2, 3
• Conducting laboratory tests and basic electrocardiogram (ECG) to help diagnose the cause of palpitations 2, 3

Diagnostic Tools

Several diagnostic tools are available for evaluating palpitations, including:

• Holter monitor: a 24-hour ECG monitoring device 2, 4
• Event monitor: a device that allows patients to record their ECG when symptoms occur 4
• Transtelephonic electrocardiographic monitor: a device that allows patients to transmit their ECG readings to a healthcare provider 2
• Treadmill exercise stress test: a test that monitors the heart's activity during exercise 2
• Echocardiography: an imaging test that uses sound waves to create images of the heart 2
• Electrophysiologic studies: tests that evaluate the heart's electrical activity 2, 3

Selection of Diagnostic Tools

The selection of diagnostic tools depends on the patient's symptoms, medical history, and the suspected cause of palpitations. For example:

• Event recorders may be preferred over Holter monitors for patients with intermittent palpitations 4
• Ambulatory ECG monitoring and/or electrophysiological study may be undertaken if the initial evaluation results are negative and the patient is suspected to have heart disease or arrhythmic origin 3

Considerations for Asymptomatic Patients

For asymptomatic patients, the evaluation of palpitations may involve:

• A thorough history and physical examination to identify potential causes of palpitations 2, 3
• Laboratory tests and basic ECG to rule out underlying cardiac or noncardiac conditions 2, 3
• Consideration of outpatient evaluation options, such as Holter monitoring or event recording, if the patient is suspected to have a cardiogenic cause of palpitations 2, 4