What is the treatment for palpitations?

From the Guidelines

Palpitations can be effectively treated with a combination of lifestyle changes and medications, with flecainide being a preferred choice for long-term management of AVNRT, as evidenced by the highest quality study 1.

Treatment Options

The treatment of palpitations depends on the underlying cause, and a thorough diagnosis is essential to determine the best course of action. For immediate relief, lifestyle changes such as deep breathing exercises, avoiding stimulants like caffeine and alcohol, and staying hydrated can be beneficial.

• If palpitations are caused by anxiety, beta-blockers like propranolol (10-40mg as needed) or metoprolol (25-100mg daily) may be prescribed to reduce heart rate, as suggested by 1.
• For arrhythmia-related palpitations, medications such as flecainide (50-200mg twice daily) or calcium channel blockers like verapamil (120-360mg daily) might be recommended, with flecainide showing greater long-term efficacy than verapamil 1.

Lifestyle Modifications

Lifestyle modifications are essential for long-term management of palpitations, including:

• Regular exercise
• Stress reduction techniques
• Adequate sleep
• Avoiding triggers If palpitations are accompanied by chest pain, dizziness, shortness of breath, or fainting, immediate medical attention is necessary as these could indicate a serious cardiac condition, as highlighted by 1.

Medication Efficacy

The efficacy of medications for palpitations has been studied, with flecainide showing excellent chronic tolerance and safety in patients without structural heart disease, as reported by 1.

• Class Ic agents, such as flecainide and propafenone, are contraindicated for patients with structural heart disease.
• Class Ic drugs are often combined with beta-blocking agents to enhance efficacy and reduce the risk of one-to-one conduction over the AV node if atrial flutter occurs. The treatment works by either addressing the underlying cause or by modifying the heart's electrical system to maintain a normal rhythm, reducing the sensation of irregular or rapid heartbeats that characterize palpitations, as discussed in 1.

From the FDA Drug Label

For patients with PSVT and patients with PAF the recommended starting dose is 50 mg every 12 hours. Flecainide doses may be increased in increments of 50 mg bid every four days until efficacy is achieved For PAF patients, a substantial increase in efficacy without a substantial increase in discontinuations for adverse experiences may be achieved by increasing the flecainide dose from 50 mg to 100 mg bid.

Palpitations treatment with flecainide may be effective for patients with Paroxysmal Supraventricular Tachycardia (PSVT) and Paroxysmal Atrial Fibrillation (PAF). The recommended starting dose is 50 mg every 12 hours, which may be increased in increments of 50 mg bid every four days until efficacy is achieved. For PAF patients, increasing the dose to 100 mg bid may achieve a substantial increase in efficacy. 2

From the Research

Palpitations Treatment Overview

• Palpitations are a common symptom that can be caused by various factors, including cardiac arrhythmias, psychiatric illness, and substance use 3.
• A thorough history and physical examination, followed by targeted diagnostic testing, can help distinguish cardiac from noncardiac causes of palpitations 3.

Diagnostic Approach

• A 12-lead electrocardiogram (ECG) is an essential diagnostic tool for evaluating palpitations, and early ECG recording is crucial for accurate diagnosis 4.
• Ambulatory ECG monitoring, such as Holter monitoring, can be used to diagnose palpitations that occur intermittently 5.
• Echocardiogram and other imaging tests may be necessary to assess for structural heart disease 6.

Management Strategies

• Treatment of palpitations depends on the underlying cause and severity of symptoms 6, 5.
• Beta blockers are often used as a first-line treatment for arrhythmias, including supraventricular tachycardia and ventricular tachyarrhythmias 7.
• Management must be tailored on a case-by-case basis, taking into account the frequency, nature, and severity of symptoms, as well as the presence of underlying heart disease 6.

Special Considerations

• Patients with palpitations accompanied by symptoms such as dizziness, excessive fatigue, or chest pain require prompt evaluation and treatment to stabilize their condition 5.
• Early management of palpitations by a specialized cardiac unit can lead to high diagnostic accuracy and effective treatment 4.