What is the assessment and management of palpitations?

From the Guidelines

Palpitations should be assessed through a comprehensive approach including history, physical examination, and targeted investigations, prioritizing the most recent and highest quality study, which is the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.

Key Components of Assessment

• Begin by asking about the nature of palpitations (racing, skipping, fluttering), associated symptoms (syncope, chest pain, dyspnea), triggers, and duration.
• Obtain a complete medical history focusing on cardiac conditions, thyroid disorders, and medication use.
• Physical examination should assess vital signs, cardiac rhythm, and signs of structural heart disease.

Initial Investigations

• Initial investigations include a 12-lead ECG, complete blood count, electrolytes, thyroid function tests, and possibly cardiac enzymes if acute coronary syndrome is suspected.
• For intermittent palpitations, ambulatory monitoring with Holter monitors (24-48 hours) or event recorders (up to 30 days) may be necessary.

Management

• Management depends on the underlying cause.
• For benign palpitations, reassurance and lifestyle modifications (reducing caffeine, alcohol, and stress) are appropriate.
• For arrhythmias, specific treatments include beta-blockers (metoprolol 25-100mg twice daily), calcium channel blockers (diltiazem 120-360mg daily), or antiarrhythmics (amiodarone 200mg daily after loading).
• Atrial fibrillation may require rate control, anticoagulation with direct oral anticoagulants (apixaban 5mg twice daily) or warfarin (target INR 2-3), and possibly cardioversion.
• Ventricular arrhythmias might need referral for electrophysiology studies and consideration of implantable cardioverter-defibrillators.
• Underlying conditions like thyroid disorders or anemia should be treated appropriately.
• Patients with concerning features (syncope, family history of sudden death, structural heart disease) require urgent cardiology referral.
• Patient education about when to seek emergency care is essential for effective management of palpitations, as emphasized in the 2015 ACC/AHA/HRS guideline 1.

From the Research

Assessment of Palpitations

• Palpitations are a common, non-specific presenting complaint in primary healthcare and emergency departments, and are mostly a symptom of benign underlying disease, but can be a sign of life-threatening conditions 2.
• History and physical examination are important in the assessment of patients with palpitations, and the use of a 12-lead electrographic (ECG) monitor on presentation is the gold standard of diagnosis 2, 3.
• If the aetiology cannot be determined, an ambulatory Holter 24-48-h monitor can be used 2.

Management of Palpitations

• Treatment and follow-up of patients presenting with palpitations as the main complaint will depend on the aetiology and investigation findings 2.
• Patients with palpitations accompanied by dizziness, excessive fatigue, or chest pains should receive adequate acute care aiming to stabilise their condition before referring to a higher level of care 2.
• Beta-blockers are effective in maintaining sinus rhythm and controlling the ventricular rate during atrial fibrillation, and should be considered as first-line agents in the management of patients with atrial fibrillation 4, 5.
• Beta-blockers are particularly indicated in patients with heart failure and atrial fibrillation, and the choice of beta-blockers in this condition should be guided by tolerability and effects on symptoms and well-being 5.

Specific Considerations

• Atrial fibrillation is the most common arrhythmia in the general population and is frequently associated with organic heart disease, and beta-blockers are very effective in preventing atrial fibrillation after coronary artery bypass surgery 4.
• The risk of proarrhythmia associated with beta-blocker treatment is very low, and beta-blockers alone, or in combination with digoxin, are very effective in controlling the ventricular rate at rest and during exercise 4.
• A step-wise guide to the evaluation and management of patients with palpitations can help identify patients at highest risk for serious arrhythmias, and effective management of the varied causes of palpitations can be achieved through a proper evaluation and approach to medical therapy 6.