When are heart palpitations an emergency and what work‑up and treatment should be done in an adult, especially if they have known cardiac disease, hypertension, diabetes, thyroid disorder, anemia, or are older than 60 years?

When Heart Palpitations Are an Emergency

Hospitalize immediately any adult with palpitations accompanied by syncope, near-syncope, chest pain, dyspnea, or hemodynamic instability, as these symptoms indicate potentially life-threatening ventricular arrhythmias requiring urgent monitoring and management. 1

Emergency Warning Signs Requiring Immediate Hospitalization

Palpitations become emergent when accompanied by:

• Syncope or near-syncope – indicates possible ventricular arrhythmia or hemodynamically significant rhythm disturbance requiring immediate hospitalization 1
• Chest pain – suggests possible acute coronary syndrome or ischemia-triggered arrhythmia 1
• Dyspnea or signs of heart failure – pulmonary edema, elevated jugular venous pressure, third heart sound, or pulmonary crackles indicate decompensation 1
• Hemodynamic instability – hypotension, altered mental status, or shock 1
• Documented ventricular arrhythmia on any rhythm strip 1

High-Risk Patient Populations Requiring Lower Threshold for Urgent Evaluation

Patients with Known Cardiac Disease

• Structural heart disease (coronary artery disease, cardiomyopathy, valvular disease, congenital heart disease) dramatically increases risk of sudden cardiac death regardless of symptom severity 1
• Prior myocardial infarction – palpitations may herald recurrent ischemia or ventricular tachycardia 1
• Heart failure – new palpitations suggest worsening disease or atrial fibrillation with rapid ventricular response 1

Age ≥60 Years

• Ventricular arrhythmias occur in 70-80% of persons over age 60, with complex ectopy common even when asymptomatic 1
• Incidence of sudden cardiac death increases progressively with advancing age 1
• Atrial fibrillation prevalence rises sharply: approximately 1% under age 60 versus 9-12% in those 75-84 years 1

Patients with Hypertension

• Hypertension is the most common comorbidity in atrial fibrillation (present in 81-83% of Medicare beneficiaries with AF) 1
• Uncontrolled blood pressure increases risk of both arrhythmias and stroke 1

Patients with Diabetes Mellitus

• Diabetes is present in 36-53% of patients with atrial fibrillation and increases stroke risk 1
• Metabolic disorders can precipitate or exacerbate arrhythmias 1

Patients with Thyroid Disorders

• Thyrotoxicosis can precipitate atrial fibrillation and other tachyarrhythmias 1
• Must be excluded as reversible precipitant before labeling arrhythmia as primary cardiac 2

Patients with Anemia

• Anemia is present in 42-46% of patients with atrial fibrillation and can precipitate or worsen palpitations 1
• Pallor and tachycardia on examination suggest anemia as contributing factor 1

Initial Diagnostic Work-Up

Immediate Bedside Assessment

• 12-lead ECG – first-line diagnostic tool, must be obtained immediately in all patients with palpitations 1
• Vital signs – heart rate, blood pressure (check both arms), respiratory rate, oxygen saturation 1
• Focused physical examination looking for:
  • Irregular pulse suggesting atrial fibrillation 1
  • Jugular venous distension indicating heart failure 1
  • New cardiac murmurs (ischemic mitral regurgitation, aortic stenosis) 1
  • Signs of heart failure (pulmonary crackles, third heart sound, peripheral edema) 1
  • Blood pressure differential between arms suggesting aortic dissection 1

Laboratory Evaluation

• Cardiac troponin (high-sensitivity preferred) – to detect myocardial injury or infarction 1
• Thyroid function tests (TSH, free T4) – thyroid disorders are common precipitants 1
• Complete blood count – to assess for anemia 1
• Basic metabolic panel – electrolyte abnormalities (potassium, magnesium, calcium) and renal function 1
• Blood glucose – hypoglycemia can cause palpitations 3

Rhythm Documentation Strategy

For patients with daily palpitations:

• 24-48 hour Holter monitoring is appropriate for frequent symptoms 3, 4

For patients with infrequent or unpredictable palpitations:

• Two-week continuous event recorder as initial strategy 3
• 30-day external continuous monitoring for less frequent symptoms 4
• Implantable loop recorders for very infrequent but concerning symptoms, especially if associated with syncope 4, 5

Echocardiography

• Transthoracic echocardiogram should be obtained to assess:
  • Left ventricular systolic and diastolic function 1
  • Valvular abnormalities (mitral valve prolapse, aortic stenosis, mitral regurgitation) 1
  • Structural heart disease (cardiomyopathy, wall motion abnormalities) 1
  • Left atrial size in patients with atrial fibrillation 1

Treatment Approach Based on Diagnosis

If Atrial Fibrillation is Documented

Stroke risk stratification using CHA₂DS₂-VASc score: 1, 2

• Congestive heart failure: 1 point
• Hypertension: 1 point
• Age ≥75 years: 2 points
• Diabetes mellitus: 1 point
• Prior stroke/TIA/thromboembolism: 2 points
• Vascular disease: 1 point
• Age 65-74 years: 1 point
• Female sex: 1 point

Anticoagulation decisions: 1, 2

• Score ≥2 (men) or ≥3 (women): Oral anticoagulation strongly recommended (Class I) 1, 2
• Direct oral anticoagulants (DOACs) preferred over warfarin as first-line therapy 1, 2
• Score 0 (men) or 1 from sex alone (women): No anticoagulation recommended 1, 2

Rate and rhythm control: 1

• Beta-blockers or calcium channel blockers for rate control 1
• Consider rhythm control with antiarrhythmic drugs or catheter ablation based on symptoms 1

If Ventricular Arrhythmias are Documented

For patients with structural heart disease and sustained ventricular tachycardia:

• Hospitalization mandatory for monitoring and management 1
• Antiarrhythmic drugs (amiodarone preferred in elderly or those with heart failure) 1
• ICD therapy should be considered for secondary prevention in survivors of cardiac arrest or sustained VT 1

For elderly patients (>60 years):

• Treat ventricular arrhythmias similarly to younger patients, but adjust dosing for altered pharmacokinetics 1
• Do not implant ICD if life expectancy <1 year due to major comorbidities 1

If Benign Arrhythmias (Premature Beats, Sinus Tachycardia)

Reassurance and risk factor modification:

• Address precipitating factors: caffeine, alcohol, nicotine, stimulant medications 1, 3
• Optimize management of hypertension, diabetes, thyroid disease, anemia 1
• Weight reduction in obese patients (target BMI 20-25 kg/m²) 1
• Beta-blockers may reduce symptoms if troublesome 1

Critical Pitfalls to Avoid

• Do not dismiss palpitations in elderly patients as benign – complex ventricular ectopy is common and may presage sudden cardiac death 1
• Do not withhold anticoagulation based on bleeding risk scores alone – absolute benefit of anticoagulation outweighs bleeding risk at CHA₂DS₂-VASc ≥2 2
• Do not use aspirin instead of anticoagulation for stroke prevention in atrial fibrillation – aspirin is not recommended even in low-risk patients 1, 2
• Do not assume palpitations correlate with arrhythmia – palpitations are frequently reported during normal rhythm, and many patients with serious arrhythmias have no palpitations 1, 3, 6
• Do not overlook medication-induced QT prolongation – review all medications, supplements, and over-the-counter drugs for potential to cause torsades de pointes 1
• Do not forget to assess for reversible precipitants – infection, fever, anemia, thyroid disorders, electrolyte abnormalities must be corrected 1