I have palpitations (a heart‑thumping sensation); what evaluation and management steps should I take?

Evaluation and Management of Palpitations

If you are experiencing palpitations, you should obtain a 12-lead ECG immediately, characterize whether the rhythm feels regular or irregular, and determine if you have any high-risk features (syncope, chest pain, dyspnea, or exertional symptoms) that require urgent evaluation. 1

Immediate Steps and Risk Stratification

High-risk features requiring urgent evaluation include:

• Syncope or presyncope occurring with palpitations 1, 2
• Chest pain or dyspnea during episodes 1
• Palpitations triggered by physical exertion 1
• Any documented wide-complex tachycardia on rhythm strips 1

If any of these features are present, you should be hospitalized for monitoring and evaluation, as they may indicate life-threatening ventricular arrhythmias. 2

Essential Initial Evaluation

Mandatory First Test

• Obtain a 12-lead ECG immediately to identify baseline rhythm, look for pre-excitation patterns (Wolff-Parkinson-White syndrome), QT prolongation, or conduction abnormalities 1
• Do not rely on automated ECG interpretation—manual review by a physician is essential, as automated systems frequently produce incorrect diagnoses 1

Critical History Elements

Document the specific pattern of your palpitations: 1

• Sudden onset and termination suggests AVNRT or AVRT (re-entrant supraventricular tachycardia)
• Gradual acceleration and deceleration suggests sinus tachycardia
• Regular versus irregular rhythm is the single most important distinguishing feature
• Response to vagal maneuvers (bearing down, Valsalva)—if episodes terminate with these maneuvers, this confirms AV-nodal re-entrant tachycardia 1

Ask about associated symptoms: 1

• Polyuria occurs in approximately 15% of patients with supraventricular tachycardia
• Syncope, presyncope, chest discomfort, or dyspnea

Lifestyle and Medication Review

Immediately stop all of the following: 1

• Caffeine, alcohol, and nicotine
• Review all medications for QT-prolonging drugs, stimulants (cocaine, amphetamines), anabolic steroids, and over-the-counter supplements 2

Ambulatory Monitoring Strategy

The choice of monitoring depends on symptom frequency: 1

• Daily palpitations: 24-48 hour Holter monitoring 1
• Weekly episodes: External event recorder or loop recorder (superior diagnostic yield and more cost-effective than Holter) 1, 3
• Monthly or less frequent but severe episodes: Implantable loop recorder 1

The goal of monitoring is to capture the cardiac rhythm during a symptomatic episode—non-diagnostic monitoring should not be considered conclusive, and monitoring must continue until symptoms occur while wearing the device. 1

When to Obtain Echocardiography

Order transthoracic echocardiography if: 1

• Any sustained supraventricular tachycardia is documented
• Clinical suspicion exists for structural heart disease (valvular disease, cardiomyopathy, heart failure signs)
• To assess left atrial size, ventricular dimensions, wall thickness, systolic function, and exclude valvular or pericardial disease

Empiric Medical Therapy

Beta-blocker therapy may be initiated while awaiting monitoring results if you have excluded significant bradycardia (resting heart rate ≥50 bpm). 1 Metoprolol or atenolol are reasonable first-line agents. 1

Critical pitfall to avoid: Never start Class I (flecainide, propafenone) or Class III (sotalol, amiodarone) antiarrhythmic drugs without documented arrhythmia, as they carry substantial pro-arrhythmic risk. 1

Mandatory Specialist Referral Criteria

You must be referred immediately to cardiac electrophysiology if: 1

• Wolff-Parkinson-White syndrome (pre-excitation on ECG) with any history of palpitations
• Wide-complex tachycardia of unknown origin documented on any rhythm strip
• Severe symptoms during palpitations (syncope, marked dyspnea)
• Frequent or poorly tolerated episodes despite optimal medical therapy
• Patient preference for definitive cure rather than lifelong medication

For documented AVNRT or AVRT, catheter ablation achieves >95% acute success with <5% recurrence and <1% risk of complete heart block, making it an excellent option for young patients with structurally normal hearts. 1

Special Considerations

If Hyperthyroidism is Suspected

Check thyroid function tests—hyperthyroidism is a common non-cardiac cause that must be excluded. 4, 1 Atrial fibrillation occurs in 5-15% of hyperthyroid patients, more commonly in those over 60 years. 1 Beta-blockers are the preferred initial agent for rate control in hyperthyroidism, and most patients will spontaneously convert to sinus rhythm once euthyroid. 1

Benign Palpitations Without High-Risk Features

If you have brief, infrequent palpitations without syncope, chest pain, dyspnea, exertional triggers, family history of sudden cardiac death, or structural heart disease, reassurance with lifestyle modification is appropriate. 1 However, even "benign" palpitations warrant a baseline ECG and consideration of 24-48 hour monitoring if episodes are frequent enough to capture. 1

Common Pitfalls to Avoid

• Do not attribute palpitations to anxiety without thorough cardiac evaluation 1
• Never ignore syncope occurring with palpitations—it may signal ventricular arrhythmia or complete AV block 1
• Do not dismiss patient reports of palpitations even when ambulatory monitoring shows no arrhythmia, as serious pathology can still be present 1