How should I evaluate and manage palpitations in a perimenopausal woman (approximately 45‑55 years old)?

Evaluation and Management of Palpitations in Perimenopausal Women

Palpitations during perimenopause are usually benign and related to increased sympathetic activity caused by hormonal changes, but you must systematically exclude cardiac arrhythmias before attributing symptoms to menopause alone. 1

Initial Risk Stratification

Immediately identify high-risk features that mandate urgent cardiac evaluation:

• Syncope or presyncope accompanying palpitations indicates potentially life-threatening arrhythmia 2, 3
• Chest pain or dyspnea during episodes suggests cardiac origin 2, 3
• Palpitations occurring during exertion require exercise testing to exclude structural heart disease 2, 3
• Family history of sudden cardiac death mandates screening for inherited arrhythmia syndromes 2

If any of these features are present, proceed directly to urgent cardiology evaluation. 2

Mandatory Initial Workup

Obtain these tests in every perimenopausal woman presenting with palpitations:

• 12-lead ECG immediately to identify baseline rhythm, pre-excitation patterns (Wolff-Parkinson-White), QT prolongation, and conduction abnormalities 2, 3
• Thyroid function tests (TSH, free T4) because hyperthyroidism is a common non-cardiac cause and occurs more frequently in perimenopausal women 2
• Complete blood count to exclude anemia as a cause of compensatory tachycardia 2
• Serum electrolytes, especially potassium, which affects arrhythmia risk 2
• Renal function (creatinine, GFR) as baseline for medication decisions 2

Pattern Characterization

Document these specific features to guide diagnosis:

• Sudden onset and sudden termination suggests re-entrant tachycardia (AVNRT or AVRT), not sinus tachycardia 2, 3, 4
• Gradual acceleration and deceleration indicates sinus tachycardia, which is the expected pattern in perimenopausal hormonal changes 5, 2
• Response to vagal maneuvers (Valsalva, carotid massage): termination confirms AV-nodal re-entrant mechanism 2, 4
• Regular versus irregular rhythm: irregular palpitations suggest atrial fibrillation; regular with sudden onset/offset suggests AVNRT/AVRT 2, 4
• Polyuria occurs in approximately 15% of supraventricular tachycardia cases and is a specific clue to SVT 2, 4

Ambulatory Monitoring Strategy

Select monitoring based on symptom frequency:

• Daily palpitations: 24-48 hour Holter monitoring 2, 6
• Weekly episodes: external event recorder or loop recorder (superior diagnostic yield and more cost-effective than Holter) 2, 6, 7
• Monthly or less frequent but severe episodes: implantable loop recorder 2

The goal is to capture the cardiac rhythm during a symptomatic episode, not just a brief monitoring window. 2

Management Based on Findings

If No Arrhythmia Documented and Low-Risk Features

This is the most common scenario in perimenopausal women:

• Reassurance is appropriate when brief, infrequent palpitations occur without high-risk features and monitoring shows no arrhythmia 2, 1
• Beta-blocker therapy (metoprolol or atenolol) may be prescribed empirically after confirming resting heart rate ≥50 bpm, as beta-blockers are effective for physiological symptomatic sinus tachycardia triggered by emotional stress and hormonal fluctuations 5, 2
• Eliminate triggers: stop all caffeine, alcohol, and nicotine immediately 2
• Review all medications for QT-prolonging drugs, stimulants, and over-the-counter supplements 2

If Supraventricular Tachycardia Documented

Even young perimenopausal women with documented SVT and normal structural hearts require definitive management:

• Refer to cardiac electrophysiology for consideration of catheter ablation, which achieves >95% acute success for AVNRT with <5% recurrence and <1% risk of complete heart block 2
• Beta-blocker or non-dihydropyridine calcium-channel blocker (diltiazem, verapamil) while arranging electrophysiology referral 2
• Verapamil terminates acute SVT in ~93% of cases but beta-blockers are often preferred for long-term suppression 2

Do not start Class Ic (flecainide, propafenone) or Class III (sotalol, amiodarone) antiarrhythmics without documented sustained arrhythmia and exclusion of structural heart disease due to substantial pro-arrhythmic risk. 2

If Atrial Fibrillation Documented

Atrial fibrillation requires specific management:

• Transthoracic echocardiography to assess left atrial size, ventricular dimensions, systolic function, and exclude valvular disease 2
• CHA₂DS₂-VASc score to determine stroke risk and anticoagulation need 2
• Rate control with beta-blocker as first-line therapy 2

If Hyperthyroidism Confirmed

Restoration of euthyroid state is the primary goal, as this usually results in spontaneous resolution of arrhythmias:

• Beta-blockers are the preferred initial agent for rate control in hyperthyroidism 2
• If beta-blockers are contraindicated or cardiac function is impaired, use a non-dihydropyridine calcium-channel blocker instead 2
• Assess stroke risk using CHA₂DS₂-VASc score if atrial fibrillation is documented 2
• Most patients with thyrotoxicosis-induced arrhythmias will spontaneously convert to sinus rhythm once euthyroid 2

Mandatory Specialist Referral Criteria

Refer immediately to cardiac electrophysiology for:

• Wolff-Parkinson-White syndrome (pre-excitation on ECG) due to potential for lethal arrhythmias 2
• Wide-complex tachycardia documented on any rhythm strip 2
• Severe symptoms during palpitations (syncope, marked dyspnea) 2
• Frequent or poorly tolerated SVT despite optimal medical therapy 2
• Patient preference for definitive cure rather than lifelong medication 2

Critical Pitfalls to Avoid

• Never attribute palpitations to menopause or anxiety without obtaining a 12-lead ECG and checking thyroid function 2, 1
• Never ignore syncope occurring with palpitations, as it may signal ventricular arrhythmia or complete AV block 2
• Do not rely on automated ECG interpretation systems—they are unreliable and frequently produce erroneous diagnoses 2
• Never start antiarrhythmic drugs empirically without documented arrhythmia 2
• Do not dismiss the diagnosis if ambulatory monitoring shows no arrhythmia—patients may still report palpitations during normal rhythm, and further evaluation may be needed based on symptom burden and risk factors 2