From the Guidelines
The diagnostic workup for palpitations should begin with a thorough history and physical examination, followed by a 12-lead electrocardiogram (ECG) to identify any underlying arrhythmias or structural heart abnormalities, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.
Initial Evaluation
The initial evaluation of a patient with palpitations should include a thorough history and physical examination to identify any underlying cardiac or non-cardiac causes of the symptoms. This should be followed by a 12-lead ECG to identify any underlying arrhythmias or structural heart abnormalities.
Ambulatory Cardiac Monitoring
If the initial evaluation is inconclusive and palpitations are intermittent, ambulatory cardiac monitoring is recommended, with the choice of monitor depending on symptom frequency. For symptoms occurring daily, a 24-48 hour Holter monitor is appropriate; for weekly episodes, a 7-30 day event recorder; and for very infrequent episodes, an implantable loop recorder may be necessary, as suggested by the acc/aha/esc guidelines for the management of patients with supraventricular arrhythmias 1.
Additional Testing
Additional testing may include laboratory studies to check electrolytes, thyroid function, and complete blood count, as well as an echocardiogram to assess cardiac structure and function if structural heart disease is suspected, as recommended by the eacvi appropriateness criteria for the use of transthoracic echocardiography in adults 1. Exercise stress testing can be valuable if palpitations are exercise-induced.
Referral to a Specialist
For patients with concerning features such as syncope, family history of sudden cardiac death, or abnormal ECG findings, referral to a cardiologist or electrophysiologist is warranted, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. The goal of this stepwise approach is to correlate symptoms with a specific cardiac rhythm disturbance, as management strategies differ significantly based on the underlying cause of palpitations.
Some key points to consider in the diagnostic workup of palpitations include:
- A thorough history and physical examination to identify any underlying cardiac or non-cardiac causes of the symptoms
- A 12-lead ECG to identify any underlying arrhythmias or structural heart abnormalities
- Ambulatory cardiac monitoring to correlate symptoms with a specific cardiac rhythm disturbance
- Additional testing, such as laboratory studies and echocardiogram, to assess cardiac structure and function if structural heart disease is suspected
- Referral to a cardiologist or electrophysiologist for patients with concerning features or abnormal ECG findings.
From the Research
Diagnostic Workup for Palpitations
The diagnostic workup for palpitations typically involves a combination of the following steps:
- History and physical examination to identify potential underlying causes and assess the patient's overall health 2, 3, 4, 5, 6
- 12-lead electrocardiogram (ECG) to evaluate the heart's rhythm and identify any potential abnormalities 2, 3, 4, 5, 6
- Ambulatory electrocardiogram monitoring, such as Holter monitoring or event monitoring, to capture episodes of palpitations and determine their cause 2, 3, 4, 5, 6
- Electrophysiological study to evaluate the heart's electrical activity and identify any potential arrhythmias 2, 3
- Laboratory tests, such as blood work, to rule out underlying conditions that may be contributing to the palpitations 3, 4, 6
- Imaging studies, such as echocardiography, to evaluate the heart's structure and function 3, 6
- Exercise stress testing to evaluate the heart's response to physical activity and identify any potential ischemic symptoms 6
Special Considerations
- Patients with a history of cardiovascular disease, palpitations at work, or palpitations that affect sleep may require a more in-depth evaluation for heart disease 6
- Patients with symptoms such as dizziness, near-syncope, or syncope may require urgent evaluation and treatment 4, 5
- Patients with palpitations accompanied by chest pain, shortness of breath, or other symptoms of heart failure may require immediate medical attention 6