Palpitations? Here Are Three Therapeutic Options

Matthew F. Watto, MD; Paul N. Williams, MD


June 21, 2022

This transcript has been edited for clarity.

Matthew F. Watto, MD: Hey! Welcome back to The Curbsiders. I'm Dr Matthew Watto, here with my great friend, Dr Paul Nelson Williams.

Paul N. Williams, MD: I'm always excited to hear how you refer to me, what degree of friend I am, because that's a good barometer for what the rest of our day will look like. It's nice knowing I'm in "great" territory right now.

Watto: I'm sure people want to hear about palpitations because that's why they clicked on the video. We talked with Dr Joshua Cooper. You and Eddie Jiang produced this podcast. One of the very simple yet wonderful pearls that he gave us is that when he's asking a patient about palpitations, he asks them to actually tap out on their hand how strong it is and the rhythm that they were feeling. He said that can be helpful to him when he's assessing them.

I was interested to learn that some patients describe PVCs (premature ventricular contractions) as a "flip-flopping" sensation in their chest, a very brief pounding, or their heart stopping. That's a historical clue, but Dr Cooper didn't focus on that one as much.

Tachyarrhythmias such as SVT (supraventricular tachycardia) have a very abrupt onset. Anxiety or psychiatric causes could induce up to 30% of palpitations, according to the articles I was reading. An abrupt onset might be anxiety, and a very fast onset could be an SVT. Paul, any other things that you think about as red flags based on this or things you took home?

Williams: We spent a lot of shoe leather talking about symptoms and how we may not take palpitations seriously enough. You mentioned anxiety. On the other hand, there are things you have to be especially concerned about in terms of historical features, which I found really helpful.

Chest pain should not accompany palpitations. If present, that should prompt a more aggressive workup. Dr Cooper also mentioned lightheadedness. Probably the biggest, most worrisome red flag is loss of consciousness, or syncope. That's a worrisome or malignant arrhythmia that needs evaluation and probably intervention. That's when you should refer the patient quickly and promptly to electrophysiology for more aggressive management.

Watto: Paul, you said on the episode many times that you have a pretty low threshold to refer to electrophysiology, and I think you're pretty well sourced with electrophysiology where you're practicing.

Williams: You mentioned SVTs — the supraventricular tachycardias specifically. I thought just reviewing the management of those and Dr Cooper's specific approach was also pretty helpful, at least in knowing what to tell patients about what's available.

He mentioned three approaches.

The first is pretty conservative; you reassure patients that most of the time the SVTs, and specifically AVNRT (atrioventricular nodal reentrant tachycardia) and AVRT (atrioventricular reentrant tachycardia), are benign and are not going to kill the patient. If they're tolerable and they're not really interfering with the quality of life, he counsels them to do vagal maneuvers like bearing down or placing an ice pack on the face.

Watto: I love that one.

Williams: Not bilateral carotid massage. That's never a good idea.

The next step up in terms of therapy are the medications. Beta-blockers are an option and also the non-dihydropyridine calcium channel blockers (verapamil and diltiazem) which, if I remember correctly, he favors because the side-effect profile is a little bit more favorable, especially for younger patients.

Watto: Right. Beta-blockers have a certain reputation; whether it's deserved is debatable. He made another point about medical treatment. If it doesn't last more than 20 minutes, probably by the time the medicine kicks in, it's not going to be that helpful. It just depends on the frequency and duration of the episodes whether the medication might help the patient, but he said it is an option.

Williams: The last approach, the one I conceptualize as being most invasive (although I probably shouldn't), is catheter ablation, which can be both diagnostic and therapeutic. You can figure out what's going on and ablate as well, with something like a 95% success rate.

Watto: It sounded great.

Williams: If patients are really bothered by the symptoms, it seems like a very reasonable approach. Obviously, that will be directed by your friendly neighborhood electrophysiologist.

Watto: Paul, I'm prompting you to go out of order. Let's go back to the office before we send them to Dr Cooper and his colleagues in electrophysiology. You might think, oh, an EKG is kind of pointless. Actually, EKG can find the diagnosis up to about 30% of the time. I was surprised by that number. The EKG can be helpful because you can see if it is abnormal or if there is any kind of structural issue or rhythm disturbance. If you see something, it's helpful. If it's completely normal, that doesn't necessarily rule everything out.

With respect to monitoring, it seems like 2 weeks is the golden number where it's long enough that you're going to catch the arrhythmia but not so long that the patient is wearing this thing forever. If it's not worn long enough (eg, only 24-48 hours) the patient might not have an episode during the monitoring. The 2-week monitoring is often recommended. If the patient has had episodes of syncope but they are infrequent, such as once every couple of years, they might need one of the implantable loop recorders.

Did this change things for you at all?

Williams: In terms of the monitoring, not so much because, as you mentioned, I do often let my friends, the electrophysiologists, dictate what monitoring device they will use. It's a famous board question. It has come up on every test I've ever taken, so it's probably still worth knowing even if I'm not ordering the monitors myself.

Watto: What if I order a monitor, and because the patient's having symptoms a couple of times a week, I get a 2-week monitor and we just see some PVCs on there? You never have to worry about those, right?

Williams: I love this framing device. The PVC thing was very helpful because I never quite know what to do with those or how worried to be about them. Certainly, in young patients who don't have structural heart disease or history of ischemic heart disease and they're infrequent, you can be pretty blasé about them, it sounds like.

If they become frequent — I think that the magic number is more than 10% of the heartbeats are PVCs — that can actually lead to cardiomyopathy. That really does warrant intervention, whether that is medications or ablation.

The other point that Dr Cooper made is that it's bidirectional. PVCs can cause cardiomyopathy and cardiomyopathies can cause PVCs. The two go hand-in-hand.

I remember back in my resident days on inpatient service, I would get a call about PVCs and check the patient's electrolytes. If they were normal, I was done. It turns out there's probably a little bit more to think about and there's more nuance to it. Don't just blow off all the PVCs that you might see.

Watto: This was a jam-packed episode, and if you want to hear more about it, click on this link to hear the full interview with Dr Cooper and more of Paul's wonderful voice and insights.

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