Φ
Read This First
The One Job at First Encounter
When a patient presents with a new complaint of palpitations, your job is not to treat the palpitation. It is to determine whether it is dangerous.
The majority are benign — PACs, PVCs, brief SVT, or anxiety. But a meaningful minority represent AFib (stroke risk), significant structural disease, conduction system disease, or inherited channelopathy. A structured, complete workup — every time — is the only way to tell the difference.
The History Is Your Most Powerful Diagnostic Tool
No test replaces a carefully taken history. Perform it first, perform it completely, and let it guide the urgency of everything that follows. A patient who taps out an irregular rhythm, reports syncope, or has a family history of sudden death is a different workup than one who gets palpitations after three cups of coffee.
1
Step 1 — Most Important
The History
Character of the Palpitation — Ask Every Question
| Question | Why It Matters |
|---|---|
| "How would you describe it — fluttering, pounding, racing, or skipping?" | Each descriptor has a different differential; skipping → PAC/PVC; racing → SVT/AFib |
| "Is it fast, slow, or just irregular?" | Fast + regular → SVT/AT/flutter; Fast + irregular → AFib; Slow + skipping → PAC/PVC |
| "Does it start and stop suddenly, or gradually?" | Abrupt on/off = reentrant SVT; Gradual onset = sinus tachycardia or anxiety |
| "Can you tap the rhythm out for me on the desk?" | One of the most useful in-office maneuvers — irregular tapping strongly suggests AFib |
| "How long does each episode last?" | Seconds → PAC/PVC; Minutes to hours → SVT, AFib; Continuous → rate issue |
| "How often is it happening?" | Daily? Weekly? With exertion only? Drives monitor selection. |
Associated Symptoms — Red Flag Screen · Document Each Explicitly
| Symptom | Red Flag Significance |
|---|---|
| Syncope or near-syncope | Highest-risk symptom — hemodynamic compromise during arrhythmia; think VT, high-degree AV block, severe structural disease. Escalate immediately. |
| Chest pain during episode | Possible ischemia-triggered arrhythmia or concurrent ACS — escalate |
| Dyspnea out of proportion | May indicate reduced EF or hemodynamic compromise during tachycardia |
| Diaphoresis | High sympathetic output or hemodynamic stress during episode |
| Neurologic symptoms | Possible embolic event from AFib; possible hemodynamic compromise |
| Family history of sudden cardiac death | Raises concern for inherited channelopathy (LQTS, CPVT, Brugada) — escalate immediately to Dr. Rasch |
Context Clues — Always Ask
Triggers: Exertion · caffeine · alcohol · stress · positional change · large meal · decongestants · stimulants · recreational drugsTiming: At rest · during activity · nocturnal · postprandial
Medications: Full review — stimulants, decongestants, thyroid supplements, weight loss products
History: Prior arrhythmia · structural heart disease · prior ablation · anxiety/panic disorder
Family: Sudden unexplained death · cardiomyopathy · inherited arrhythmia syndrome
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Step 2 — Required · No Exceptions
Mandatory Workup — Every Patient, Every First Visit
These four components are required for every new palpitation complaint. They are not optional based on clinical impression or patient demographics.
A
12-Lead EKG — Immediate, Every Visit
Order and perform at the first visit. If the patient is symptomatic at the time of presentation, perform the EKG before any other testing. A normal EKG does not rule out arrhythmia — but an abnormal EKG can change everything.
EKG Findings — What You're Looking For & What to Do
| Finding | Significance | Action |
|---|---|---|
| Delta waves (WPW) | Pre-excitation — risk of VF in AFib | Escalate to Dr. Rasch immediately — EP referral |
| Prolonged QTc (>450 ms M / >470 ms F) | Risk of Torsades de Pointes / VF | Escalate; review & eliminate QT-prolonging meds |
| Brugada pattern (RBBB + STE V1–V2) | Inherited channelopathy; sudden death risk | Escalate to Dr. Rasch immediately — EP referral |
| 2nd or 3rd degree AV block | Conduction system disease; pacemaker territory | Escalate — pacemaker evaluation; Dr. Hamzei (EP) |
| Ischemic changes (STD, TWI, Q waves) | Ischemia as arrhythmia trigger or concurrent CAD | Order nuclear stress test before monitoring |
| RBBB + T-wave inversions V1–V3 ± epsilon wave | Possible ARVC | Escalate immediately — EP referral |
| LVH pattern | Structural disease; hypertensive substrate | Echo if not on file within 12 months |
| AFib / AFL on EKG | Active arrhythmia captured | Initiate AFib Protocol #001 immediately |
| PACs or PVCs on tracing | Premature beats identified as source | Reassure if structurally normal; quantify with monitor |
| Normal EKG | Does not rule out arrhythmia | Proceed with ambulatory monitoring (Step 2C) |
EKG Pattern Reference — Key Morphologies
Textbook pattern illustrations for rapid reference. Each strip represents lead II or the most diagnostic lead for that pattern.
Lead II · 25 mm/s · 10 mm/mV
Normal Sinus Rhythm
Lead I
WPW — Delta Wave
Lead V1
Brugada Pattern
Lead II
Prolonged QT
Lead II
PVC — Premature Ventricular
Lead II
PAC — Premature Atrial
Lead II
Atrial Fibrillation
Lead II
SVT (AVNRT)
AV Conduction Disease — Serious Findings
Lead II
Complete (3°) AV Block
Lead II
Mobitz II AV Block
B
Nuclear Stress Test — If Ischemic EKG Changes Present
When to Order Before Proceeding to Monitoring
Any ischemic EKG changes — ST depression, new T-wave inversions, pathologic Q waves — should prompt a nuclear stress test before ambulatory rhythm monitoring becomes the primary next step. Ischemia is a critical trigger and substrate for arrhythmia. Rule it out before assuming a primary electrical problem.Important: A patient with active chest pain and ischemic EKG changes should be transferred to the ER — not stress tested. Coordinate with Dr. Rasch before ordering if there is any uncertainty about urgency.
C
Ambulatory Cardiac Monitor — Every Patient
Every patient with a new palpitation complaint who does not have a diagnosis confirmed on the office EKG requires ambulatory monitoring. This is not optional.
Preferred Monitor: MCOT (Mobile Cardiac Outpatient Telemetry)
MCOT provides continuous real-time rhythm recording, auto-detection of arrhythmias (even when asymptomatic), and patient-triggered recordings. A monitoring center alerts for significant findings in real time. A 7-day event monitor is an acceptable alternative when MCOT is not covered.
Monitor Selection by Symptom Frequency
| Symptom Frequency | Monitor | Duration |
|---|---|---|
| Daily symptoms | Holter monitor | 24–48 hours |
| Several times per week | MCOT (preferred) | 7–14 days |
| Weekly to monthly | MCOT or 7-day event monitor | 14–30 days |
| Infrequent / unexplained syncope | Implantable Loop Recorder (ILR) | Up to 3 years — discuss with Dr. Rasch |
Patient Instructions — Give These Explicitly
When you feel the palpitation: press the button. Note the time, what you were doing, and how long it lasted. This symptom-rhythm correlation is the entire point of the monitor — without it, the data is far less useful.
D
Echocardiogram — Required Unless Recent Study on File
Order Echo Unless a Study Within the Past 12 Months Is Already on File
The threshold for ordering an echo is intentionally low. It answers two critical questions: (1) Is there structural heart disease that explains the palpitation? (2) Does structural disease change the management or risk profile of any arrhythmia found?
Echo Findings & Clinical Significance in Palpitation Workup
| Finding | Clinical Significance |
|---|---|
| Reduced EF (<50%) | High-burden PVCs may be causative (PVC cardiomyopathy); antiarrhythmic options limited; escalate to Dr. Rasch |
| LVH / concentric remodeling | Hypertensive substrate for arrhythmia; diastolic dysfunction |
| MVP / MR / valvular disease | MVP is a common palpitation cause; MR and AS create substrate for atrial arrhythmias |
| LA enlargement | Elevated filling pressures; substrate for AFib; may be the key clinical context |
| Regional wall motion abnormality | Possible prior MI — ischemic substrate for VT/ventricular arrhythmia |
| Structurally normal | Strongly supports benign etiology of PACs/PVCs/SVT; critical for patient reassurance and management decisions |
E
Labs
Order at First Palpitation Visit
| Lab | Rationale |
|---|---|
| TSH | Hyperthyroidism — common, reversible cause of palpitations, AFib, and sinus tachycardia |
| CMP | K⁺ and Mg²⁺ (electrolyte-driven ectopy) · creatinine (baseline before medications) · glucose |
| CBC | Anemia — hyperdynamic state; polycythemia can also drive arrhythmia |
| HbA1c | Hypoglycemic episodes as cause of palpitations |
| Urine pregnancy test | Women of reproductive age — pregnancy causes palpitations and limits medication options |
| Urine drug screen | Consider in younger patients or if stimulant use suspected — cocaine, methamphetamine, MDMA are highly arrhythmogenic; ask without judgment |
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Step 3
Differential Diagnosis & Management by Rhythm
PACs & PVCs — Premature Beats
Most common outcome of palpitation workup
PACs: Brief "flip-flop" or skipping sensation, often at rest, worse after caffeine or alcohol. EKG: early P' wave, narrow QRS, incomplete compensatory pause.
PVCs: Strong "thud" or "skipped beat" with a compensatory pause. Often worse at rest or with bradycardia. EKG: wide bizarre QRS, no preceding P wave, full compensatory pause. RVOT morphology (LBBB, inferior axis) is the most common and most benign pattern.
Echo required if PVC burden >10% or any symptoms beyond the palpitation itself — reduced EF in the setting of frequent PVCs suggests PVC-induced cardiomyopathy; escalate to Dr. Rasch.
Management — PACs & PVCs
First line: Reassure + eliminate triggers (caffeine, alcohol, decongestants, poor sleep, dehydration, low K⁺/Mg²⁺).Treatment is optional — only if symptoms are bothersome to the patient.
If treating — beta-blocker first line: Metoprolol succinate 25–50 mg QD or atenolol 25 mg QD.
Alternative — Verapamil: Works particularly well for PVCs. IR 40–80 mg BID–TID or SR formulation. Avoid in reduced EF.
If PVC burden >10,000/day or >10% and symptoms persist despite medication — discuss EP ablation referral with Dr. Rasch.
Non-Sustained SVT — Paroxysmal SVT
Sudden onset/offset · Regular · 150–250 bpm · Self-terminating
Sudden-onset, sudden-offset racing sensation. Regular. Rates 150–250 bpm. May last seconds to minutes. Often terminates with Valsalva. Most common type is AVNRT (reentry within AV node). EKG: narrow QRS, retrograde P buried in or just after QRS.
Management — SVT by Frequency and Symptoms
Rare, isolated, well-tolerated episodes: No pharmacologic treatment required. Reassure. Lifestyle modification. Monitor for recurrence.Symptomatic or more frequent episodes — start AV nodal blocker:
· Beta-blocker first-line: metoprolol succinate 25–50 mg QD
· Verapamil as alternative: SR 120–240 mg QD
· Diltiazem SR 120–180 mg QD also acceptable
Recurrent symptomatic SVT or patient desires definitive treatment: Refer to EP for catheter ablation — >95% success rate for AVNRT. Discuss with Dr. Rasch.
Atrial Fibrillation / Atrial Flutter
The rhythm we are most concerned about finding — stroke risk requires action
AFib and AFL are the rhythms we are most concerned about discovering in a palpitation workup. They increase stroke risk and require anticoagulation if detected. Do not defer these decisions.
Action When AFib or AFL Is Discovered
Initiate AFib Protocol #001 immediately.· Assess CHA₂DS₂-VASc score — initiate OAC if indicated (Eliquis preferred)
· Do not defer anticoagulation decisions to a later visit
· Initiate rate control if HR not controlled
· Determine paroxysmal vs. persistent pattern via monitor data
· Refer for TEE-guided DCCV if persistent AFib confirmed
Significant Pauses · High-Degree AV Block · Sick Sinus Syndrome
Conduction system failure — pacemaker territory
Patients reporting palpitations with near-syncope, syncope, or sudden slowing of heart rate — and those found on monitor to have pauses >3 seconds, Mobitz II, or complete heart block — have failure of the cardiac conduction system.
Medication adjustments alone are insufficient. These patients frequently require a permanent pacemaker.
🚨 Refer to Dr. Hamzei (Electrophysiology) — Do Not Delay
Patients with symptomatic pauses or high-degree AV block are at risk for syncope, fall, and sudden cardiac death. Alert Dr. Rasch immediately and coordinate urgent EP referral to Dr. Hamzei. This is not a watchful waiting situation.Document specifically: Duration and frequency of pauses · Whether patient was symptomatic during the pause · Any medications potentially contributing (beta-blockers, CCBs, digoxin — consider holding pending EP evaluation if clinically appropriate).
WPW · LQTS · Brugada · Inherited Channelopathies
Rare but potentially lethal — EKG pattern or family history triggers this pathway
WPW / Pre-excitation: Delta waves on EKG → refer to EP immediately. Standard AV nodal blockers (adenosine, verapamil, diltiazem) can be dangerous by unmasking rapid accessory pathway conduction in AFib. Catheter ablation is first-line treatment.
Long QT / Brugada / CPVT: EKG pattern or family history of sudden cardiac death → escalate to Dr. Rasch immediately, EP referral, genetic counseling consideration. Review and eliminate all QT-prolonging medications in LQTS patients.
4
Step 4
Management Summary
Diagnosis → Treatment at a Glance
| Diagnosis | First-Line Management | Escalate? |
|---|---|---|
| PACs / PVCs — asymptomatic | Reassure + trigger elimination | No |
| PACs / PVCs — symptomatic | Beta-blocker first line · Verapamil alternative (esp. PVCs) | No |
| PVC burden >10% + any symptoms | Echo · beta-blocker · consider EP ablation referral | Yes — discuss with Dr. Rasch |
| Non-sustained SVT — rare / mild | No treatment; lifestyle; monitor for recurrence | No |
| Non-sustained SVT — symptomatic | AV nodal blocker (BB or verapamil) | EP referral if recurrent |
| AFib / AFL — new discovery | Initiate AFib Protocol #001 · OAC · rate control | Yes — Dr. Rasch loop-in |
| Sinus tachycardia | Identify and treat underlying cause — do not suppress with BB first | No (unless PE suspected) |
| Pauses >3s / AV block | Hold contributing meds if safe; urgent EP referral | Yes — Dr. Hamzei (EP) urgently |
| WPW / delta waves | No AV nodal blockers · urgent EP referral | Yes — Dr. Rasch immediately |
| LQTS / Brugada / channelopathy | Eliminate QT-prolonging meds · urgent EP referral | Yes — Dr. Rasch immediately |
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Step 5
Follow-Up Plan
Follow-Up by Outcome
| Scenario | Follow-Up Timing |
|---|---|
| Monitor ordered, awaiting results | Review at 2–4 weeks — do not wait for patient to call |
| Benign PACs/PVCs, asymptomatic, echo normal | 3–6 months; sooner if symptoms change |
| PVC burden >10% on monitor | Echo if not done; discuss with Dr. Rasch before next appointment |
| SVT confirmed, started on AV nodal blocker | 4–6 weeks; reassess symptoms; discuss ablation if recurrent |
| AFib / AFL discovered | Follow AFib Protocol #001 timeline |
| High-risk finding (pause, AV block, WPW, channelopathy) | Escalate immediately — do not schedule routine follow-up |
| Normal full workup, symptoms resolved | 6–12 months or PRN; return if symptoms recur or escalate |
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Step 6
Escalate to Dr. Rasch If…
Syncope or presyncope during palpitation episode — urgent
Pauses >3 seconds or high-degree AV block on monitor — urgent · Dr. Hamzei (EP) referral
WPW / delta waves — EP referral · do not give AV nodal blockers until evaluated
Brugada pattern, prolonged QTc, ARVC pattern on EKG — EP referral
Ischemic EKG changes — coordinate nuclear stress test
PVC burden >10% — especially with any reduction in EF on echo; PVC cardiomyopathy workup
AFib / AFL discovered — initiate AFib protocol; loop Dr. Rasch
SVT confirmed, recurrent, patient desires ablation — EP referral discussion
Family history of sudden cardiac death or inherited arrhythmia syndrome
Palpitations exclusively with exertion — exercise stress testing discussion
Full workup unrevealing after MCOT + echo + labs — ILR discussion
Any scenario where you are uncertain about the diagnosis or patient safety — always better to ask.