Stethopedia | Approach

Approach to

Palpitations

Cardiovert if the arrhythmia causes instability; treat the cause of sinus tachycardia. Otherwise sort the ECG by QRS width and regularity; if sinus, look for WPW, long QT, Brugada and match monitoring to symptom frequency.

  1. Awareness of a fast, forceful or irregular heartbeat
  2. 12-lead ECG in symptoms: QRS width, regularity; delta wave, long QT, Brugada1,10
  3. K, Mg, CBC, TSH, glucose; review drugs, caffeine, stimulants3,10
  4. Arrhythmia causing instability?

Unstable: synchronized cardioversion now9,10

  • Hypotension or signs of shock
  • Acutely altered mental status
  • Ischemic chest pain
  • Acute heart failure, pulmonary edema
  • Sinus tach: treat cause, no shock

→ Pads, sedation; pulseless or polymorphic VT: defibrillate

If stable: what does the ECG show?

CausesCluesWorkupManagement

Narrow, regular

  • AVNRT, orthodromic AVRT
  • Atrial flutter 2:1 (rate ~150)
  • Focal atrial tachycardia
  • Abrupt onset and offset1
  • Neck pounding: AVNRT (LR 177)5
  • Delta wave on baseline ECG: WPW1
  • Find P waves; compare with baseline
  • Adenosine unmasks flutter, AT1
  • Modified Valsalva, legs raised8
  • Adenosine 6 mg rapid push, then 12 mg1
  • Fails: IV β-blocker or diltiazem; ablation1

Narrow, irregular

  • Atrial fibrillation
  • Flutter with variable block
  • MAT (COPD), frequent PACs
  • Irregularly irregular; no P waves
  • Alcohol, thyroid, OSA, infection3
  • TSH, creatinine, CBC; echo3
  • CHADS-65 for stroke risk3
  • β-blocker; diltiazem if EF >40%2,3
  • OAC if CHADS-65 positive; DOAC first3
  • <12 h, no stroke/TIA: cardiovert, no OAC3

Wide QRS (≥120 ms)

  • VT; less often SVT with aberrancy
  • Pre-excited AF (WPW)
  • Torsades: long QT, low K or Mg
  • Prior MI or low EF: VT likely4
  • AV dissociation, fusion beats7
  • Syncope; FHx of sudden death4
  • If any doubt, it is VT4
  • Echo, ischemia workup; QTc4
  • Rule out high K, TCA, Na blockers10
  • Stable VT: procainamide; HFrEF: amio4,10
  • Pre-excited AF: procainamide; no nodal/amio1,2
  • Torsades: IV Mg; stop QT drugs4

Sinus or ectopy

  • PACs, PVCs
  • Sinus tach: bleed, PE, sepsis, thyroid10
  • Psychiatric, e.g. panic (31% overall)6
  • Skipped beat, then a thump
  • Episodes <5 min: LR 0.38 for arrhythmia5
  • Syncope, exertion, FHx SCD: high risk4
  • Holter, patch or loop by frequency5
  • Echo: murmur, syncope, frequent PVCs4
  • Sinus tach: treat cause, not rate1,10
  • Symptomatic PVCs: β-blocker4
  • Reassure once rhythm–symptom match

Can't-miss cause Superscripts link to the references below.

References

  1. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. J Am Coll Cardiol. 2016;67:e27–e115. PubMed 26409259
  2. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation. Circulation. 2024;149:e1–e156. PubMed 38033089
  3. Andrade JG, Aguilar M, Atzema C, et al. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society comprehensive guidelines for the management of atrial fibrillation. Can J Cardiol. 2020;36:1847–1948. PubMed 33191198
  4. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Circulation. 2018;138:e272–e391. PubMed 29084731
  5. Thavendiranathan P, Bagai A, Khoo C, Dorian P, Choudhry NK. Does this patient with palpitations have a cardiac arrhythmia? JAMA. 2009;302:2135–2143. PubMed 19920238
  6. Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. Am J Med. 1996;100:138–148. PubMed 8629647
  7. Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83:1649–1659. PubMed 2022022
  8. Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015;386:1747–1753. PubMed 26314489
  9. Wigginton JG, Agarwal S, Bartos JA, et al. Part 9: adult advanced life support: 2025 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2025;152(16 Suppl 2):S538–S577. PubMed 41122884
  10. Gay E, Levy N, eds. ACLS: Tachycardia; Narrow Complex Tachycardia; Wide Complex Tachycardia; Atrial Fibrillation & Flutter. In: Department of Medicine Housestaff Manual, 30th ed. 2024:4, 8–10.

For education only; not a substitute for clinical judgment or local protocols. Where sources differ, the flowchart follows the current guideline.

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