Management of patients with palpitations: a position paper from the ...

Managing patients with palpitations 931Table 10 General recommendations for the treatmentof palpitationsTherapy should be directed towards the aetiological cause.Patients should be reassured in case of a benign cause.Use of adrenergic substances such as caffeine or alcohol-containingbeverages should be restrained.Good control of cardiovascular risk factors, specifically ofhypertension, should be ensured.If there is a recent stressful life-event, psychiatric counselling may be ofhelp.In patients with symptoms of anxiety and depression, a specific therapyis warranted.If a specific arrhythmia is found, the appropriate therapy may beantiarrhythmic drugs, ablation, or even an implantable defibrillator.In the case that arrhythmias are found to be related to systemicdiseases or to the use of pro-arrhythmic drugs, therapy, of course,must aim to remove the underlying conditions.Table 11 Criteria for the hospitalization of patientswith palpitationsDiagnostic purposesSevere structural heart disease, suspected or ascertainedPrimary electrical heart disease, suspected or ascertainedFamily history of sudden deathNeed to perform EPS, invasive investigations or in-hospitaltelemetric monitoringTherapeutic purposesBradyarrhythmias requiring implantation of pacemakerPacemaker/ICD malfunction not rectifiable by reprogrammingVentricular tachyarrhythmias requiring immediate interruption and/or ICD implantation or catheter ablationSupraventricular tachycardias requiring interruption immediately orin a short time, or catheter ablationPresence of heart failure or other symptoms of haemodynamiccompromiseSevere structural heart diseases requiring surgery or interventionalproceduresSevere systemic causesSevere psychotic decompensationClearly, patients with palpitations will benefit from the samepreventive measures recommended to the general populationand to patients with cardiovascular disease. 93 Especially in patientswith ventricular ectopy 94 and possibly also in patients with atrialectopic beats 95 , although scientific evidence is lacking, intensifiedreduction of cardiovascular risk factors may be warranted. Thismay comprise, among others, smoking cessation, therapy of dyslipidemia,management of hypertension, heart failure, and diabetesmellitus, to name but a few. Moderate exercise is a healthy habitthat helps in controlling cardiovascular risk factors. On the otherhand, high-intensity endurance sport practice has been related toan increased risk of atrial fibrillation. 96It is beyond the scope of this paper to discuss in depth thespecific therapy in all arrhythmic conditions causing palpitations.In this regard, we refer the readers to current guidelines. 16,17 Inthe case that arrhythmias are found to be related to systemic diseasesor to the use of pro-arrhythmic drugs, therapy, of course,must aim to remove the underlying conditions. The general recommendationsfor the treatment of palpitations are listed inTable 10.When to hospitalize the patientDiagnostic purposesThe vast majority of patients with palpitations can be assessed in anoutpatient setting. Indeed, most of the investigations required forthe diagnostic evaluation of patients with palpitations can becarried out in an ambulatory or day-hospital setting. In the studyby Weber and Kapoor, 47 an EPS and a haemodynamic studywere performed in only 5% of patients.However, depending on the availability of outpatient ECG monitoringdevices, hospitalization may be considered for patients withvery frequent symptoms, when short-term bed-side monitoring islikely to reveal the underlying diagnosis. Moreover, patients withpalpitations should also be hospitalized when the initial clinicalevaluation suggests an imminent risk for serious arrhythmias(Table 11). For example, patients with primary electrical heartdiseases should be carefully evaluated when presenting with97 – 116palpitations.Therapeutic purposesThe criteria for the hospitalization of patients with palpitations fortherapeutic purposes are reported in Table 11. Generally, patientswith cardiac arrhythmias and/or structural heart disease will needemergency hospitalization when they complain of palpitationsassociated with haemodynamic compromise, chest pain, orsyncope, as well as if implantation or revision of implanted117 – 121devices is indicated.Conflicts of interest: A.R. is a consultant for sanofi-aventis,Boehringer-Ingheleim, Biosense Webster, and St Jude Medical,and has received honoraria from sanofi-aventis, Boehringer Ingheleim,and Medtronic. L.M. has received honoraria or consulting feesfrom Bard, Biosense Webster, Medtronic, Boston Scientific, St JudeMedical, Sanofi Aventis, Biotronik, and Sorin Group, and hasreceived research grants from Biosense Webster, Medtronic,Boston Scientific, and St Jude Medical. C.B.-L. has received researchgrants from Octopus, AtriCure, and Medtronic. M.J.P.R. is a consultantor advisory-board member for Biosense Webster, BoehringerIngelheim, St Jude Medical, and Stereotaxis. J.M.M. is aconsultant to Medtronic, has received honoraria from BostonScientific and St Jude Medical, and has had research supportfrom all three companies.References1. Mayou R. Chest pain, palpitations and panic. J Psychosom Res 1998;44:53–70.2. Messineo FC. Ventricular ectopic activity: prevalence and risk. Am J Cardiol 1989;64:53J–6J.Downloaded from http://europace.oxfordjournals.org/ at :: on December 6, 2011