Palpitations with Unclear Arrhythmia Risk

Clinical History

‍38-year-old female with intermittent palpitations 2–3 times per week for a month. Episodes last 10–30 seconds, no syncope, no chest pain, no dyspnea. Describes fluttering. No family history of sudden death or cardiomyopathy. Drinks 3–4 cups of coffee daily. ECG: normal sinus rhythm, no pre-excitation, normal QTc. No echo done.

Clinical Question

‍She’s anxious about this. Can I work this up myself?

Specialist Guidance

‍You can work this up in primary care. With a normal ECG and no red flags, this is most likely premature atrial or ventricular complexes, which are benign. I would order a TTE to establish structural baseline and a 14-day patch monitor. Use the patch, not a 24-hour Holter. If she’s only symptomatic a few times a week, a 24-hour recording will probably miss it. The patch gives you two weeks of continuous data and a much better chance of capturing what’s going on. Check TSH and CBC if not done recently. Cut back the coffee.

Refer to cardiology if monitoring reveals sustained SVT, afib, or frequent PVCs, or if the echo shows any structural abnormality. The referral threshold is what the workup shows, not the symptom of palpitations itself.

Outcome

TTE: structurally normal. 14-day patch monitor: occasional PACs, less than 1% burden, no sustained arrhythmia. Reduced caffeine. Symptoms decreased. Managed entirely in primary care. No referral required.

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