Initial Investigations for Palpitations in Young Adults

Core Initial Investigations

The European Society of Cardiology recommends a 12-lead ECG, even if the initial ECG was normal, to compare with previous ECGs, particularly in patients with pre-existing cardiac pathology 1, 2
Cardiac biomarkers, such as troponin, should be repeated after 6-12 hours if initial values are negative, as recommended by the European Heart Journal 2, 3
Continuous multi-lead ECG monitoring is recommended if the patient is experiencing symptoms during evaluation, according to the European Heart Journal 1

Ambulatory ECG monitoring, such as a Holter monitor or event recorder, should be used to capture arrhythmias during symptomatic episodes, as suggested by the European Heart Journal 4, 5
Transthoracic echocardiography should be performed to assess cardiac structure and function, presence of valvular disease, and evidence of hypertrophic cardiomyopathy, as recommended by the European Heart Journal 1, 6, 7

Extended ambulatory monitoring or implantable loop recorder should be considered if palpitations are the predominant symptom and initial monitoring is non-diagnostic, according to the European Heart Journal 4, 5
Exercise stress testing or cardiac MRI should be performed if structural heart disease is suspected, as recommended by the American College of Cardiology and the European Heart Journal 3, 4, 7, 8
Exercise stress testing or pharmacological stress testing with imaging should be considered if symptoms suggest coronary origin, as suggested by the American Heart Association and the European Heart Journal 3, 9

Signal-averaged ECG and cardiac MRI with gadolinium enhancement should be performed for suspected arrhythmogenic cardiomyopathy, as recommended by the European Heart Journal 7, 8
Genetic testing should be considered if family history is positive for suspected long QT or WPW syndrome, according to the European Heart Journal 8

Premature discharge without adequate rhythm monitoring should be avoided if symptoms are recurrent or concerning, as recommended by the American Heart Association and the European Heart Journal 3, 9
Anxiety should remain a diagnosis of exclusion after cardiac causes have been ruled out, according to the European Heart Journal 4