Medications for Palpitations

First-Line Medications

The American College of Cardiology recommends beta-blockers, calcium channel blockers (diltiazem, verapamil), and digoxin as first-line medications for treating palpitations, with the specific choice depending on the underlying cause and patient characteristics 1, 2
For patients with atrial fibrillation/flutter and preserved left ventricular ejection fraction (LVEF >40%), the European Heart Society recommends beta-blockers, diltiazem, verapamil, or digoxin as first-choice drugs 2
For patients with atrial fibrillation/flutter and reduced ejection fraction (LVEF ≤40%), the European Heart Society recommends beta-blockers and/or digoxin 2
For supraventricular tachycardia (SVT), adenosine is the drug of choice for acute termination of regular narrow-complex tachycardias in a monitored setting 3, 4
For ventricular arrhythmias, beta-blockers are first-line therapy for symptomatic ventricular premature contractions (PVCs) 5

For patients with atrial fibrillation who have hemodynamic instability or severely depressed LVEF, amiodarone may be considered to achieve acute control of heart rate 2
For paroxysmal atrial fibrillation, flecainide, propafenone, and sotalol are recommended as initial antiarrhythmic therapy for patients with minimal heart disease 1, 6
For patients with heart failure, amiodarone or dofetilide are preferred for rhythm control 6

Amiodarone can be associated with bradycardia requiring permanent pacemaker implantation, more commonly in women 8
When starting antiarrhythmic drugs, ECG monitoring is essential to assess PR interval, QRS duration, and QT interval depending on the medication 8
Concomitant drug therapies should be monitored closely, particularly digoxin and warfarin doses which typically need reduction when starting amiodarone 8

The treatment algorithm involves identifying the underlying cause of palpitations, assessing cardiac function, selecting appropriate medication, monitoring response, and adjusting therapy as needed 1, 2, 5
For atrial fibrillation with preserved EF, beta-blockers, diltiazem, verapamil, or digoxin are recommended 2
For atrial fibrillation with reduced EF, beta-blockers and/or digoxin are recommended 2
For SVT, beta-blockers or calcium channel blockers are recommended 1, 4
For PVCs, beta-blockers are recommended 5

Using AV nodal blocking agents in pre-excited atrial fibrillation, which may accelerate ventricular response 4
Combining AV nodal blocking agents with longer duration of action, which can lead to profound bradycardia 4
Starting antiarrhythmic drugs without appropriate ECG monitoring 8
Failing to reduce doses of digoxin and warfarin when initiating amiodarone therapy 8