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  • Gregg M. Yamada, MD FACC

How Cardiologists Evaluate Palpitations or Arrhythmias

It's important for you to know the basics of how cardiologists evaluate arrhythmias.

Palpitations=abnormal heart beats=arrhythmia. I will use the terms palpitations, arrhythmia, abnormal heart beats interchangeably.

Palpitations, or abnormal heart beats, are a common complaint.

There are excellent websites on the topic of arrhythmias. Take a quick glance at those sites prior to reading this post.

Malignant (dangerous) or Benign (safe)

First, we distinguish between dangerous arrhythmias and safe arrhythmias. Arrhythmias arising from the atria (top chambers) are generally safe. Those arising from the ventricles (bottom chambers) are more likely to be dangerous.

Examples of atrial arrhythmias include:

Dangerous arrhythmias arising from the ventricles are usually associated with serious underlying structural or functional cardiac problems. For this reason, screening studies such as stress testing and echocardiography are performed. If you have a negative TST and a normal echo, the arrhythmias are most likely benign. Dangerous arrhythmias may be associated with fainting (syncope), near fainting (near syncope), chest discomfort (angina). Benign or atrial arrhythmias will rarely lead to syncope, except in the volume depleted (dehydrated) individual.

Presenting complaints

  • PVC, PAC: patients complain of ‘extra heart beats’ or ‘skipped beats’ that are typically single, but recurrent.

  • PSVT: rapid heart beats

  • AFIB—typically irregular (fast or slow) heart beats are noted.

  • VTACH: life threatening arrhythmias associated with dizziness, near fainting. Obviously, this explanation is oversimplified as there are ‘dangerous’ and ‘benign’ forms of this ventricular arrhythmia. Such variations will be discussed by your cardiologist.

Recording the Arrhythmia:

Key to the diagnosis of the arrhythmia is documenting/recording a ‘rhythm strip’ EKG.

In some patients the arrhythmia is precipitated by exercise and recorded during a stress test. Others may require implantable recording devices (ILR).


Once the type of rhythm is documented by an EKG recording, patients will be told to discontinue:

  • Caffeine: coffee, tea, chocolate, energy drinks

  • Alcohol

  • Other precipitating causes such as thyroid disease, stress, lack of sleep, sleep apnea, stimulants are also excluded.


Caffeine is discontinued because for patients who have adequate blood pressure beta blockers or calcium channel blockers are prescribed. Beta blocker medications such as metoprolol, atenolol (older), Bystolic (newer): beta blockers conflict with caffeine. Calcium channel blockers: Cardizem (diltiazem); verapamil (older) are common. These are standard in the treatment of PAC, PVC, PSVT, AFIB.

Special Considerations


  1. Arrhythmias are characterized as either malignant or benign.

  2. In patients with palpitations, where the stress test and echo are normal, the arrhythmia is typically benign (safe).

  3. Of the benign arrhythmias, AFIB is a special consideration given stroke risk.

  4. Malignant arrhythmias which result in sudden cardiac death (SCD) occur in patients with weak hearts (cardiomyopathy), valve disease (e.g. aortic stenosis) or significant CAD (e.g. require CABG).

  5. Once the arrhythmia is defined, reversible conditions are treated. An arrhythmia specialist (electrophysiologist) may be consulted.

Note: Understanding your heart condition is not difficult. Patients become frustrated and confused when doctors don’t explain things clearly. If you don’t understand what your doctor is talking about, then you won’t be able to ask meaningful questions. I hope that my posts provide you with a framework that you can build upon to become an active participant in your healthcare.

Stay Healthy!

Gregg Yamada MD FACC


Disclaimer: I hope you find my medical blogs to be educational, pertinent, interesting, and thought provoking. The information provided is educational and should not be taken as medical advice. I am a doctor, but I am not your doctor. Please schedule an appointment with your doctor to discuss these issues and to determine what is right for you.

© 2022. Gregg M. Yamada, MD FACC. All rights reserved



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