How should I approach the management of palpitations in patients with a history of anxiety or panic disorders?

In managing palpitations in patients with a history of anxiety or panic disorders, first exclude serious cardiac causes by clinical assessment, ECG, and appropriate investigations such as blood tests and echocardiogram if indicated (e.g., murmur or suspected structural heart disease) ¹. Reassure patients if no underlying heart disease is found and palpitations are infrequent, as palpitations related to anxiety or panic are common and often benign ¹.

Address the anxiety or panic disorder concurrently by following stepped care principles: recognition, diagnosis, and offering psychological therapies such as cognitive behavioural therapy (CBT), medication (preferably SSRIs or SNRIs), or guided self-help, tailored to the severity and patient preference ².

Provide lifestyle advice to reduce triggers such as caffeine, alcohol, smoking, and stress, which can exacerbate palpitations and anxiety symptoms ¹.

Ensure clear communication and shared decision-making about the management plan, including the possibility that palpitations may be a manifestation of anxiety or panic attacks rather than cardiac pathology ¹,².

Refer to cardiology if palpitations are frequent, associated with features suggestive of cardiac disease, or if diagnosis remains unclear after initial assessment ¹. Similarly, refer to specialist mental health services if panic disorder symptoms persist despite initial primary care interventions ².

Provide written information and support resources about panic attacks and palpitations, and advise patients to seek urgent care if symptoms suggest serious cardiac events (e.g., syncope, chest pain) ¹,².