{"id":11231,"date":"2026-10-07T00:20:10","date_gmt":"2026-10-07T08:20:10","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=11231"},"modified":"2026-09-17T16:38:58","modified_gmt":"2026-09-18T00:38:58","slug":"pance-question-of-the-day-palpitations-lightheadedness","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-palpitations-lightheadedness","title":{"rendered":"PANCE\u00ae Question of the Day: Palpitations and lightheadedness"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_86 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-palpitations-lightheadedness\/#The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\" >The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-palpitations-lightheadedness\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-palpitations-lightheadedness\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-palpitations-lightheadedness\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-palpitations-lightheadedness\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-palpitations-lightheadedness\/#References\" >References&nbsp;<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Prepare for the PANCE\u00ae with this emergency department scenario involving a<\/em><\/strong> <strong><em>patient experiencing palpatations and lightheadedness. What are the best, next steps in her care? Let\u2019s find out!<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A <strong>37-year-old woman <\/strong>presents to the emergency department for <strong>evaluation of the acute onset of palpitations and lightheadedness<\/strong>. The patient was sitting at her desk when the symptoms began abruptly. She has otherwise been in her usual state of health. She has <strong>no significant past medical history and does not take any medicatio<\/strong>n. Temperature is 37\u00b0C (98.6\u00b0F), pulse is 170\/min and regular, respirations are 22\/min, blood pressure is 120\/74 mmHg, and oxygen saturation is 99% on room air. The <strong>patient is well appearing but anxious<\/strong>. Cardiopulmonary examination is otherwise unremarkable. Lead II of the patient\u2019s electrocardiogram (ECG) is shown below. <\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"501\" height=\"226\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/10\/image-2.png\" alt=\"An ECG of the patient's heart.\" class=\"wp-image-11234\" style=\"aspect-ratio:2.2119205298013247;width:434px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/10\/image-2.png 501w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/10\/image-2.png?resize=300,135 300w\" sizes=\"auto, (max-width: 501px) 100vw, 501px\" \/><figcaption class=\"wp-element-caption\">\u00a0\u00a0\u00a0\u00a0\u00a0Reproduced from:\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/Supraventricular_tachycardia\" target=\"_blank\" rel=\"noopener\">Wikipedia<\/a>\u00a0<\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following is the <em>best, next step<\/em> in management?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Defibrillation<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Adenosine<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Synchronized cardioversion<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Metoprolol<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Vagal maneuvers<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down to find the answer!&nbsp;<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Learn with Osmosis\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/iDxHtjjCMbU?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Vagal maneuvers<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Correct: <\/strong>See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Defibrillation<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Defibrillation is indicated for ventricular fibrillation or pulseless ventricular tachycardia. This patient has a pulse and is hemodynamically stable with a regular, narrow-complex supraventricular tachycardia (SVT). Initial management should consist of vagal maneuvers.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Adenosine<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Adenosine is indicated in the management of patients with stable SVT if vagal maneuvers do not convert the arrythmia to normal sinus rhythm. Vagal maneuvers should be attempted for this stable patient before proceeding to adenosine.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Synchronized cardioversion<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Synchronized cardioversion is indicated for patients with SVT who are hemodynamically unstable, such as those with hypotension, altered mental status, or signs of shock. This patient with stable SVT should first be managed with vagal maneuvers.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Metoprolol<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Beta-blockers such as metoprolol may be used to treat stable SVT when vagal maneuvers and adenosine are ineffective or contraindicated. Vagal maneuvers should be attempted first in this patient.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-image alignleft size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"936\" height=\"505\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/10\/image-3.png\" alt=\"Osmosis.org style illustration showing treatment for typical AVNRT, with vagal maneuvers including the Valsalva maneuver, carotid massage, and an ice bath, followed by IV adenosine if vagal maneuvers are unsuccessful.\" class=\"wp-image-11235\" style=\"aspect-ratio:1.8516320474777448;width:538px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/10\/image-3.png 936w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/10\/image-3.png?resize=300,162 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/10\/image-3.png?resize=768,414 768w\" sizes=\"auto, (max-width: 936px) 100vw, 936px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>This patient presents with the abrupt onset of palpitations and lightheadedness and is hemodynamically stable. Her ECG demonstrates a regular, narrow-complex tachycardia with absent P-waves, consistent with supraventricular tachycardia (SVT), most likely typical atrioventricular nodal reentrant tachycardia (AVNRT).<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Patients with stable AVNRT should be treated in a stepwise fashion. <strong>Initial treatment consists of vagal maneuvers<\/strong>, such as the Valsalva maneuver. If vagal maneuvers fail to convert AVNRT to normal sinus rhythm, the next step is intravenous adenosine. <strong>Adenosine transiently blocks conduction through the atrioventricular node and frequently terminates AVNRT.<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">If vagal maneuvers and adenosine are unsuccessful or contraindicated, then rate-controlling agents such as beta-blockers, like metoprolol, or calcium channel blockers, like verapamil or diltiazem, may be considered. Catheter-directed ablation is an effective definitive treatment for patients with recurrent symptomatic AVNRT.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>All unstable patients with SVT, such as those with altered mental status, hypotension, or signs of shock, should have immediate synchronized cardioversion.<\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><strong>Stable AV nodal reentrant tachycardia (AVNRT) is treated in a stepwise fashion, starting with vagal maneuvers, followed by adenosine if unsuccessful, and then rate-controlling agents if needed. Hemodynamically unstable SVT requires synchronized cardioversion.<\/strong><\/strong><\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Review this Osmosis content: <\/strong><a href=\"https:\/\/www.osmosis.org\/learn\/Supraventricular_tachycardia:_Clinical_sciences\">Supraventricular tachycardia: Clinical sciences<\/a><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Page RL, Joglar JA, Caldwell MA, et al. 2015 <strong>ACC\/AHA\/HRS Guideline for the Management of Adult Patients with Supraventricular Tachycardia: A Report of the American College of Cardiology\/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society<\/strong> [published correction appears in J Am Coll Cardiol. 2016 Dec 27;68(25):2922-2923]. J Am Coll Cardiol. 2016;67(13): e27-e115. doi: 10.1016\/j.jacc.2015.08.856<\/li>\n\n\n\n<li>Mayuga KA, Fedorowski A, Ricci F, et al. <strong>Sinus Tachycardia: a Multidisciplinary Expert Focused Review. Circ Arrhythm Electrophysiol<\/strong>. 2022;15(9): e007960. doi:10.1161\/CIRCEP.121.007960<\/li>\n\n\n\n<li>Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. <strong>Harrison&#8217;s Principles of Internal Medicine,<\/strong> 20e. McGraw Hill; 2018.<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image aligncenter size-large\"><a href=\"http:\/\/osmosis.org\/plans\/pa\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?w=700\" alt=\"\" class=\"wp-image-5904\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><strong><em>Get your&nbsp;<a href=\"http:\/\/osmosis.org\/plans\/pa\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>&nbsp;today to discover why millions of clinicians and caregivers love learning by Osmosis.<\/em><\/strong><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A 37-year-old develops sudden palpitations and lightheadedness with a rapid, regular heart rhythm. Can you interpret the clinical findings and determine the best next step in management?<\/p>\n","protected":false},"author":208,"featured_media":11236,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[20,38,1371,37,1366],"tags":[1690,2967,429,195,3454,489,3108,431,440,462,1970,280,731,967,315],"class_list":["post-11231","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-exam-prep","category-pance","category-pance-questions","category-pa","category-questions","tag-arrhythmias","tag-board-exam-prep","tag-cardiac-assessment","tag-cardiology","tag-cardiovascular-medicine","tag-clinical-reasoning","tag-clinical-vignette","tag-ecg-interpretation","tag-emergency-medicine","tag-osmosis","tag-palpitations","tag-pance","tag-patient-management","tag-physician-assistant-education","tag-tachycardia"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - 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