Patients in primary care with palpitations

Out of scope

Patients with previously documented arrhythmias

Key Messages

  • Less than 50% of patients with palpitations have an arrhythmia
  • A normal 12 lead ECG makes a life threatening arrhythmia unlikely
  • Symptoms of skipped beats, thumping, or slow pounding are unlikely to be associated with significant arrhythmias
  • Patients with palpitations and pre-existing cardiac disease or family history of sudden cardiac death need referral


History and Examination

  • Frequency of palpitations: Daily/Weekly/Monthly/Yearly
  • Type of palpitations: Rate/Rhythm/Character
  • Onset/Offset and Duration: Sudden or gradual, less or greater than 5 mins
  • Associated symptoms, haemodynamic compromise?
  • Circumstances at initiation: Exercise/positional?
  • Character of palpitation
    • Extra-systolic (skipping/missing a beat/sinking of heart)
    • Tachycardic (beating/fluttering in chest, sudden onset)
    • Anxiety-related (regular, slight heart rate increase, related to stress, tingling in hands or face, gradual onset)
    • Pulsation (heart pounding, regular, related to exercise, gradual onset)
  • History of haemodynamic compromise
    • Dyspnoea
    • Syncope
    • Pre-syncope/dizziness
    • Fatigue
    • Chest pain
    • Neurovegetative symptoms
  • PMHx: Cardiac disease/Thyroid/Systemic/Anxiety/Depression
  • FHx: Sudden cardiac death/Cardiac disease
  • Drug Hx
    • Ask about lifestyle factors – caffeine, alcohol, illicit drugs
    • Review medications such as theophyllines, beta-agonists, and long QT drugs (anti-depressants, anti-psychotics, anti-arrhythmics most commonly)
  • Pulse, blood pressure, cardiac and chest examination
  • Look for signs of structural heart disease
  • Hypertension
  • Murmur
  • Heart failure
  • Vascular disease
  • Systemic disease, e.g. Thyrotoxicosis, anaemia

Differential Diagnoses

  • Arrhythmia
  • Pacemaker failure/malfunction
  • Structural heart disease, e.g. valve disorder, HCM, congenital heart disease
  • Anxiety, depression, panic attacks
  • Systemic causes, e.g. hyperthyroidism, pregnancy, anaemia, phaeochromocytoma
  • Drug related, e.g. Hydralazine, Beta-blocker withdrawal, caffeine, nicotine, illicit drugs

Red Flags

  • Haemodynamic instability
  • Signs of cardiac failure
  • Associated chest pain or syncope
  • Significant injury

The presence of any of these findings should prompt the clinician to consider acute admission

Palpitations during exertion – consider urgent referral


12 lead ECG is mandatory

  • Blood tests only required if systemic disease suspected, e.g. hyperthyroidism or anaemia
  • Echocardiogram should be requested in suspected structural heart disease
  • Prolonged rhythm monitoring may be helpful but is not mandatory
  • Choose rhythm monitoring depending on frequency of symptoms:
    • Daily symptoms: 24 Holter monitor
    • Symptoms every other day: 48 or 72 Holter monitor
    • Weekly symptoms: Cardiocall
    • Symptoms less than weekly: No routine rhythm monitoring, but consider implantable loop recorder if significant symptoms or injury during episodes
  • Advise patient if they experience a sustained attack to try and obtain 12 lead ECG during episode.
  • Essential to document patient symptoms during rhythm monitoring
12 Lead ECG
  • Palpitations and simultaneous 12-lead ECG is diagnostic gold standard
  • Normal ECG at time of symptomatic palpitations = none arrhythmic diagnosis
  • Abnormal ECG at time of palpitations = arrhythmic diagnosis
  • If no symptoms at time of 12 lead ECG still instructive for presence/abscence of structural heart disease, but diagnosis tentative

ECGs suggesting arrhythmic cause:

  • Ventricular pre-excitation (delta wave, short PR interval)
  • P-wave abnormalities, SVT premature beats, sinus brady
  • Left ventricular hypertrophy
  • Frequent ventricular premature beats
  • Q waves
  • Signs of ARVC (TWI with QRS duration greater than110 ms in the right precordial ECG leads (V1–V3), epsilon wave)
  • Brugada syndrome (RBBB with coved type/saddle type ST segments in V1-V3)
  • Early repolarisation (J point elevation)
  • Long or short QT (QTc greater than 460ms or QTc less than 300ms)


If symptoms are:

  • Brief and have gradual onset
  • No symptoms of haemodynamic compromise
  • Extra-systolic type or anxiety type palpitation character
  • No structural heart disease
  • Normal 12 lead ECG

Then patient should be reassured and no further investigation is needed

If patients require further investigation consider prolonged rhythm monitoring and echocardiography as described in the investigation section or onward referral for specialist opinion.

If palpitations are disabling, patient should be advised not to drive pending investigations.


Referral Criteria

Patients with any of the following should be considered for referral:

  • Structural heart disease
  • Abnormal ECG/Holter or known 1˚ electrical disorder
  • FHx of sudden cardiac death
  • Tachycardiac palpitation character
  • Haemodynamic compromise symptoms
  • Suspected but not diagnosed AF/AFL with significant stroke risk
  • Symptoms on exercise
  • Severe/frequent symptoms -> impaired quality of life
    • e.g. missed work, attended A+E, avoidance behaviour

Referral Instructions

e-Referral Service Selection

  • Specialty: Cardiology
  • Clinic Type: Not Otherwise Specified
  • Service: DRSS-Western-Cardiology- Devon CCG-15N / DRSS-Western-Cardiology-Cornwall-Devon CCG-15N

Referral Forms

DRSS referral form

Supporting Information

Patient Information

Arrhythmia Alliance

Atrial Fibrillation Association

Sudden Adult Death Trust

Cardiac Risk in the Young

Pathway Group

This guideline has been signed off by the Western Locality on behalf of NEW Devon CCG

Publication date: December 2015


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