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Palpitations


 

Introduction

Most episodes of palpitations seen in primary care are not associated with cardiac pathology and only a minority of cases require advanced investigation or specialist assessment.

 

In scope                         Symptoms of palpitations

Not in scope                  palpitations related to anxiety  

                                        Atrial Flutter/Atrial Fibrillations

                                          

  

Red Flag Features

  • Palpitations associated with haemodynamic instability or syncope
  • Palpitations precipitated by exercise
  • Family history of sudden death before aged 40 years in a first-degree relative
  • Inherited cardiac condition


 

Investigations required prior to referral

Consider:

  • ECG
  • FBC, eGFR, Thyroid function, Electrolytes including calcium and magnesium (if suspicious of arrhythmia)
  • Urine catecholamines if pheochromocytoma is suspected
  • 24-hour tape in patients with frequent / preferably daily symptoms if suspicious of a sustained tachyarrhythmia.
  • Echocardiogram (helpful in patients with significant palpitations/confirmed arrhythmias on 24 hour tape) 

 

Management optimisation

 If there are:

  • no red flags
  • normal examination
  • normal ECG. 

These patients may be managed in the community with the elimination of precipitating factors and reassurance. Beta blockers can be considered if highly symptomatic. 

Discuss alcohol and drug use, smoking status and caffeine intake. Consider providing an information leaflet

 

Sinus tachycardia

•            Manage any underlying cause.

•            If frequent and bothersome, consider a cardio selective beta blockere.g. bisoprololif suitable.

•            If persistent sinus tachycardia which has a significant impact on the quality of life, consider advice and guidance or routine cardiology referral .
 

Ectopic beats

•            Manage underlying causes, e.g. alcohol, anxiety.

•            If isolated and no other cardiac symptoms, reassure the patient.

•            If frequent and bothersome, consider a cardio selective beta blocker, e.g. bisoprololif suitable.


Atrial fibrillation or flutter see: Atrial Fibrillation / Flutter (cornwall.nhs.uk)


Supraventricular tachycardia

•            Consider teaching the patient the Valsalva manoeuvre.

•            If frequent and bothersome, consider:

•            a cardio selective beta blocker, e.g. bisoprololif suitable or

•            calcium channel blocker, e.g. diltiazem.

•            If frequent and bothersome symptoms, and the patient will accept an ablation, consider advice and guidance or routine cardiology referral.

For patients diagnosed with arrythmias provide advice on driving.

 

Advice and Guidance

Obtain advice and guidance via Cardiology eRS

Same day advice is available by contacting the Cardiologist of the week via Switchboard between 8.30am and 6pm.



Referral

Arrange 999 ambulance for a patient with haemodynamic instability and any of:

  • sustained ventricular arrhythmia or supraventricular tachycardia.
  • Chest pain
  • Breathlessness
  • Loss of consciousness
  • Persisting tachyarrhythmia
  • Syncope or pre syncope
  • Signs of decompensated heart failure
  • Evidence of systemic cause such as thyrotoxicosis, severe anaemia, or sepsis

 

For emergency management of tachyarrhythmias please see Tachycardia Algorithm 2021.pdf (resus.org.uk)

 

Urgent Cardiology Referral: If the patient has any red flags:

•            Palpitations associated with syncope or near syncope

•            Palpitations precipitated by exercise

•            Family history of sudden death before aged 40 years in a first degree relative

•            Second or third degree atrioventricular block on ECG

 

Routine Cardiology Referral:

  • Symptoms/investigations suggestive of sustained tachycardia e.g. SVT /VT
     
  • Red flags/ abnormal examination
     
  • Significant abnormality on ECG. 

 

 Investigations required for all referrals: 

  • ECG
  • FBC, eGFR, Thyroid function, Electrolytes including calcium and magnesium (is suspicious of arrhythmia)

Consider the following in addition:

  • Urine catecholamines if pheochromocytoma is suspected.
  • 24 hour tape in patients with frequent / preferably daily symptoms if suspicious of a sustained tachyarrhythmia. Please attach a good quality copy if a 24 hour tape has been performed.

If a 24 hour tape is not mentioned, it will be assumed that one has not been done and may be requested by the cardiology department prior to the referral.

 

Referral to cardiology may not be required for:

  • symptoms suggestive of an awareness of normal sinus rhythm
  • sinus tachycardias
  • ectopic beats
  • AF that is rate controlled/not symptomatic and does not require Direct current cardioversion (DCCV).  See  Atrial Fibrillation / Flutter (cornwall.nhs.uk)
  • IF there are:
    • no red flags
    • normal examination
    • normal ECG  

These patients may be managed in the community with the elimination of precipitating factors and reassurance. Beta blockers can be considered if highly symptomatic. 

 

Supporting Information

For professionals                    NICE Clinical Knowledge Summaries (CKS) – Palpitations

For patients                                British Heart Foundation – Palpitations

  

 

 

Page Review Information

 

Review date

14/3/2025

Next review date

14/3/2027

Clinical editor

Dr Melanie Schick

Contributors

Dr Lucy Walker, Consultant Cardiologist, RCHT