Palpitations assessment

Also known as Heart racing · Skipped beats · Awareness of heartbeat

GP-fellowship guide to palpitations assessment: the history that classifies rhythm by description (regular fast, irregular, skipped beats), causes from cardiac arrhythmia to anxiety, hyperthyroidism and stimulants, red flags that demand urgent cardiology (syncope with palpitations, structural heart disease, family sudden death), ECG for all patients, Holter versus event recorder matched to symptom frequency with yield numbers, benign ectopy reassurance and the PVC burden threshold above which cardiomyopathy risk rises, and electrophysiology referral triggers.

medium5 referencesUpdated 21 Aug 20264 min readVerification in progress

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Key points

Palpitations are an awareness of heartbeat patient finds abnormal. The history sorts them into regular fast, irregular, or skipped beats, and each pattern points to its own rhythm.^[4]
Every patient gets a 12-lead ECG, TSH, FBE and electrolytes. Monitoring follows symptom frequency: Holter for daily symptoms, event recorder or loop recorder for gaps of weeks to months. A 15-day patient-activated recorder diagnosed 89% of arrhythmias versus 1.8% for 24 h Holter in one comparison.^[2]
PVCs in a structurally normal heart with low burden are benign and need reassurance. Burden above about 10% of daily beats associates with reduced LVEF (29% vs 17% burden in reduced-LVEF patients) — monitor and refer.^[1]
Red flags: syncope with palpitations, structural heart disease, family sudden death under 40. Any one means cardiology referral, not watchful waiting.

Overview

Palpitations are a common ambulatory complaint, and cardiac causes carry the most concern because sudden death is possible when structural disease or channelopathy sits underneath.^[4] The consultation has three tasks: classify the rhythm by description, find reversible drivers, and match monitoring to how often symptoms occur.^[4]

References5Show

[1]Del Carpio Munoz F, Syed FF, Noheria A, et al. Characteristics of premature ventricular complexes as correlates of reduced left ventricular systolic function: study of the burden, duration, coupling interval, morphology and site of origin of PVCs J Cardiovasc Electrophysiol, 2011.PMID 21332870
[2]de Asmundis C, Conte G, Sieira J, et al. Comparison of the patient-activated event recording system vs. traditional 24 h Holter electrocardiography in individuals with paroxysmal palpitations or dizziness Europace, 2014.PMID 24574492
[3]Homme JL, Kranz LA, House M, et al. Diagnostic yield of 24 to 48-hour ambulatory cardiac monitoring in discharged emergency department patients Am J Emerg Med, 2025.PMID 40215590
[4]Wexler RK, Pleister A, Raman SV Palpitations: Evaluation in the Primary Care Setting Am Fam Physician, 2017.PMID 29431371
[5]Barsky AJ, Ahern DK, Delamater BA, et al. Differential diagnosis of palpitations. Preliminary development of a screening instrument Arch Fam Med, 1997.PMID 9161349