BMJ 2016;352:h5649 doi: 10.1136/bmj.

h5649 (Published 6 January 2016) Page 1 of 6

Practice

PRACTICE

PRACTICE POINTER

Assessment of palpitations
1 2
Chris P Gale associate professor honorary consultant cardiologist , A John Camm professor of
34
clinical cardiology

Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK; 2York Teaching Hospital NHS Foundation Trust, York,
1

UK; 3Division of Clinical Sciences, St George’s University of London, London, UK; 4Brompton Hospital, Imperial College, London, UK

What are palpitations? ventricular extrasystoles (at least 30 per hour) may be more of
a concern in patients older than 55 years.5
Palpitations are a symptom characterised by awareness of the
Among 73 healthy patients (confirmed by non-invasive cardiac
heartbeat, often described as a strong, skipping, fluttering,
investigations) with about 10 000 ventricular extrasystoles per
racing, pounding, thudding, or jumping sensation in the chest.
24 hours, one sudden death and one death from cancer occurred
Some patients describe a sensation of having to cough or their
over a 10 year follow-up, compared with an expected 7.4 deaths
breath being taken away. However, patients occasionally mean
calculated from a standardised mortality ratio.6
something other than palpitations, such as chest discomfort,
which may need a different line of investigation. However, in a study of 678 apparently healthy patients aged
between 55 and 75 years, 56 had more than 30 ventricular
extrasystoles per hour, of whom 12 died or had a myocardial
What causes palpitations? infarction; in contrast, of 567 patients who had less than 10
Most palpitations are benign (being atrial, nodal, or ventricular ventricular extrasystoles per hour, 50 experienced such events
extrasystoles1), and probably less than half of cases are due to (hazard ratio 2.65, 95% confidence interval 1.41 to 4.95;
heart rhythm abnormalities or arrhythmias. Anxiety is a common P=0.0025).5 Although the extrasystole threshold seems much
cause of palpitations; up to a third have psychological causes.2 lower in this study, the patients were older and the risk of events
Infrequently, however, they may be incapacitating and can lead was greater in those with higher Framingham risk scores.
to syncope or sudden cardiac death. Equally, a large proportion Extrasystoles may sometimes be due to underlying myocardial
of patients with palpitations (67% in one study3) are diagnosed ischaemia, scar, hypertension, heart failure, or, much less
as having panic, stress, or anxiety when, instead, they have an frequently, a cardiac myopathic process or inherited cardiac
underlying arrhythmia.3 4 condition such as a channelopathy. Notably, very frequent
Palpitations that are due to a heart rhythm abnormality are ventricular extrasystoles (>20% of all heart beats) may cause,
usually tachyarrhythmias or extrasystoles. They are rarely due rather than result from, left ventricular systolic dysfunction.7
to bradycardias. By far the most frequent form of palpitation
comes from ventricular extrasystoles,1 which the patient often Supraventricular arrhythmias
describes as “missed or skipped beats.” Other common causes
Paroxysmal supraventricular tachycardias are related to
include atrial fibrillation and/or flutter (paroxysmal, persistent,
conduction abnormalities in the atrioventricular node or to the
or permanent), paroxysmal supraventricular tachycardias or
presence of bypass tracts. Atrial fibrillation and flutter, on the
ventricular tachycardias (usually non-sustained and related to
other hand, are associated with hypertension, heart failure,
exercise) arising from the outflow tract of the right ventricle,
diabetes, coronary artery disease, obesity, sleep apnoea,
and sinus tachycardia.
thyrotoxicosis, acute or chronic alcohol misuse, and valvular
heart disease, and they increase in incidence with age.8 Atrial
Extrasystoles fibrillation and sustained atrial tachycardia at rates greater than
Generally, ventricular or atrial extrasystoles are not associated 120 beats per minute can also induce left ventricular systolic
with clinically significant structural heart disease. Relatively dysfunction.
infrequent ventricular extrasystoles are common in the
population and are not usually of concern in younger patients;
an underlying cause is usually not identified. Frequent

Correspondence to: C P Gale [email protected]

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BMJ 2016;352:h5649 doi: 10.1136/bmj.h5649 (Published 6 January 2016) Page 2 of 6

PRACTICE

What you need to know

Palpitations are common, and often frightening for the patient, but are usually benign; most are due to atrial or ventricular extrasystoles
For all patients with palpitations, undertake a careful history, examination, blood tests (full blood count, urea, creatinine, electrolytes,
and thyroid function tests), and a 12 lead electrocardiogram for risk stratification. This will determine if and how quickly they need referral
to a specialist
Refer patients to secondary care if the palpitations are provoked by exercise or associated with lightheadedness, syncope, persistent
breathlessness, chest pain, or recurrent sustained tachyarrhythmias; if there is a history or signs of structural heart disease, heart failure,
or hypertension or a family history of sudden cardiac death; or if the 12 lead electrocardiogram is abnormal
Ambulatory rhythm monitors are not always needed in primary care. If needed, tailor the monitoring to the frequency of symptoms (for
example, use 24 hour to seven day Holter monitoring only if palpitations occur daily to weekly)

How do we investigate them? tests, and 12 lead electrocardiogram may identify the underlying
cause in up to 40% of patients.5 Moreover, the correlation
Clinical history between palpitations and arrhythmias is poor,9 and the diagnostic
The history is central to ascertaining the cause of palpitations yield in the community setting is determined by symptom
and therefore whether the patient warrants referral to cardiology frequency.
and how urgently. Boxes 1 and 2 outline what to ask. If, from the history, clinical examination, and initial blood tests,
you are happy that the patient is describing infrequent
Clinical examination extrasystoles, an ambulatory rhythm monitor is not necessary.
Although often normal, careful examination for signs of disease For palpitations that are not thought to be extrasystoles or for
associated with palpitations is necessary. These include signs patients with a high burden of extrasytoles, an ambulatory
of heart failure (raised jugular venous pressure, ankle swelling, rhythm monitor may help to clarify the diagnosis. However,
gallop rhythm, crackles), valvular heart disease (murmurs), restrict a 24 hour Holter monitor to patients who have at least
thyrotoxicosis (tremor, thinness, goitre), and anaemia (pallor). daily symptoms, a 48 hour Holter monitor to those with
Hypertension may be present. symptoms on most days, and a seven day monitor to those with
weekly symptoms, even if the 12 lead electrocardiogram is
Clinical investigations normal. Inappropriate use of short periods of ambulatory
monitoring for infrequent symptoms is cumbersome for patients,
Essential investigations should include blood tests and a 12 lead delays the diagnosis, and is costly.10 In a specialist
electrocardiogram. Other investigations may include ambulatory electrophysiology clinic, the Holter monitor is necessary. This
rhythm monitoring. If underlying heart disease is suspected (or is to decipher the morphology and anatomical origin of the
confirmed), the patient should be referred to cardiology for arrhythmia and detect short asymptomatic episodes that suggest
further investigations including an echocardiogram and the type of arrhythmia responsible for symptomatic episodes,
sometimes an exercise tolerance test. rather than to identify its presence.
The table⇓ shows the diagnostic scenarios of ambulatory rhythm
Blood tests monitoring. The absence of an arrhythmia on an ambulatory
These include: rhythm monitor is often reassuring for the patient. The recording
• A full blood count (checking for anaemia and infection); of an arrhythmia that corresponds to the patient’s symptoms
• Serum urea, creatinine, and electrolytes (checking for renal helps to clinch the diagnosis. Absence of an arrhythmia during
impairment or deranged sodium or potassium an episode of palpitations is also diagnostic and is of great value
concentrations as possible causes of arrhythmias); and to the patient and practitioner. Of note, when palpitations do
not occur during an ambulatory recording and no arrhythmias
• Thyroid function tests. are identified, the investigation is not diagnostic. The clinician
should, therefore, not dismiss the patient’s symptoms but
12 lead electrocardiogram consider an alternative ambulatory rhythm monitor over a great
length of time.
Even though patients rarely experience palpitations during the
consultation (and less so during the recording of the Patient activated event recorders—These allow investigation
electrocardiogram), this test is crucial in offering more of palpitations over a much longer period of time (typically a
information than other cardiac investigations for the evaluation month) and are usually reserved for patients in secondary care
of palpitations. Box 3 lists key electrocardiographic features with infrequent but sufficiently prolonged symptoms, who can
that should lower the threshold for seeking further advice. activate the devices and have been risk stratified as an urgent
Palpitations in the context of a normal electrocardiogram are referral (see next section). They diagnose clinical arrhythmia
much less likely to be associated with a cardiac pathology or in a greater proportion of patients with paroxysmal palpitations
adverse clinical outcome. For patients with infrequent and dizziness than do Holter monitors,11 12 and they are more
palpitations, asking them to attend your practice or the cost effective.10 Some hospitals now provide smart phone
emergency department to have an electrocardiogram recorded monitors that can be used in concert with a smart phone
during symptoms is not unreasonable. application (figure⇓).
Implantable loop recorder—This is a small battery powered
Ambulatory rhythm monitors device inserted under the skin over the left chest wall that
Ambulatory rhythm monitors include Holter monitors, patient records the heart beat. For palpitations that are uncommon but
activated event recorders (specific devices or modified smart associated with syncope, this may be needed because the patient
phones), wearable patch monitors (for up to three or four weeks, is not able to activate recording devices.13
and the implantable loop recorder. These are not always required
in general practice, however, as the history, examination, blood
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PRACTICE

Box 1: What to ask about palpitations

What does the patient mean by “palpitations”? Ensure s/he is not describing a different symptom such as chest discomfort instead
Ask the patient to tap out on the table what s/he experiences during the palpitations. Are they fast (tachyarrhythmia), irregular (atrial
fibrillation), or missed beats (extrasystoles)? Show how to tap out the normal rhythm if s/he does not understand
How long do the palpitations last, and how often do they occur?
Assess the severity. What does the patient do when the palpitations are present? Does s/he ignore them or sit or lie down? Or does
s/he collapse or lose consciousness? Syncope during palpitations needs urgent specialist review
When do the palpitations occur? Palpitations during exertion or immediately afterwards need urgent specialist review as they may reflect
cardiomyopathy, myocardial ischaemia, or channelopathy
Do they start suddenly? Can they be provoked?
Are the palpitations associated with breathlessness or chest pain? A brief sensation of having to cough or “breath taken away” suggests
extrasystoles, whereas persistent breathlessness may be a sign of heart failure or myocardial ischaemia. Chest pain during palpitations
may reflect coronary artery disease or a tachyarrhythmia
How do the palpitations end? Sudden termination suggests a paroxysmal supraventricular tachycardia. Can the patient end the attacks
by coughing, straining (Valsalva manoeuvre), or breath holding, especially with the face in water (diving reflex), suggesting paroxysmal
supraventricular tachycardia?

Box 2: What to ask about medical and family history

What drugs is the patient taking? The following classes of drugs (with examples) are associated with tachyarrhythmias: β agonists
(salbutamol), antimuscarinics (amitriptyline), theophylline (phylocontin), dihydropyridine calcium channel blockers (nifedipine), class 1
anti-arrhythmics (flecainide, disopyramide), drugs that may prolong the QT interval (erythromycin, moxifloxacin), and illicit drugs (cocaine,
amphetamines)
Are there any contributing lifestyle factors? Alcohol excess, caffeine, and illicit drugs provoke extrasystoles and atrial fibrillation
Are there other social or medical factors that may lower the threshold for some arrhythmias? For example, business or other worries,
lack of sleep, and fever are associated with ventricular extrasystoles and atrial fibrillation
Are there medical conditions that may be associated with atrial fibrillation and flutter? For example, hypertension, heart failure, coronary
artery disease, valvular heart disease, diabetes, obesity, sleep apnoea, thyrotoxicosis, and acute or chronic alcohol misuse
Are there medical conditions that may be associated with tachyarrhythmias? For example, anaemia, thyrotoxicosis
Is there a family history of sudden cardiac death? Sudden cardiac death (which may have caused drowning, epilepsy, or a road traffic
accident) under the age of 40 years is suggestive of an arrhythmia and raises the possibility of an inherited cardiac condition

Box 3: 12 lead electrocardiogram practice pointers for palpitations—when to consider specialist referral
Atrial fibrillation or atrial flutter
Second degree atrioventricular block
Third degree atrioventricular block
Myocardial infarction
Left ventricular hypertrophy (with or without strain pattern)
Left bundle branch block
Abnormal T waves and ST segments
Pre-excitation (Wolff-Parkinson-White pattern of a slow rise in the initial portion of the QRS (delta wave))
Abnormal QT/QTc interval

When should we seek specialist input? Routine cardiology referral (preferably to

cardiologists who are also cardiac
The cornerstone of the assessment of palpitations is risk electrophysiologists)
stratification, to determine the need for referral and its urgency.14
• Palpitations associated with symptoms such as chest pain
or lightheadedness;
Low risk features for which referral is not
mandatory • A history of recurrent sustained tachyarrhythmia, atrial
fibrillation, or flutter;
• Isolated palpitations (described as skipped beats, pounding,
or short fluttering) that are not provoked by exercise and • A history or physical signs of structural heart disease,
not associated with symptoms such as lightheadedness, hypertension, or heart failure;
syncope, persistent breathlessness, or chest pain; • A clear history of palpitations, consistent with a paroxysmal
• No history or signs of structural heart disease, heart failure, supraventricular tachycardia (sudden onset and offset of a
or hypertension and no family history of sudden cardiac fast regular heartbeat), with multiple non-diagnostic
death; and ambulatory rhythm monitor recordings (these patients could
be referred directly to an electrophysiologist for
• A normal 12 lead electrocardiogram.
electrophysiological studies and any necessary treatment);
In these cases, palpitations are generally due to extrasystoles or or
sinus tachycardia.
• An abnormal 12 lead electrocardiogram (apart from second
degree or third degree atrioventricular block, which requires
urgent referral).
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BMJ 2016;352:h5649 doi: 10.1136/bmj.h5649 (Published 6 January 2016) Page 4 of 6

PRACTICE

Urgent cardiology referral How patients were involved in creating

• Palpitations during exercise; this article
• Palpitations associated with syncope or pre-syncope; We invited a patient to comment on the paper and the patient’s
• Family history of sudden cardiac death or inheritable own experience and expectations of an “ideal” consultation with
cardiac conditions; or a primary care physician, inserting their comments in the
• Second degree or third degree atrioventricular block on the relevant section.
12 lead electrocardiogram.
Contributors: CPG wrote the first draft, and CPG and AJC then wrote
subsequent drafts. CPG is the guarantor.
Can the patient drive? Competing interests: We have read and understood the BMJ policy on
In the United Kingdom, the Driver and Vehicle Licensing declaration of interests and declare the following interests: none.
Agency (DVLA) regulations state that if an arrhythmia has Provenance and peer review: Commissioned; externally peer reviewed.
caused incapacity or is likely to cause incapacity, the patient
must not drive.15 It is the clinician’s responsibility to notify the 1 Hiss RG, Lamb LE. Electrocardiographic findings in 122,043 individuals. Circulation
1962;25:947-61.
patient of this, document it in the case records, and advise the 2 Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. Am J Med
patient to contact the DVLA, who will make the final 1996;100:138-48.
3 Lessmeier TJ, Gamperling D, Johnson-Liddon V, et al. Unrecognized paroxysmal
recommendation.16 Similarly, US and European guidelines for supraventricular tachycardia: potential for misdiagnosis as panic disorder. Arch Intern
fitness to drive for class 1 licence holders recommend that Med 1997;157:537-43.
driving should stop while patients have symptoms (with 4 Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. Psychiatric disorders in medical
outpatients complaining of palpitations. J Gen Intern Med 1994;9:306-13.
tachyarrhythmias or bradyarrhythmias). Driving may resume 5 Sajadieh A, Nielsen OW, Rasmussen V, et al. Ventricular arrhythmias and risk of death
once symptoms are controlled for one month, although in the and acute myocardial infarction in apparently healthy subjects of age >or=55 years. Am
J Cardiol 2006;97:1351-7.
United States a longer restriction is recommended pending 6 Kennedy HL, Whitlock JA, Sprague MK, Kennedy LJ, Buckingham TA, Goldberg RJ.
evaluation of any broad complex tachycardia.17 For class 2 (large Long-term follow-up of asymptomatic healthy subjects with frequent and complex
ventricular ectopy. N Engl J Med . 1985;312:193-7.
lorries and buses) licence holders, the restrictions are more 7 Baman TS, Lange DC, Ilg KJ, et al. Relationship between burden of premature ventricular
stringent. complexes and left ventricular function. Heart Rhythm 2010;7:865-9.
8 Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults:
national implications for rhythm management and stroke prevention: the AnTicoagulation
What should we tell the patient? 9
and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001;285:2370-5.
Barsky AJ. Palpitations, arrhythmias, and awareness of cardiac activity. Ann Intern Med
2001;134:832-7.
A patient adviser suggests: “Be honest and reassuring. Explain 10 Kinlay S, Leitch JW, Neil A, Chapman BL, Hardy DB, Fletcher PJ. Cardiac event recorders
what they are, how they arise, and at what threshold you would yield more diagnoses and are more cost-effective than 48-hour Holter monitoring in
refer them to a specialist, or if and why additional tests may not 11
patients with palpitations: a controlled clinical trial. Ann Intern Med 1996;124:16-20.
Thavendiranathan P, Bagai A, Khoo C, Dorian P, Choudhry NK. Does this patient with
be needed.” If specialist referral is not necessary, and the palpitations have a cardiac arrhythmia? JAMA 2009;302:2135-43.
palpitations are considered to be, for example, infrequent 12 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
extrasystoles, spend some time explaining that these are due to paroxysmal palpitations or dizziness. Europace 2014;16:1231-5.
extra heart beats that usually arise from the main pumping 13 National Institute for Health and Care Excellence. Transient loss of consciousness
(‘blackouts’) management in adults and young children. NICE, 2010 (NICE clinical guideline
chamber of the heart; that, although palpitations may be 109).
frightening, they are unlikely to cause harm; that further tests 14 Wolff A, Campbell C. 10 steps before your refer for palpitations. Br J Cardiol 2009;16:182-6.

are not needed but that you would refer to a specialist if the 15 Driver and Vehicle Licensing Agency. For medical practitioners: at a glance guide to the
current medical standards of fitness to drive. DVLA, 2014.
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sustained.
Cite this as: BMJ 2015;351:h5649
© BMJ Publishing Group Ltd 2016

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BMJ 2016;352:h5649 doi: 10.1136/bmj.h5649 (Published 6 January 2016) Page 5 of 6

PRACTICE

Table

Table 1| Possible outcomes of ambulatory rhythm monitoring

Palpitations during ambulatory rhythm monitoring?

Ambulatory rhythm monitor results Yes No
Arrhythmia Arrhythmia diagnosed Coincidental arrhythmia or asymptomatic form (possibly diagnostic)
No arrhythmia Palpitations are not due to arrhythmia No diagnosis possible

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PRACTICE

Figure

Smartphone monitor and app, with two metal finger pads on reverse and heart rhythm on screen. Reproduced with permission
from AliveCor

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