Synopsis
Assess palpitations safely, identify high-risk presentations and choose monitoring that is long enough to capture the symptom-rhythm correlation.
- Palpitations describe awareness of the heartbeat; they are a symptom, not a rhythm diagnosis.
- Record a 12-lead ECG during symptoms whenever possible, but a normal resting ECG does not exclude an intermittent arrhythmia.
- Match monitor duration to event frequency: 24-48 hour Holter for symptoms at least daily, longer event or patch monitoring for less frequent episodes, and an implantable loop recorder for rare but concerning events.
- Syncope, exertional onset, structural heart disease, an abnormal baseline ECG or a family history of sudden cardiac death before 40 years raises concern.
- Ask the patient to mark symptoms and activities; a tracing without contemporaneous symptoms may not explain the complaint.
- Check reversible contributors such as anaemia, thyroid disease, electrolyte disturbance, infection, pregnancy, stimulants and medicines.
- Isolated ectopic beats in a structurally normal heart often need explanation and trigger reduction rather than antiarrhythmic treatment.
Key red flags
Look for hypotension or shock, syncope, pulmonary oedema, myocardial ischaemia, severe breathlessness or altered consciousness while the rhythm is present.
Exertional events, unexplained syncope, congenital heart disease, cardiomyopathy, previous myocardial infarction, or sudden death or inherited cardiomyopathy in a close relative are red flags.
Investigation priorities
Document rhythm and screen for conduction disease, pre-excitation, long QT, Brugada pattern, ischaemia or hypertrophy.