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.
Key red flags
Look for hypotension or shock, syncope, pulmonary oedema, myocardial ischaemia, severe breathlessness or altered consciousness while the rhythm is present.
Investigation priorities
Document rhythm and screen for conduction disease, pre-excitation, long QT, Brugada pattern, ischaemia or hypertrophy.
Management branches
The patient is symptomatic during assessment.
- Perform ABCDE assessment, record observations and attach continuous ECG monitoring.
- Obtain a 12-lead ECG without delaying resuscitation; give oxygen only if hypoxaemic and obtain IV access if instability is possible.