When should I refer a patient with suspected arrhythmogenic cardiomyopathy to a cardiologist?

Refer a patient with suspected arrhythmogenic cardiomyopathy urgently to a cardiologist if they have:

• A history of syncope or near syncope, especially if exertional.
• Palpitations precipitated by exercise.
• A family history of sudden cardiac death under the age of 40 years.
• Second or third degree atrioventricular block on the 12-lead ECG.
• Signs or symptoms of structural heart disease, heart failure, or hypertension.
• Resting ECG abnormalities other than second or third degree AV block.
• Recurrent sustained tachyarrhythmias, atrial fibrillation, or flutter.
• Frequent ventricular extrasystoles or suspicion of ventricular tachycardia.

Routine referral is appropriate if the patient has accompanying chest pain or lightheadedness, or if there is suspicion of underlying heart disease based on clinical assessment or ECG findings.

Patients with isolated palpitations, a normal 12-lead ECG, and no high-risk features generally do not require referral.

In all cases, initial assessment should include a 12-lead ECG and consideration of family history and symptoms suggestive of arrhythmogenic cardiomyopathy or other structural heart disease.

These recommendations are based on expert opinion and UK clinical guidelines on palpitations and cardiovascular assessment in primary care ¹.