What initial investigations should I consider for a patient presenting with new-onset palpitations?

Initial investigations for a patient presenting with new-onset palpitations should include:

• Perform a 12-lead electrocardiogram (ECG) to detect arrhythmias or conduction abnormalities.
• Arrange blood tests including full blood count, urea and electrolytes, thyroid function tests, liver function tests, and HbA1c to identify any underlying systemic causes.
• Carry out a cardiovascular risk assessment and manage any identified risk factors.
• If a murmur is detected on examination or heart failure is suspected, arrange an echocardiogram to assess for structural heart disease.
• If palpitations are infrequent and not captured on ECG, consider ambulatory ECG monitoring such as 24-48 hour Holter monitoring for frequent symptoms or event recorders for infrequent episodes.

Referral urgency depends on clinical features such as syncope, exercise-induced palpitations, family history of sudden cardiac death, or ECG abnormalities.

These investigations help identify arrhythmias, structural heart disease, or systemic causes that may underlie palpitations and guide further management.

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