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.

NICE CKS