How can I differentiate between benign and concerning causes of palpitations in primary care?

To differentiate between benign and concerning causes of palpitations in primary care, start with a thorough clinical assessment focusing on history, symptoms, and risk factors.

• Concerning features warranting urgent cardiology referral include: history of syncope or near syncope, palpitations precipitated by exercise, family history of sudden cardiac death under 40 years, and second or third degree atrioventricular block on ECG.
• Routine cardiology referral is indicated if: palpitations are accompanied by chest pain or lightheadedness, there is a history or signs of structural heart disease, heart failure, hypertension, abnormal resting ECG (other than AV block), recurrent sustained tachyarrhythmia, or frequent ventricular extrasystoles or suspected ventricular tachycardia.
• Benign features include: isolated palpitations with a normal 12-lead ECG, no exercise provocation, no associated lightheadedness, syncope, breathlessness, chest pain, structural heart disease, or family history of sudden cardiac death.
• Investigations in primary care: perform ECG during symptoms if possible, arrange ambulatory ECG monitoring based on symptom frequency, and request blood tests (full blood count, urea and electrolytes, thyroid function, liver function, HbA1c) to identify underlying causes.
• Physical examination: look for murmurs or signs of heart failure; if present, arrange echocardiogram to assess for structural heart disease.
• Lifestyle advice and management: address cardiovascular risk factors and lifestyle triggers such as caffeine, alcohol, smoking, and stress.

In summary, palpitations without high-risk features and with normal ECG and investigations are likely benign and can be managed with reassurance and lifestyle advice, whereas the presence of concerning clinical features or abnormal investigations necessitates referral and further cardiology assessment ¹,²,⁴.