management of palpitations in primary care

Initial assessment and investigation: In primary care, start with a detailed history and physical examination including a 12-lead ECG to identify any abnormalities or signs of structural heart disease. Arrange blood tests including full blood count, urea and electrolytes, thyroid function tests, liver function tests, and HbA1c to identify underlying causes. Carry out a cardiovascular risk assessment and manage risk factors accordingly.

Referral criteria: Urgently refer to cardiology if the patient has syncope or near syncope, palpitations precipitated by exercise, family history of sudden cardiac death under 40 years, or second/third degree AV block on ECG. Routinely refer if there is accompanying chest pain, lightheadedness, history or signs of structural heart disease, heart failure, hypertension, abnormal resting ECG (other than AV block), recurrent sustained tachyarrhythmia, or suspected ventricular tachycardia or frequent ventricular extrasystoles.

Management if no referral needed: If palpitations are isolated, ECG is normal, and no high-risk features are present, reassure the patient and provide lifestyle advice to reduce triggers such as stress, caffeine, alcohol, smoking, and drugs. For sinus tachycardia, manage the underlying cause and cardiovascular risk factors. For atrial or ventricular extrasystoles without underlying heart disease and infrequent palpitations, reassurance and lifestyle advice are appropriate.

Further investigations: If symptoms are infrequent but prolonged, advise the patient to seek ECG during an episode. For short-lived but frequent symptoms, arrange ambulatory monitoring (24-48 hour Holter). For infrequent short episodes, consider event or loop recorders. Request echocardiogram if a murmur is detected or structural heart disease is suspected.

Driving and work advice: Advise patients about DVLA regulations regarding arrhythmias and driving cessation until the underlying cause is controlled (4 weeks for Group 1, 3 months for Group 2). Patients in safety-critical occupations may need to stop work until diagnosis or treatment is confirmed.