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Assessment of palpitations

BMJ 2016; 352 doi: (Published 06 January 2016) Cite this as: BMJ 2016;352:h5649
  1. Chris P Gale, associate professor1, honorary consultant cardiologist2,
  2. A John Camm, professor of clinical cardiology34
  1. 1Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
  2. 2York Teaching Hospital NHS Foundation Trust, York, UK
  3. 3Division of Clinical Sciences, St George’s University of London, London, UK
  4. 4Brompton Hospital, Imperial College, London, UK
  1. Correspondence to: C P Gale c.p.gale{at}

What you need to know

  • Palpitations are common, and often frightening for the patient, but are usually benign; most are due to atrial or ventricular extrasystoles

  • For all patients with palpitations, undertake a careful history, examination, blood tests (full blood count, urea, creatinine, electrolytes, and thyroid function tests), and a 12 lead electrocardiogram for risk stratification. This will determine if and how quickly they need referral to a specialist

  • Refer patients to secondary care if the palpitations are provoked by exercise or associated with lightheadedness, syncope, persistent breathlessness, chest pain, or recurrent sustained tachyarrhythmias; if there is a history or signs of structural heart disease, heart failure, or hypertension or a family history of sudden cardiac death; or if the 12 lead electrocardiogram is abnormal

  • Ambulatory rhythm monitors are not always needed in primary care. If needed, tailor the monitoring to the frequency of symptoms (for example, use 24 hour to seven day Holter monitoring only if palpitations occur daily to weekly)

What are palpitations?

Palpitations are a symptom characterised by awareness of the heartbeat, often described as a strong, skipping, fluttering, racing, pounding, thudding, or jumping sensation in the chest. Some patients describe a sensation of having to cough or their breath being taken away. However, patients occasionally mean something other than palpitations, such as chest discomfort, which may need a different line of investigation.

What causes palpitations?

Most palpitations are benign (being atrial, nodal, or ventricular extrasystoles1), and probably less than half of cases are due to heart rhythm abnormalities or arrhythmias. Anxiety is a common cause of palpitations; up to a third have psychological causes.2 Infrequently, however, they may be incapacitating and can lead to syncope or sudden cardiac death. Equally, a large proportion of patients with palpitations (67% in one study3) are diagnosed as having panic, stress, or anxiety when, instead, they have an …

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