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ALL / Cardiology

Investigating palpitations

Investigating palpitations

Palpitations are a common presenting symptom.

Possible causes include
  • arrhythmias
  • stress
  • increased awareness of normal heart beat / extrasystoles

First-line investigations include:
  • 12-lead ECG: this will only capture the heart rhythm for a few seconds and hence is likely to miss episodic arrhythmias. However, other abnormalities linked to the underlying arrhythmia (for example a prolonged QT interval or PR interval, or changes suggesting recent myocardial ischaemia) may be seen.
  • thyroid function tests: thyrotoxicosis may precipitate atrial fibrillation and other arrhythmias
  • urea and electrolytes: looking for disturbances such as a low potassium
  • full blood count

Capturing episodic arrhythmias

First-line investigations are often normal in patients complaining of palpitations. The next step is to exclude an episode arrhythmia.

The most common investigation is Holter monitoring
  • portable battery operated device
  • continuously records ECG from 2-3 leads
  • usually done for 24 hours but may be used for longer if symptoms are less than daily
  • patients are asked to keep a diary to record any symptomatic palpitations. This can later be compared to the rhythm strip at the time of the symptoms
  • at the end of the monitoring a report is generated summarising a number of parameters including heart rate, arrhythmias and changes in ECG waveform

If no abnormality is found on the Holter monitor, and symptoms continue, other options include:
  • external loop recorder
  • implantable loop recorder
+PassMedicine Notes

Palpitations are a common presenting symptom.

Possible causes include
  • arrhythmias
  • stress
  • increased awareness of normal heart beat / extrasystoles
First-line investigations include:
  • 12-lead ECG: this will only capture the heart rhythm for a few seconds and hence is likely to miss episodic arrhythmias. However, other abnormalities linked to the underlying arrhythmia (for example a prolonged QT interval or PR interval, or changes suggesting recent myocardial ischaemia) may be seen.
  • thyroid function tests: thyrotoxicosis may precipitate atrial fibrillation and other arrhythmias
  • urea and electrolytes: looking for disturbances such as a low potassium
  • full blood count

Capturing episodic arrhythmias

First-line investigations are often normal in patients complaining of palpitations. The next step is to exclude an episode arrhythmia.

The most common investigation is Holter monitoring
  • portable battery operated device
  • continuously records ECG from 2-3 leads
  • usually done for 24 hours but may be used for longer if symptoms are less than daily
  • patients are asked to keep a diary to record any symptomatic palpitations. This can later be compared to the rhythm strip at the time of the symptoms
  • at the end of the monitoring a report is generated summarising a number of parameters including heart rate, arrhythmias and changes in ECG waveform
If no abnormality is found on the Holter monitor, and symptoms continue, other options include:
  • external loop recorder
  • implantable loop recorder


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