Palpitations

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

Ready Reckoner

Key distinguishing features of the most common diagnoses

AnxietySinus TachycardiaAtrial EctopicsVentricular EctopicsSVT
Sudden OnsetPossibleNoPossiblePossibleYes
‘Heart Racing’YesYesNoNoYes
‘Heart Misses a Beat’PossibleNoYesYesNo
Underlying Beart DiseaseNoNoNoPossiblePossible
Rate/Rhythm Abnormal During EpisodeNoYesYesYesYes

Possible Investigations

Likely:ECG, TFT.

Possible:U&E, 24 h ECG or event monitor, Tilt table test.

Small Print:Echocardiography, further secondary care cardiac investigations, 24 h urinary 5-HIAA, 24 h urinary-free catecholamines and VMAs.

  • ECG: May show arrhythmia itself or evidence of ischaemic heart disease or Wolff– Parkinson–White syndrome.
  • TFT: Thyrotoxicosis can cause palpitations or exacerbate other causes.
  • U&E: Electrolyte disturbance can precipitate or aggravate some arrhythmias.
  • 24 h ECG or event monitor: To provide ECG evidence of the arrhythmia.
  • Echocardiography: To investigate possible structural lesions such as valvular problems or cardiomyopathy.
  • Further secondary care investigations: Might include investigation for underlying ischaemic heart disease.
  • 24 h urinary 5-HIAA: If carcinoid syndrome suspected.
  • 24 h urinary-free catecholamines and VMAs: If phaeochromocytoma suspected.
  • Tilt table test: if suspicion of PoTS

Top Tips

  • Take time to obtain a clear history, as the patient’s perception of a ‘palpitation’ may differ markedly from yours.
  • In paroxysmal cases, suggest that the patient attends the surgery or casualty urgently during an attack to obtain an ECG.
  • Patients can easily be taught to take their own pulse. Self-reported pulse rates can help considerably in establishing a diagnosis or they can measure their pulse using one of the various pieces of electronic gadgetry available for domestic use, though beware of fuelling neurosis.
  • Most patients with palpitations fear heart disease, and this anxiety exacerbates the symptoms. Ensure this fear is resolved whenever possible.

Red Flags

  • Multiple, or multifocal, ventricular ectopics suggest significant ischaemic heart disease – and may herald VT or fibrillation if they follow an infarct.
  • Sudden onset of tachycardia in a young adult with breathlessness, dizziness, chest pain and polyuria suggests significant SVT.
  • Take very seriously patients with palpitations which are linked with syncope, or which come on after exercise, or who have an existing cardiac history, or who have a family history of sudden death in under 40s. All need referral.
  • Remember that digoxin can aggravate as well as resolve some arrhythmias.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.