Palpitations in primary care: when should I worry?

Palpitations are a common chief complaint you see in primary care, so when should you be concerned? There are numerous causes of palpitations such as cardiac, metabolic disorders, or even psychiatric disorders. So if they show up in my office, this is my typical approach. 

If they are experiencing symptoms at the office visit: get an EKG and assess the patient. 

• EKG normal: may be PACs or PVCs (usually described by patient as feeling like a skipped beat and they do not occur with exercise) 
• EKG shows arrhythmia: manage as appropriate 

If they are NOT symptomatic at the office visit: focus on history and physical, but still obtain an EKG 

Low risk palpitations 

• Well tolerated, unsustained, and no evidence of heart disease
• Lifestyle modification education (ex. Avoid caffeine, stay hydrated, etc.) and f/u 2 weeks with close observation of symptoms
•  If the patient is very worried and needs more reassurance, you can order an event monitor 

High risk palpitations 

• Sustained palpitation or poorly tolerated 
• Signs of heart disease (based on history, physical, and EKG)
• Personal or family history of syncope, arrhythmia, sudden death, cardiomyopathy, or long QT syndrome 
• If history concerning for VT, I order a Holter monitor 
• I refer for ED eval if they are very frequent and associated with syncopal episodes

Labs and Diagnostics

Labs: 

• TSH to r/o thyroid disorders
• CBC to r/o anemia

Echo: 

• Poorly tolerated or sustained palpitations 
• Concerns for hypertrophic cardiomyopathy
• Murmur noted on exam 
• EKG suggesting possible prior MI, LBBB, or ventricular hypertrophy  

Heart monitor (consider how often they occur and if they will be able to catch it in 24-48 hours)

• 24-48 Holter monitor 
• 2-4 week event monitor 

Referral: consider a cardiology consult if appropriate. I err on the side of caution if I’m not sure.

Note 

This is a general guideline I follow and each situation is different so obviously use your clinical judgment.