Palpitations
Red Flags — must not miss
| Red flag | Why dangerous | Action |
|---|---|---|
| Syncope or pre-syncope during palpitations | Haemodynamic compromise during tachyarrhythmia — ventricular tachycardia, AF with rapid ventricular response in structural heart disease, or AVRT with accessory pathway (WPW). Highest-risk palpitations presentation. Risk of sudden cardiac death. | 999 if ongoing · Urgent cardiology if resolved |
| Exercise-induced palpitations | Catecholaminergic polymorphic VT (CPVT), ischaemia-related arrhythmia, or HOCM causing exercise-induced arrhythmia. Significant sudden cardiac death risk — exercise must be restricted until full cardiac exclusion is completed. | Same-day cardiology; no exercise |
| Structural heart disease + palpitations | Palpitations in a patient with IHD, cardiomyopathy, or valve disease carry a dramatically higher probability of ventricular arrhythmia than in a structurally normal heart. VT is far more likely and far more dangerous in this context. | Same-day assessment |
| Family history of sudden cardiac death under 40 | Inherited channelopathy (LQTS, Brugada, CPVT, ARVC, HCM) — all associated with both palpitations and sudden cardiac death. Requires specialist cardiac evaluation with family cascade screening. | Urgent cardiology + cascade |
| QTc over 450 ms (M) / 470 ms (F) on ECG | Prolonged QT increases risk of torsades de pointes — a polymorphic VT that can degenerate to VF. May be drug-induced (check medication list) or congenital LQTS. Stop culprit drug immediately; check electrolytes. | Stop culprit drug + same-day cardiology |
| Wide complex tachycardia on ECG | Wide complex tachycardia (QRS over 120 ms during tachycardia) is VT until proven otherwise — treat as such until specialist review. Never assume aberrantly conducted SVT in an older patient or one with structural heart disease without specialist confirmation. | 999 if ongoing; cardiology if resolved |
| Signs of haemodynamic instability | Palpitations with hypotension, pallor, cold peripheries, or impaired consciousness during the episode indicates haemodynamic compromise — ACS, massive PE, VT, or rapid AF in a structurally compromised heart. | 999 immediately |
😰 Cardiac Anxiety and Health Anxiety
Palpitations — particularly those felt as "the heart stopping" (ectopics) — are among the most anxiety-provoking cardiac symptoms. Health anxiety amplifies perception of normal cardiac variation and creates a cycle: awareness → anxiety → increased sympathetic drive → more ectopics → more awareness. Breaking this cycle requires both explanation and behavioural intervention.
"Some people find that the more they focus on their heart, the more they notice every small change — have you found that happening to you?"📱 Smartwatch and Health-Monitoring Behaviour
Obsessive pulse-checking and smartwatch monitoring in patients with palpitations reinforces health anxiety and symptom amplification. While the smartwatch provides genuinely useful data, continuous monitoring creates hypervigilance that perpetuates the symptom experience even when the arrhythmia is benign. Limiting monitoring to only during symptomatic episodes is a key behavioural intervention.
"The data from your watch during episodes is really useful — but I wonder if checking it constantly between episodes might actually be making the anxiety worse?"💼 Occupational Impact
Palpitations during work — particularly a stressful profession such as law — can be destabilising. The patient may be avoiding high-stakes court appearances or client meetings for fear of an episode. Conversely, work stress may be the primary driver of palpitation frequency. Explore both directions: impact of palpitations on work, and impact of work on palpitations.
"Has this been affecting your work at all — have you found yourself avoiding certain situations in case an episode comes on?"🌡️ Perimenopausal Context
Perimenopause is the single most common biological context for new palpitations in women aged 45–55. Oestrogen withdrawal destabilises cardiac autonomic regulation, causing palpitations during hot flushes and at rest. However, perimenopausal palpitations is a diagnosis of exclusion — AF, SVT, and thyroid disease must be excluded first. Prematurely attributing palpitations to menopause in a woman in this age group who turns out to have AF is a serious clinical error.
"I know that the menopause can cause palpitations — it's very common — but before we assume that's the cause, I want to make sure we've checked a few things properly."🤝 Partner and Family Concern
Partners witnessing episodes of apparent arrhythmia are often terrified and may push the patient to seek urgent care. This can be both helpful (driving early presentation) and harmful (reinforcing catastrophic thinking). Understanding what the partner has been telling the patient about the episodes shapes the patient's own illness model and expectations.
"Has your family or partner been worried about these episodes — and what have they been saying about what they think it might be?"🏃 Exercise and Physical Activity
Patients who exercise regularly and develop palpitations during activity require urgent arrhythmia exclusion before they can safely return to sport. Conversely, patients who have become sedentary because of fear of triggering palpitations are suffering significant quality-of-life restriction — and sedentary behaviour itself increases AF risk through deconditioning.
"Have you changed what you're doing physically since these episodes started — are you exercising less, or avoiding things you used to do?"- Opening with "What is your heart rate during episodes?" before an open question
- Not asking about syncope or presyncope during episodes
- Not asking about exercise-induced episodes — the highest-risk trigger
- Attributing palpitations to "just the menopause" without cardiac exclusion
- Not checking for QT-prolonging medications in the drug history
999 or A&E Now
Immediate assessment- Ongoing haemodynamic instabilityPalpitations + hypotension, pallor, cold peripheries, reduced consciousness → call 999
- Wide-complex tachycardia on ECGVT until proven otherwise — do not manage in primary care without specialist advice
- QTc over 500 ms + palpitationsTorsades de pointes risk — stop culprit drug immediately; A&E
- Palpitations + syncope at presentationHaemodynamic compromise during arrhythmia — immediate resuscitation may be needed
- New rapid AF with haemodynamic compromiseFast AF with systolic BP under 90 mmHg → A&E for IV rate control or cardioversion
Same-Day to 2-Week Assessment
Rapid assessment- History of syncope during palpitations (resolved)Even if now resolved: same-day cardiology referral; possible VT
- Exercise-induced palpitationsCPVT, ischaemia-related arrhythmia — restrict exercise; same-day cardiology
- New AF confirmed (haemodynamically stable)2-week cardiology; anticoagulation decision required promptly; rate control
- Palpitations + structural heart diseaseVT probability elevated; urgent Holter and cardiology review within 2 weeks
- Family history SCD under 40 + palpitationsInherited channelopathy exclusion: urgent specialist cardiac assessment with cascade
- QTc 450–500 ms + palpitationsReview QT-prolonging medication; check electrolytes; 2-week cardiology referral
Primary Care Management
GP management with review- Benign ectopics (isolated)Single thump then pause, no structural disease, no syncope, normal ECG → reassure; lifestyle
- Palpitations with clear benign triggerCaffeine-excess, alcohol, fatigue, anxiety — lifestyle modification; review at 4 weeks
- Perimenopause-attributed (after exclusion)Normal ECG, normal TFTs, classic perimenopausal history → HRT discussion
- SVT with normal ECG and no syncope4-week Holter or event recorder; low-dose beta-blocker while awaiting referral
- Anxiety-related palpitations (after exclusion)CBT via NHS Talking Therapies; lifestyle modification; reduce smartwatch checking behaviour
"Your heart has its own electrical system that tells it when to beat. Most of the time it works perfectly on its own automatic setting. Palpitations happen when there's a short-circuit in that electrical system, or when something external — like stress, too much caffeine, or a thyroid problem — is pushing the electrical system harder than usual. The key thing we're trying to work out today is which type this is: the kind that doesn't need any specific treatment beyond lifestyle changes, or the kind where the electrical circuit needs resetting or medical treatment. That's exactly what the heart tracing and the monitors are going to help us answer."
Benign Ectopic Beats (VE / SVEB)
Single thump or "missed beat" followed by a compensatory pause. Very common — present in most adults. Confirmed on Holter with symptom-rhythm correlation showing ectopic without sustained arrhythmia. Often worsened by caffeine, alcohol, fatigue. Reassurance is the primary treatment; lifestyle modification reduces frequency.
Sinus Tachycardia (secondary cause)
Gradually building fast regular rhythm driven by a physiological trigger: anxiety, pain, fever, anaemia, dehydration, thyrotoxicosis. Identified by gradual onset and gradual offset on Holter, and by identifying and treating the underlying cause. Treat the cause, not the rhythm.
Drug/Caffeine-Induced Palpitations
Temporal correlation between new medication or increased caffeine/alcohol intake and onset of palpitations. Often confirmed by complete resolution after drug withdrawal or lifestyle change. No ongoing investigation needed if arrhythmia excluded on ECG and symptoms fully resolve.
Perimenopausal Palpitations (after exclusion)
Confirmed only after cardiac arrhythmia and thyroid disease are excluded on ECG, TFTs, and Holter. Associated with hot flushes, irregular periods, sleep disturbance. Managed with HRT (NICE-recommended for perimenopausal symptoms) alongside cardiac reassurance.
Supraventricular Tachycardia (SVT — AVNRT / AVRT)
Abrupt onset, regular, 140–220 bpm, terminates abruptly (sometimes with Valsalva). Normal resting ECG between episodes. Requires Holter during an episode for confirmation — or can be inferred clinically with high confidence from the history. Refer to cardiology for electrophysiology study and catheter ablation discussion.
Atrial Fibrillation (paroxysmal or persistent)
Irregularly irregular palpitations, confirmed on ECG or Holter as AF. Requires CHA₂DS₂-VASc scoring for anticoagulation and rate/rhythm control decision. Cardiology referral for cardioversion or ablation in selected younger patients. AF is the most clinically important diagnosis to establish in palpitations — stroke risk is the key consequence.
Thyrotoxicosis
Suppressed TSH + elevated FT4. Clinical signs: weight loss, heat intolerance, tremor, goitre. AF may be the presenting feature. Requires carbimazole under endocrinology; propranolol for symptom control; definitive treatment (radioiodine or surgery) planned with specialist. AF resolves with euthyroid restoration in about 60%.
Atrial Flutter
Regularly irregular palpitations at typically 150 bpm (2:1 block). Sawtooth flutter waves on ECG baseline. Rate control and anticoagulation (same CHA₂DS₂-VASc thresholds as AF) — cardiology referral for cardioversion and ablation consideration (higher success rate than AF ablation).
Ventricular Tachycardia (VT)
Wide complex tachycardia on ECG — VT until proven otherwise in any patient with structural heart disease. Associated with syncope, haemodynamic compromise, or family history of SCD. Emergency management — 999 if ongoing; cardiology same day if resolved. ICD assessment likely.
WPW with Pre-Excited AF (dangerous)
AF in a patient with an accessory pathway can conduct at extremely fast rates to the ventricles → VF. AV nodal blocking agents (verapamil, diltiazem, digoxin, adenosine) are absolutely contraindicated — they block the AV node but allow unrestricted conduction down the accessory pathway. EP study and ablation urgently.
Long QT + Torsades de Pointes
Polymorphic VT (torsades) in a patient with long QT — presents as palpitations, syncope, or sudden cardiac death. Drug-induced (stop all QT-prolonging agents immediately) or congenital LQTS. IV magnesium for acute torsades; permanent pacemaker and/or ICD for congenital LQTS under cardiology.
Validate
A patient who has been obsessively monitoring their heart rate for weeks is frightened. Acknowledge the fear before beginning to explain the clinical reasoning.
"I can see this has been really worrying you — three episodes where your heart suddenly raced to 160 beats a minute would frighten anyone."Explain
The patient wants to know "What is it?" and "Is it going to kill me?" — address both directly, with the caveat of pending investigation results.
"The pattern you're describing — sudden start, sudden stop, 160 bpm — is most consistent with a type of heart rhythm called SVT. This is almost always not dangerous, but we need to capture it on a monitor to confirm that and rule out anything more serious."Offer
Give the patient a concrete action today — don't leave them with "we'll investigate and see." Give them the specific monitoring plan and the self-management technique.
"I'm going to arrange a heart monitor today — and I'm also going to teach you a technique you can use yourself to stop the episode if it happens again."Caffeine blocks adenosine receptors and increases catecholamine release — raising resting heart rate, shortening refractory periods, and increasing ectopic burden. High caffeine intake directly precipitates SVT in susceptible individuals and dramatically worsens ectopic frequency.
Keep a 2-week caffeine diary. Include all sources: coffee, tea, energy drinks, cola, dark chocolate. Taper gradually to avoid withdrawal headaches. Trial 2 weeks of complete caffeine elimination — if episodes markedly improve, caffeine is likely the primary driver.
Alcohol causes sympathetic nervous system activation, electrolyte derangement, and direct atrial inflammation — all precipitating AF and SVT. "Holiday heart syndrome" (AF after binge drinking) is the extreme form of this. Even moderate regular alcohol (14+ units/week) significantly increases AF recurrence.
AUDIT-C screening if alcohol is a significant trigger. If AF is confirmed, abstinence is the single most impactful non-pharmacological intervention for reducing recurrence. Brief intervention in primary care is effective for reducing harmful alcohol consumption.
Chronic stress maintains a high sympathetic tone — shortening atrial refractory periods and increasing ectopic burden. Sleep deprivation has an independent dose-dependent relationship with AF incidence. Reducing sympathetic drive through stress management directly reduces palpitation frequency.
Sleep hygiene: consistent sleep-wake times; phone off by 10 pm; avoid caffeine after 2 pm. Mindfulness-based stress reduction (MBSR) or NHS Talking Therapies referral for CBT. Specific advice for a solicitor: schedule protected non-work time; identify the most stressful triggers at work.
Valsalva increases intrathoracic pressure → reflexively activates the parasympathetic vagal response → slows AV node conduction → interrupts the re-entrant SVT circuit. Modified Valsalva (bear down like straining on the toilet then immediately lie flat and raise legs) is more effective than the standard Valsalva — 43% vs 17% success (REVERT trial).
Technique (REVERT modified Valsalva): 1. Sit upright; bear down hard as if straining on the toilet for 15 seconds; 2. Immediately lie flat; 3. Have someone elevate legs to 45° for 15 seconds; 4. Sit back up. Alternative: plunge face into bowl of cold water for 15 seconds (diving reflex).
Continuous heart rate monitoring between episodes creates a hypervigilance loop — every normal heart rate variation becomes a "symptom," increasing anxiety and the perception of palpitations. The smartwatch is diagnostically useful during episodes; it is harmful between them. This is a key behavioural intervention.
Agree with the patient: smartwatch heart rate checking only when a definite symptomatic episode is occurring — not between episodes. Cover or remove the watch display between episodes if checking is compulsive. Cognitive defusion techniques (from ACT) can help. NHS Talking Therapies referral if health anxiety is significant.
Regular aerobic exercise increases vagal tone, reduces resting heart rate and sympathetic drive, and significantly reduces AF recurrence and frequency. Sedentary behaviour is independently associated with increased AF risk. Exercise also reduces anxiety and the psychological burden of palpitations.
Clarify: if palpitations are only at rest, exercise is not contraindicated and should be encouraged. If there is any history of exercise-induced palpitations — exercise is restricted until cardiac clearance is obtained. Goal: 150 min/week brisk walking, cycling, or swimming.
"This tablet slows your heart rate slightly, which both treats the fast rhythm and helps prevent episodes. Don't stop it suddenly — your heart rate can rebound. Let me know if you feel unusually tired or short of breath, as we can adjust the dose."
Bisoprolol for rate control in AF scores in the Tasks domain specifically — name the drug, the starting dose, and the titration target (resting HR 60–80 bpm). In an SCA about palpitations, the examiner expects the anticoagulation decision to be made separately from and before the rate control decision.
"Because we've found an irregular heart rhythm, your risk of a blood clot forming is increased — this tablet protects you from that. Take it every day, ideally at the same time. If you ever need surgery or a dental extraction, tell the surgeon you're on a blood thinner."
Critical SCA scoring point: in confirmed AF, calculating CHA₂DS₂-VASc and making the anticoagulation decision is a separate and prioritised task from rate control. The examiner expects you to address anticoagulation before or simultaneously with rate control. Naming a specific DOAC, specific dose, and specific monitoring plan scores in the Tasks domain.
"This is a specific heart rhythm tablet that works differently from the beta-blocker — it actually stops the abnormal electrical circuit from firing. It's been prescribed by your heart specialist and is very effective as long as your heart structure is normal, which we've confirmed."
In the SCA, prescribing flecainide without echo confirmation of structurally normal heart is a significant patient safety deduction. The critical SCA statement is: "I would not start flecainide until the echocardiogram has confirmed there is no structural heart disease." This demonstrates safe prescribing thinking and scores highly in the Tasks domain.
"This tablet reduces the amount of thyroid hormone your body is making — which should bring your palpitations under control as your levels normalise. Critically: if you develop a sore throat, any mouth ulcers, or a fever at any point while taking it, stop the tablet immediately and get an urgent blood test — same day."
The agranulocytosis warning with carbimazole is the most examinable safety point — naming it explicitly and advising the patient to report sore throat or fever and stop the drug same day scores both in Tasks and Relating to Others. Failure to mention this is a significant patient safety omission.
Driving — DVLA Requirements
For AF: must stop driving for 4 weeks after starting treatment for AF. Can resume driving once rate controlled and asymptomatic. For unexplained syncope during palpitations: same DVLA rules as syncope (6 months Group 1, 5 years Group 2). For SVT without syncope: no automatic driving ban — but advise patient not to drive during an episode. DVLA medical standards GOV.UK should be checked for current guidance.
"I need to mention the driving rules, because they're a legal requirement. For your type of rhythm problem, you should not drive if you're experiencing symptoms that might affect your ability to control the car — and once we start treatment, we need to confirm it's working before you drive long distances."Occupation — High-Demand Professional
A solicitor working under chronic stress has an elevated sympathetic drive that directly increases palpitation frequency. The fear of having an episode in a courtroom or during a client meeting drives significant anticipatory anxiety. Understanding the specific work scenarios the patient fears allows targeted advice — Valsalva technique can be applied discreetly even in professional settings.
"Can you tell me which work situations worry you most about an episode starting? Because there are techniques you can use discreetly — even in a meeting — that might stop an episode before it becomes problematic."Managing Uncertainty During Investigation
Patients waiting for a Holter result or a cardiology appointment often experience their worst psychological burden during this period — every palpitation is potentially "the bad one." A clear plan, a specific technique for self-management, and a concrete timeline for investigation results dramatically reduces this uncertainty burden and improves patient experience.
"I know the waiting for results is often the hardest part. Here's exactly what's going to happen and when — and here's what to do if you have an episode in the meantime that doesn't stop on its own."Smartwatch — Helpful Data vs Harmful Behaviour
The patient's smartwatch has provided genuinely valuable diagnostic data — rate 160–170 bpm during episodes. However, continuous monitoring between episodes creates hypervigilance and amplifies symptom perception. A clear behavioural contract — use the smartwatch only during an episode, cover the display otherwise — is a specific and deliverable intervention at this consultation.
"The data from your watch during episodes is really useful to us — please keep using it when an episode happens. But between episodes, I'd actually like you to try covering the heart rate display — checking it every few minutes when you're feeling anxious is making things worse, not better."1–2 Weeks — Blood results review
Review TFTs, FBC, U&E, glucose. If TFTs confirm hyperthyroidism → start carbimazole + endocrinology referral. If ECG confirmed AF → confirm anticoagulation started and rate controlled. If initial bloods all normal → await Holter result.
3–4 Weeks — Holter result review
Review Holter results with symptom-rhythm correlation. If arrhythmia captured → confirm diagnosis and treatment plan. If symptoms without arrhythmia → highly reassuring; address psychosocial factors. If no episode on Holter → extend monitoring with event recorder or ILR referral if clinical suspicion remains.
6–8 Weeks — Treatment response
Assess palpitation frequency and episode severity since treatment began. Check beta-blocker tolerance and resting HR (target 60–80 bpm for rate control in AF). If on carbimazole: repeat TFTs and FBC. Review smartwatch monitoring behaviour. Assess lifestyle change adherence.
3–6 Months — Ongoing monitoring
AF patients: annual eGFR for DOAC monitoring; review CHA₂DS₂-VASc annually (score can increase); discuss rhythm control strategy. SVT patients: review cardiology EP study outcome; assess ablation candidacy. Lifestyle adherence review at every appointment.
⚠ Three scenario-specific safety-net phrases
- Not teaching the Valsalva/REVERT technique at this consultation
- Not mentioning carbimazole agranulocytosis warning if prescribed
- Starting flecainide without echo confirmation of structurally normal heart
- Delaying anticoagulation in confirmed AF pending cardiology — stroke risk is immediate
- Not addressing the smartwatch obsessive monitoring behaviour
- Attributing definitively to menopause without investigation
Who you are
Rachel Okafor, 52, solicitor. Three episodes of racing heart in six weeks — each sudden, lasting 10–15 minutes, and stopping abruptly. Your smartwatch showed 160–170 bpm during one episode. You're perimenopausal (irregular periods for 18 months). T2DM well-controlled on metformin. Occasional alcohol, 5–7 units per week. 3–4 coffees a day, including an espresso mid-morning and afternoon to get through long working days.
Hidden agenda
You are terrified these palpitations will lead to a stroke or a heart attack. Your mother had a stroke at 60 and it left her severely disabled. You won't mention your mother unless directly asked: "Is there a specific thing you've been worried this might mean?" — at which point you'll say "My mum had a stroke at 60. I keep thinking about the fact that my heart is racing like this and whether it could cause something like that."
Episode details if asked
- Sudden start — "like a switch being flipped"
- Regular, very fast — watch shows 160–170 bpm
- Lasts 10–15 minutes then stops abruptly
- No chest pain, no dizziness, no fainting
- Not during exercise — usually at rest or during stressful moments at work
- First one happened when rushing to get a coffee before a court appearance
Challenges you'll present
- Mention you've read online that it might be a thyroid problem — is that possible?
- If menopause is raised: "Could it just be the menopause?" — respond positively if doctor says they need to check first
- You check your smartwatch for your pulse about 20 times a day between episodes
- When dietary advice comes: "I need the caffeine to get through my day — I can't just give it up"
Resolution: Rachel leaves satisfied if the candidate: (1) directly names and addresses her stroke fear linked to her mother; (2) doesn't prematurely attribute to menopause before investigation; (3) teaches her the Valsalva technique practically; (4) addresses the smartwatch obsessive checking; (5) explains what the Holter monitor will tell them. She responds to warmth, practicality, and respect for her intelligence as a professional.
• Wide-complex tachycardia on ECG (VT until proven otherwise)
• QTc over 500 ms + palpitations (torsades risk)
• Palpitations + syncope at presentation
• Rapid AF with systolic under 90 mmHg
• Weekly episodes → 7-day event recorder
• Monthly episodes → 30-day event recorder
• Very infrequent / unpredictable → ILR referral
• Symptomatic in surgery → ECG rhythm strip immediately
AF — anticoagulation: Apixaban 5 mg BD or rivaroxaban 20 mg OD — start now, don't wait
SVT prophylaxis: Bisoprolol 1.25–2.5 mg BD while awaiting ablation referral
Rhythm control AF: Flecainide 50–150 mg BD — specialist only; echo first (structural disease exclusion mandatory)
WPW — absolutely contraindicated: Digoxin, verapamil, diltiazem, adenosine
Flecainide — absolutely contraindicated: Structural heart disease (pro-arrhythmic)
Key safety: Carbimazole → advise patient: sore throat/fever = stop immediately + urgent FBC same day
→ "We need to check your thyroid, heart rhythm, and monitor first — menopause is possible but needs to be a diagnosis of exclusion"
→ Always ask: "Is there something specific you've been worried this might mean — something going through your mind?"
→ "If AF is confirmed today, we start the blood thinner now — we don't wait for the cardiology appointment"
→ "I wouldn't start this tablet until the echocardiogram has confirmed there is no structural abnormality"
→ "These tablets are contraindicated with this electrical pathway pattern — I'll speak to cardiology before prescribing anything"
→ Demonstrate modified Valsalva at every SVT consultation; explain 43% success rate from REVERT trial
→ TFTs are mandatory in any woman over 40 with new palpitations; thyrotoxicosis is common and treatable
→ "Stop the tablet immediately and get an urgent blood test if you develop a sore throat or fever"