Reasoning GP · Algorithm · 1-page summary
Palpitations in adults
For: adults with new or unexplained palpitations in primary care. Not for: children (use paediatric pathways). Pregnancy is in block 2; known AF management is in the AF protocol.
Core rule: palpitations are a symptom, not a diagnosis. A normal resting ECG between episodes does not exclude a paroxysmal arrhythmia — get the rhythm on paper, and screen for danger before labelling anxiety or benign ectopics.
0Stop — call 999 now — heart rate alone does not decide
- Unstable: shock, hypotension, reduced consciousness, ongoing syncope, sustained broad-complex tachycardia (treat as VT), suspected pre-excited AF → 999
- With ischaemic-type chest pain, acute breathlessness, pulmonary oedema or SpO₂ <94% → 999
- Suspected thyroid storm (fever, confusion, very fast AF, heart failure) → 999
- While waiting: 12-lead ECG if possible. Unstable → no vagal manoeuvres or carotid sinus massage. Irregular broad-complex or suspected pre-excited AF → no adenosine, verapamil, diltiazem, beta-blocker or digoxin.
1Triage — state at assessment
| Finding | Action |
|---|---|
| Broad complex | Treat as VT, never assume SVT with aberrancy → 999 |
| Narrow, regular | Likely SVT. Stable: modified Valsalva; persists → Urgent emergency assessment |
| Irregular | Possible AF: confirm on a 12-lead ECG. |
| Syncope resolved | Same-day; ≤24 h if abnormal ECG, exertional, heart failure, FH sudden death, new breathlessness or murmur (CG109) |
2Screen — one row is enough
- Exertional palpitations, especially with presyncope (possible VT) → Same-day
- FH sudden death <40, Brugada, long QT, ARVC, inherited cardiomyopathy → Same-day
- Structural heart disease (HCM, DCM, prior MI, valve) with sustained, exertional, poorly tolerated or unexplained palpitations → Same-day
- ECG: symptomatic pre-excitation, conduction disease, long/short QT, Brugada, ventricular arrhythmia, new LBBB → Same-day. Delta wave, well, no symptoms → Urgent cardiology
- New AF with heart failure, severe symptoms or a rapid rate → Same-day
- Pregnancy with syncope, sustained tachycardia, chest pain, hypoxia or heart failure → Same-day obstetric/medical
3Assess — once blocks 0–2 are answered
☐ Pulse rhythm, BP, RR, SpO₂, temperature ☐ Murmur, JVP, oedema, crackles, thyroid, pallor ☐ 12-lead ECG at first assessment ☐ FBC, U&E; TFTs if indicated and in all new AF
☐ Monitor matched to frequency: daily → 24-h Holter; every few days → 7-day patch; weekly or less → event recorder. Echo if murmur, abnormal ECG, heart failure or complex PVCs. No routine troponin unless ACS.
4Classify — only if the screen is negative
- AF / flutter — irregularly irregular, absent P waves or sawtooth → ECG-confirm (not pulse or smartwatch alone), then block 5.
- SVT — sudden on/off, regular, stopped by Valsalva → cardiology for ablation.
- Ectopics — thuds or skips, worse at rest; benign if heart normal. Couplets, NSVT, exertional or frequent → echo, monitor burden.
- Sinus tachycardia — gradual onset → find the driver: anaemia, thyroid, fever, drugs, stimulants.
- Anxiety, panic, perimenopause — only after cardiac and systemic assessment.
- Uncertain — say so; normal ECG with ongoing symptoms → ambulatory monitoring.
5Treat today — doses: NICE/SPC, BNF, local formulary
- ECG-confirmed AF: CHA₂DS₂-VASc ≥2 → offer a DOAC; men with 1 → consider; 0, or 1 from female sex alone → do not offer. Check ORBIT; do not wait for cardiology.
- AF rate control: beta-blocker (bisoprolol 2.5 mg OD, titrate) or diltiazem/verapamil first-line (CCB not in HFrEF; BB usually not in asthma). No antiarrhythmics in primary care.
- Benign ectopics: reassure, reduce triggers, correct electrolytes; low-dose beta-blocker only if very symptomatic.
- Treat the driver: anaemia, thyroid, medicines. Diagnosed anxiety → CBT and/or SSRI (CG113); no benzodiazepines.
6Refer routinely
- Urgent cardiology new paroxysmal AF, confirmed SVT (ablation), high PVC burden on monitoring, suspected ARVC.
- Routine unexplained palpitations after a negative 24-h Holter; HCM screening in family history.
- Re-refer: escalating episodes, failed rate control, cannot take anticoagulation.
- Triggers: alcohol, caffeine if it clearly triggers, weight, BP, smoking, OSA.
7Never reassure by
- A normal resting ECG between episodes.
- A normal heart rate — rhythm, symptoms and haemodynamics decide.
- Anxiety or stress — a diagnosis of exclusion after cardiac assessment.
- "Physiological" palpitations in pregnancy or the perimenopause.
- A pulse or smartwatch reading as proof of AF — confirm on ECG.
- Calling a broad-complex tachycardia SVT with aberrancy.
8Safety-net — say it, then document it
999 “Call 999 if you black out, or palpitations come with chest pain, severe breathlessness, a sudden severe headache, dizziness or near-collapse — or face drooping, arm weakness or speech problems, even if they go away.” Same-day “Contact us today for a new irregular pulse that persists, a fast pulse at rest, palpitations on exercise or lying down, new near-fainting, new ankle swelling or worse breathlessness, or bleeding or bruising on a blood thinner.”
Driving: an arrhythmia that has caused or may cause incapacity → stop driving; DVLA decides. Group 2 drivers do not drive during investigations. Symptom diary while awaiting monitoring.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
12-lead ECG done and competently read
Bloods and ambulatory monitor arranged, matched to frequency
AF on ECG: CHA₂DS₂-VASc, ORBIT and anticoagulation decided
Safety-net and DVLA advice given; review date set
Summary of the full Reasoning GP palpitations algorithm, which holds the history, ECG detail, drug doses and evidence. Sources: NICE NG196, CG109, NG145, CG113, NG136; ESC 2019 SVT; MHRA (DOACs); DVLA. Clinical reference — follow local emergency and cardiology referral arrangements and check doses: NICE/SPC, BNF.