GPAtlas🧭 When to suspect
Palpitations are an unpleasant awareness of the heartbeat – described as the heart racing, pounding, fluttering, or "skipping" or "missing" beats. They are one of the commonest cardiac presentations in primary care, and the overwhelming majority are benign, most often extrasystoles (ectopic beats) in a structurally normal heart. They can, however, be the first sign of a significant arrhythmia, and they frequently cause considerable anxiety.
The clinical task is twofold: capture the rhythm – ideally a 12-lead electrocardiogram (ECG) recorded while symptoms are present – and risk-stratify, separating benign awareness from a dangerous rhythm. The character of the palpitation, the presence of red flags (exertional onset, syncope, chest pain), and a family history of sudden cardiac death under 40 do most of the stratifying work. Palpitation is a symptom, not a diagnosis: the aim is symptom–rhythm correlation, then to place the patient on the relevant pathway.
| Reported sensation | Likely rhythm | Pointers |
|---|---|---|
| "Skipped", "missed" or thumping beats | Extrasystoles (ectopic beats) | Very common; often noticed at rest or lying down; benign in a structurally normal heart |
| Sudden-onset, regular, fast – starts and stops abruptly | Supraventricular tachycardia (SVT) | Often younger patients; may terminate with vagal manoeuvres |
| Irregularly irregular, often fast | Atrial fibrillation (AF) or flutter | Check the pulse; confirm on ECG; assess stroke risk |
| Gradual onset and offset, regular, fast | Sinus tachycardia | Look for a driver: anxiety, fever, anaemia, thyrotoxicosis, dehydration, stimulants |
| Fast, regular, with exertion, syncope or collapse | Ventricular tachycardia (VT) | Red flag – particularly with structural disease or family history of sudden death |
Across all presentations, a 12-lead ECG is mandatory – even when the patient is asymptomatic at the time – because it may reveal pre-excitation, a long QT interval, prior infarction or conduction disease that reframes the whole picture.
Source: NICE NG196 · NHS England Palpitation Referral Pathway
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