Palpitations are presented fairly frequently to the GP, sometimes in isolation but more often immersed in other symptoms. Patients use the word ‘palpitations’ to describe a remarkable variety of sensations, and it is important to establish exactly what is meant. Cardiac causes are relatively rare; anxiety about a cardiac problem, and anxiety as a cause of the symptom, are common.

Published: 2nd August 2022 | Updated: 19th September 2022

Differential diagnosis

Common Diagnoses

  • Anxiety (Increased Awareness of Normal Heartbeat)
  • Sinus Tachycardia (e.g. Stress, Fever, Exercise)
  • Atrial Ectopics
  • Ventricular Ectopics
  • Supraventricular Tachycardia (SVT)

Occasional Diagnoses

  • Structural Heart Disease (e.g. Valvular Problem, Cardiomyopathy)
  • Thyrotoxicosis (Combination of Sinus Tachycardia and Increased Awareness Even if Ventricular Ectopics are Absent)
  • Menopause (Due to Sudden Vasodilation)
  • Atrial Fibrillation (AF – Various Causes, e.g. IHD, Mitral Valve Disease, Alcohol)
  • Iatrogenic (e.g. Digoxin, Nifedipine)
  • Atrial Flutter
  • Dumping Syndrome (e.g. after Bariatric Surgery)
  • Postural tachycardia syndrome (PoTS)

Rare Diagnoses

  • Heart Block (Especially with Changes in Block)
  • Sick Sinus Syndrome
  • Drug Abuse
  • Ventricular Tachycardia (VT)
  • Phaeochromocytoma
  • Carcinoid Syndrome

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.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.