Practical Approach to Palpitations in Primary Care : Red Flags, Causes, and When to Refer
Practical Approach to Palpitations in Primary Care : Red Flags, Causes, and When to Refer
Source :Merscape Commentary
Published: November 7, 2025
Key Points (Medscape 2025)
1. Typical Case Example
• 40-year-old man with intermittent palpitations, worsened by fatigue and sleep; no syncope; heavy alcohol/caffeine use; normal exam and ECG.
2. Common Causes
• Lifestyle: caffeine, alcohol, stress, poor sleep.
• Drugs: β-agonists (salbutamol), steroids, levothyroxine, CCBs, anticholinergics, nasal decongestants; QT-prolonging drugs (CredibleMeds.org).
• Mental health: anxiety, panic, somatization.
• Illicit substances: cannabis, amphetamines, cocaine.
• Cardiac: ectopy, SVT, AF/flutter, structural disease.
3. History Clues
• Onset/offset behaviors:
• Sudden stop → paroxysmal SVT
• Triggered by cold drinks → AF/flutter
• Terminated by cough/Valsalva → AVRT
• Postural triggers → AVRT (± neck pulsations)
• Exertional palpitations = red flag
• Ask about impact on daily life.
4. Associated Symptoms (Red Flags)
• Presyncope/syncope
• Dyspnea (possible HF or fast AF)
• Chest pain (CAD vs rapid HR)
• Polyuria (atrial tachyarrhythmias)
5. Family History Importance
• Cardiomyopathies, early AF, premature CAD, ICD use.
• Ask about sudden cardiac death <40 yrs (autosomal dominant risks).
6. Physical Exam & Labs
• BP (sitting/standing), pulse, auscultation.
• Labs: CBC, ferritin, TSH, U&E, calcium, glucose/HbA1c.
7. ECG & Monitoring
• 12-lead ECG more useful initially than 24h Holter.
• Normal ECG does not rule out arrhythmia.
• Use Holter only if symptoms occur ≥3–4× weekly.
• Do NOT delay urgent referral for red flags while waiting for Holter.
8. When to Refer to Cardiology
• Exertional symptoms
• Syncope/presyncope
• Concerning family history
• Evidence of structural disease or significant arrhythmia
9. Driving Advice
• If arrhythmia causes or may cause incapacity → no driving until evaluated.
10. Management Principles
• Treat identified arrhythmias (meds, ablation, ICD).
• Many cases need reassurance + lifestyle advice.
• Reduce caffeine + alcohol, manage stress, optimize CV risk, address anxiety.
11. Case Outcome
• Normal bloods + ECG; likely alcohol/caffeine/stress-related palpitations.
• Managed with counseling and lifestyle modification.