Palpitations triage workflow

Scope

Use for

Initial outpatient palpitations assessment in clinically stable adults.

Not for

• Hemodynamic instability or ongoing sustained unstable arrhythmia.
• Inpatient telemetry-based management scenarios.

Immediate actions

• Check pulse, blood pressure, perfusion, chest pain, dyspnea, and syncope/presyncope; obtain a 12-lead ECG, ideally during symptoms.
• Record sudden versus gradual onset/offset, duration, frequency, exertional association, medications/stimulants, cardiac history, and family history of sudden death.

Red flags: escalate now

If any of these are present, stop routine steps and follow the urgency stated. Activate emergency care for instability or findings that need immediate transfer.

• Active palpitations with collapse, chest pain, hypotension, or severe breathlessness require emergency assessment; activate EMS for instability or ongoing concerning symptoms.
• Arrange urgent cardiac assessment for resolved episodes with syncope, exertional symptoms, abnormal ECG, structural heart disease, or family history of sudden cardiac death; use ED if immediate risk cannot be excluded.

First-line plan

• A normal resting ECG does not exclude intermittent arrhythmia. Match ambulatory ECG duration to episode frequency; intermittent symptoms may need a longer event monitor than a 24-hour Holter.
• Review reversible contributors and use targeted investigations for suspected anemia, electrolyte disturbance, or thyroid disease. Confirm a rhythm diagnosis before selecting rhythm-specific treatment.
• The QTc calculator supports ECG interpretation; it cannot exclude arrhythmia or establish safe disposition alone.

Follow-up and monitoring

• Assign follow-up for the ECG/monitor report and symptom diary; persistent symptoms without rhythm capture need reassessment.
• Give emergency precautions for collapse, new chest pain, severe breathlessness, or worsening sustained symptoms.

Before the patient leaves

Return precautions you can say as written:

“If symptoms get worse, new warning signs appear, or you cannot follow the plan from this visit, seek urgent care now.”

• Point to the red flags above that apply to this patient.
• Confirm follow-up timing and where to go after hours.
• Attach a relevant handout to reinforce the plan.
• Document disposition, rationale, unresolved uncertainty, and that precautions were understood.

About this workflow

Clinical owner

Family Medicine Editorial Team

Risk tier

High

Review cadence

Every 3 months

Last reviewed

September 4, 2026AI-assisted evidence review. Clinical-owner sign-off is not recorded for this update.

Review status

Evidence current. Next review due December 4, 2026.

References

• NHS Borders Arrhythmia and palpitations (September 2025) (opens in a new tab)
• NICE NG196 ECG diagnosis and ambulatory monitoring for suspected AF (opens in a new tab)