Previous changes

March to April 2020 — reviewed. A literature search was conducted in March 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone restructuring. No major changes to the recommendations have been made.

March to May 2015 — reviewed. A literature search was conducted in March 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last version of this topic. Initiation of empirical beta-blockers in primary care is no longer recommended.

November 2008 to March 2009 — converted from CKS guidance to CKS topic structure. The evidence-base was reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There were no major changes to the recommendations.

September 2008 — minor correction to the Changes section. Issued September 2008.

October 2005 — minor technical update. Issued in November 2005.

March 2005 — rewritten. Validated in June 2005 and issued in July 2005.

January 2002 — reviewed. Validated in March 2002 and issued in April 2002.

December 1998 — rewritten replacing guidance on Paroxysmal supraventricular tachycardia. Validated in March 1999 and issued in May 1999.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 January 2026.

HTAs (Health Technology Assessments)

No new HTAs since 1 January 2026.

Economic appraisals

No new economic appraisals relevant to England since 1 January 2026.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 January 2026.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 January 2026.

New policies

No new national policies or guidelines since 1 January 2026.

New safety alerts

No new safety alerts since 1 January 2026.

Changes in product availability

No changes in product availability since 1 January 2026.

Common arrhythmias on ECG

• Ventricular tachycardia (VT). See a typical trace from the ECG library.
  • No obvious P-waves.
  • Broad QRS complex (greater than 120 milliseconds [msec]).
  • Rate usually greater than 160 beats per minute (bpm).
• Supraventricular tachycardia (SVT). See a typical trace from the ECG library.
  • P-waves are usually not identifiable.
  • Regular narrow QRS complex (less than 120 msec; unless the person also has a bundle branch block).
  • Rate usually between 140 and 280 bpm.
• Long QT interval. See a typical trace from the ECG library.
  • The QT interval varies with heart rate.
  • A prolonged QT interval (greater than 450 msec) may lead to ventricular tachycardia.
• Wolff-Parkinson-White (WPW) syndrome. See a typical trace from the ECG library.
  • Short PR interval (less than 120 msec).
  • Slight widening of the QRS complex due to a slurred upstroke (delta wave) of the QRS complex.
  • WPW syndrome can cause paroxysmal tachycardia.
• Atrial fibrillation. See a typical trace from the ECG library.
  • No distinct P-waves visible.
  • There is a varying, completely irregular baseline.
  • QRS complex rate is characteristically over 160 bpm without treatment, but can be slower.
• Atrial flutter. See a typical trace from the ECG library.
  • P-wave rate 300 bpm producing a saw-tooth pattern.
  • Narrow QRS complex (unless the person has a bundle branch block as well).
  • 2:1, 3:1, or 4:1 block resulting in QRS rate of approximately 150 bpm, 100 bpm, or 75 bpm. The rhythm is irregular if the block is variable, and may resemble atrial fibrillation.
• Ventricular extrasystoles (ectopics). See a typical trace from the ECG library.
  • Early QRS complex.
  • No P-wave.
  • QRS complex is wide (greater than 120 msec) and abnormally shaped.
  • Abnormally shaped T-wave.
  • When these alternate with normal QRS complexes, the rhythm is called bigeminy. See a typical trace from the ECG library.
  • When extrasystoles occur with every third beat, the rhythm is called trigeminy.
• Atrial extrasystoles (ectopics). See a typical trace from the ECG library.
  • No P-wave or an abnormally shaped P-wave.
  • Early QRS complex of similar morphology to normal sinus beats.
• Sinus tachycardia. See a typical trace from the ECG library.
  • Rate over 100 bpm, normal sinus rhythm.

ECG features with an increased risk of arrhythmia

• Previous myocardial infarction (MI). See a typical trace from the ECG library.
  • Pathological Q-waves.
  • Inversion of T-waves.
  • Loss of R-wave progression across the chest leads following an anterior MI.
  • Left bundle branch block following a previous MI.
• Left ventricular hypertrophy. See a typical trace from the ECG library.
  • R-wave in V6 greater than 25 mm.
  • R-wave in V6 plus S-wave in V1 greater than 35 mm.
  • R-wave in I plus S-wave in III greater than 25 mm.
  • Inverted T-wave in VL, V5–V6.
  • Axis normal or deviated to the left.
• Right ventricular hypertrophy. See a typical trace from the ECG library.
  • Tall R-wave in V1.
  • T-wave inversion in V1–V3 or V4.
  • Deep S-wave in V6.
  • Right axis deviation.
• P-wave abnormalities.
  • Peaked P-waves occur with right atrial overload caused by pulmonary or tricuspid valve stenosis, or pulmonary hypertension. See a typical trace from the ECG library.
  • Broad and bifid P-waves occur with left atrial overload, most commonly caused by hypertension, but classically seen with mitral valve disease.
• Wolff-Parkinson-White (WPW) syndrome. See a typical trace from the ECG library.
  • Short PR interval (less than 120 milliseconds [msec]).
  • Slight widening of the QRS complex due to slurred upstroke (delta wave) of the QRS complex.
  • WPW syndrome can cause paroxysmal tachycardia.
• Long QT interval. See a typical trace from the ECG library.
  • The QT interval varies with heart rate.
  • A prolonged QT interval (greater than 450 msec) may lead to ventricular tachycardia.

Basis for recommendation

The recommendations on assessment of a person with palpitations are based on the European Heart Rhythm Association (EHRA) position paper Management of patients with palpitations: a position paper from the European Heart Rhythm Association [Raviele, 2011], the NHS England publication Getting it right first time. Palpitation referral pathway [NHSE, 2025], online ECG library resources [ECG Library, 2025; LITFL, 2026], and expert opinion in review articles on palpitations [Wolff, 2009; Gale, 2016; McLellan, 2019; Weinstock, 2021; Chua, 2024; Gauer, 2024; Ribero-Vargas, 2025].

Clinical features on history-taking

• These recommendations are based on the EHRA position paper [Raviele, 2011] and expert opinion in review articles [Wolff, 2009; McLellan, 2019; Weinstock, 2021; Chua, 2024; Gauer, 2024; Ribero-Vargas, 2025].
  • Expert opinion in a review article notes that history-taking is important to help diagnose any underlying cause of palpitations, and may also guide which patients need additional investigations [Weinstock, 2021].
  • The EHRA position paper states that exercise-induced palpitations may indicate underlying ischaemic, valvular, or other structural heart disease, and need specialist investigation [Raviele, 2011]. Similarly, expert opinion in a review article states that palpitations occurring with exercise or exertion may indicate a potentially serious cause, such as cardiomyopathy or supraventricular arrhythmia, whereas palpitations occurring at rest may indicate a vagally mediated cause, such as ventricular extrasystoles (Weinstock, 2021)[Weinstock, 2021].
  • Palpitations with rapid onset and offset are often due to supraventricular or ventricular tachyarrhythmias. A regular and rapid pounding sensation in the neck may be due to atrioventricular node re-entry tachycardia [Chua, 2024].
  • Expert opinion in review articles states that palpitations of longer duration or waking a person from sleep are more likely to be related to an arrhythmia than a non-cardiac cause. Sustained palpitations lasting for minutes or longer, are more commonly associated with supraventricular arrhythmias, ventricular arrhythmias, or anxiety [Weinstock, 2021; Ribero-Vargas, 2025].
  • Palpitations which are worse at night may suggest benign ectopy or atrial fibrillation [Weinstock, 2021]. In contrast, palpitations that are very transient and last only a few seconds are more likely to be due to atrial or ventricular extrasystoles (ectopics) (Weinstock, 2021 ; Ribero-Vargas, 2025)[Weinstock, 2021; Ribero-Vargas, 2025].
  • A family history of sudden early cardiac death may indicate a genetic arrhythmia syndrome such as congenital long QT syndrome or short QT syndrome, or hypertrophic cardiomyopathy [McLellan, 2019; Weinstock, 2021; Gauer, 2024].
  • Expert opinion in a review article notes that anxiety is the most common non-cardiac cause of palpitations [Weinstock, 2021]. The EHRA position paper notes that anxiety can either induce sinus tachycardia or modify a person's subjective perception of a heartbeat that is otherwise normal or which has 'minimal irregularities'. In addition, adrenergic hyperactivation associated with intense emotions and anxiety may, in some cases, predispose a person to supraventricular and/or ventricular arrhythmias [Raviele, 2011].
  • The recommendation to assess the impact of palpitations on the person's quality of life and functioning is based on expert opinion in a review article, which also notes that symptom burden will sometimes affect the management strategy offered [McLellan, 2019].

Clinical features on examination

• These recommendations are based on the EHRA position paper [Raviele, 2011] and expert opinion in review articles [Wolff, 2009; Gale, 2016; McLellan, 2019; Weinstock, 2021; Chua, 2024; Gauer, 2024; Ribero-Vargas, 2025].
  • Expert opinion in a review article notes that 'physical examination is low yield for diagnosing the cause of palpitations but should be used to guide further workup'. It can help to rule out underlying causes and guide the differential diagnosis in individual patients [Weinstock, 2021].
  • Similarly, expert opinion in additional review articles note that as palpitations are usually intermittent and short-lived, a person may be asymptomatic with no clinical signs on examination [Chua, 2024; Ribero-Vargas, 2025].
  • Checking the person's pulse can help to identify arrhythmia-induced palpitations. An irregular pulse may suggest a diagnosis of atrial fibrillation or premature ventricular contractions [Weinstock, 2021]. An expert opinion in a review article notes that an abnormal resting heart rate (less than 60 or greater than 100 beats per minute) may correlate with the presence of arrhythmia (McLellan, 2019)[McLellan, 2019].
  • Expert opinion in a review article notes that arrhythmias such as ventricular tachycardia typically present with features of haemodynamic compromise [McLellan, 2019].
  • The recommendation to check the person's body mass index (BMI) is extrapolated from expert opinion in a review article, which notes that obesity is a risk factor for atrial fibrillation and ischaemic heart disease [McLellan, 2019].
  • Assessing for comorbidities such as anaemia or thyrotoxicosis is important, as these may present with sinus tachycardia [McLellan, 2019].

Arranging an electrocardiogram (ECG)

• These recommendations are based on the EHRA position paper [Raviele, 2011] and expert opinion in review articles [Wolff, 2009; Gale, 2016; McLellan, 2019; Weinstock, 2021; Chua, 2024; Ribero-Vargas, 2025].
  • The EHRA position paper states that 'electrocardiographic documentation of a rhythm disorder during spontaneous symptoms provides the strongest evidence of causality' [Raviele, 2011]. Similarly, expert opinion in a review article states that 'the most important diagnostic test in the approach to a patient with active palpitations is the 12-lead ECG, as it is the reference standard for determining whether the cause of palpitations is arrhythmogenic' [Ribero-Vargas, 2025]. Expert opinion in a further review article states that an ECG may identify the cause of palpitations in 27% of people [Weinstock, 2021].
  • The EHRA position paper notes that an ECG recording in the absence of palpitations may provide important data that can suggest the arrhythmic origin of palpitations. Nonetheless, as palpitations are usually transient and the person is often asymptomatic when clinically assessed, there may be uncertainty in establishing a cause-effect relationship between any abnormalities detected and the reported palpitations [Raviele, 2011].
  • Similarly, expert opinion in an additional review article notes that performing a 12-lead ECG in between symptoms of palpitations may be helpful, as it may indicate signs of arrhythmogenic or structural heart disease. It highlights, however, that in most cases, the ECG will be normal even if the person has a cardiac aetiology for palpitations [Ribero-Vargas, 2025].
  • The recommendation to seek specialist advice if there is any uncertainty about the interpretation of an ECG is based on the NHS England publication [NHSE, 2025]. It is also pragmatic, based on what CKS considers to be good clinical practice. 

When should I admit a person with current palpitations?

• Arrange emergency admission if a person has current palpitations and:
  • Ventricular tachycardia (VT) on ECG.
  • Persistent supraventricular tachycardia (SVT) on ECG. Before deciding to admit, if trained and competent to do so, attempt to terminate the SVT if appropriate by:
    • Valsalva manoeuvre — for example, ask the person to blow into a 10 mL syringe for 15 seconds.
    • Carotid sinus massage —for up to 5 seconds on one side with the neck in an extended position, if there are no contraindications. Ensure that a defibrillator is available, as very rarely terminating an SVT can provoke other arrhythmias. Ideally, record an electrocardiogram (ECG) continuously during and after the procedure.
  • Is haemodynamically unstable (with clinically significant hypotension and/or tachycardia).
  • High risk structural heart disease, including ischaemic heart disease.
  • Features suggestive of a serious underlying cardiac cause or complication:
    • Significant breathlessness, chest pain, and/or syncope or near syncope.
    • Onset of palpitations precipitated by exercise.
    • High-grade or third-degree atrioventricular block on ECG.
    • Newly diagnosed atrial fibrillation with a clinically significant tachycardia and/or acute decompensated heart failure. See the CKS topic on Atrial fibrillation for more information.
    • A family history of sudden cardiac death under the age of 40 years and/or a known or suspected family history of hypertrophic cardiomyopathy.
  • A suspected serious or life-threatening systemic cause, such as severe anaemia, thyrotoxicosis, or sepsis. See the CKS topics on Anaemia - B12 and folate deficiency, Anaemia - iron deficiency, Hyperthyroidism, Neutropenic sepsis, and Sepsis for more information.

When should I refer a person with current palpitations?

Refer the person to cardiology, the urgency depending on clinical judgement, if hospital admission is not needed and there is:

• Electrocardiogram (ECG) evidence of:
  • Atrial flutter.
  • Supraventricular tachycardia (SVT) terminated by the Valsalva manoeuvre or carotid sinus massage. See the section on Hospital admission for more information.
  • Pre-excitation/Wolff-Parkinson-White syndrome.
  • Ventricular extrasystoles (ectopics) where:
    • Underlying heart disease is suspected from the clinical assessment and/or ECG.
    • Extrasystoles are frequent (such as more than 30 beats in an hour), or ventricular tachycardia (VT) is suspected.

How should I manage a person with palpitations in primary care?

• Reassure the person that hospital admission and urgent cardiology referral are not routinely needed if:
  • Palpitations are isolated, and
  • The 12-lead electrocardiogram (ECG) is normal, and
  • Symptoms are:
    • Not provoked by exercise.
    • Not associated with lightheadedness, syncope or near syncope, persistent breathlessness, or chest pain.
    • Not associated with a history or signs of structural heart disease, heart failure, or hypertension.
    • Not associated with a family history of sudden cardiac death under the age of 40 years.
• If a person does not need hospital admission or referral, or is awaiting cardiology assessment following referral:
  • Arrange blood tests including a full blood count, urea and electrolytes, thyroid function tests, liver function tests, HbA1c, and lipid profile to help identify any underlying cause, and manage appropriately.
  • Consider arranging urine toxicology if there is a history of suspected recreational drug use.
  • Perform a cardiovascular risk assessment and manage risk factors appropriately. See the CKS topic on CVD risk assessment and management for more information.
  • Advise on lifestyle measures such as reducing or avoiding stress, caffeine, alcohol, smoking, and drugs that can precipitate or exacerbate palpitations.
  • If the person has atrial fibrillation, see the CKS topic on Atrial fibrillation for more information on management.
  • If the person has sinus tachycardia, assess for and manage any underlying cause where possible.
  • If the person has atrial or ventricular extrasystoles (ectopics), if there are no features of underlying heart disease, and palpitations are infrequent, reassure the patient that the palpitations are unlikely to be a cause for concern.
• If palpitations remain poorly controlled, symptomatic, and/or distressing, consider arranging cardiology referral, depending on clinical judgement.
• Give advice about safe driving, work, and leisure activities, if appropriate.
  • The Driver and Vehicle Licensing Agency (DVLA) guidance Assessing fitness to drive: a guide for medical professionals provides information on driving restrictions and when to notify the DVLA for Group 1 and Group 2 entitlement drivers with arrhythmia and/or associated symptoms.
  • Advise that certain occupations, such as those involving working at height, underwater, or with potentially dangerous machinery, will need to stop work until a diagnosis is confirmed or the underlying condition is treated, and may need an Occupational Health assessment.
• Advise about sources of information and support, such as:
  • The NHS (website www.nhs.uk) resources Heart palpitations and Heart rhythm problems (arrhythmia).
  • The British Heart Foundation (website www.bhf.org.uk) patient information on Palpitations and Arrhythmias.
  • The Arrhythmia Alliance (website www.heartrhythmalliance.org/aa/uk) patient information on Conditions.

When should I refer a person with a history of palpitations?

If a person has a history of palpitations following initial assessment:

• Arrange urgent cardiology referral if the person has:
  • A history of syncope or near syncope.
  • Palpitations precipitated by exercise.
  • A family history of sudden cardiac death under the age of 40 years and/or a known or suspected family history of hypertrophic cardiomyopathy.
  • Second- or third-degree atrioventricular block on the 12-lead electrocardiogram (ECG).
• Arrange a routine cardiology referral if the person has:
  • Accompanying chest pain or lightheadedness.
  • A history or symptoms of structural heart disease, heart failure, or hypertension.
  • A resting ECG abnormality, other than second- or third-degree atrioventricular block.
  • A history of recurrent sustained tachyarrhythmia, atrial fibrillation, or flutter.
  • A history of symptoms that are clearly consistent with paroxysmal supraventricular tachycardia (sudden onset and offset of a fast, regular heartbeat).
  • Ventricular extrasystoles (ectopics):
    • If underlying heart disease is suspected from the clinical assessment and/or ECG, or
    • If extrasystoles are frequent (such as more than 30 beats in an hour) or ventricular tachycardia (VT) is suspected.
• If the person has suspected paroxysmal atrial fibrillation (PAF), see the CKS topic on Atrial fibrillation for more information on management.
• Reassure the person that a cardiology referral is not routinely needed if palpitations are isolated, the 12-lead ECG is normal, and if symptoms are:
  • Not provoked by exercise.
  • Not associated with lightheadedness, syncope or near syncope, persistent breathlessness, or chest pain.
  • Not associated with a history or signs of structural heart disease, heart failure, or hypertension.
  • Not associated with a family history of sudden cardiac death under the age of 40 years.

How should I investigate a person with a history of palpitations?

• If a person does not need cardiology referral:
  • Arrange blood tests, including a full blood count, urea and electrolytes, thyroid function tests, liver function tests, HbA1c, and lipid profile to help identify any underlying cause, and manage or refer appropriately.
  • Consider arranging urine toxicology if there is a history of suspected recreational drug use.
• If the cause of the palpitations remains unclear:
  • If symptoms are relatively infrequent (less than once a week) and last for an hour or more, advise the person to attend an Emergency department or primary care centre for an electrocardiogram (ECG) during the next episode.
    • Provide a letter to be given to the healthcare professional requesting an ECG immediately on presentation during an episode.
  • If symptoms are short-lived, arrange ambulatory ECG monitoring in primary care if available, or refer to cardiology. The type of monitoring required depends on the frequency and duration of symptoms:
    • If symptoms are short-lived and frequent (for example, at least every 24 hours), a 24-hour or 48-hour Holter monitor may be arranged.
    • If symptoms are short-lived and infrequent (for example, less than once a week), a self-activated recorder or a continuous loop event monitor may be needed (usually arranged following cardiology referral).
    • Consider use of a patient-activated hand-held ECG device (such as AliveCor KardiaMobile), a smart watch, or other mobile wearable device to record intermittent symptoms, depending on clinical judgement.
  • Arrange an echocardiogram in primary care if available, or refer to cardiology, if:
    • A murmur is found on examination.
    • Heart failure is suspected. See the CKS topic on Heart failure - chronic for more information.
    • Structural heart disease is suspected, for example, the ECG shows left bundle branch block, left ventricular hypertrophy, atrial enlargement, or Q-waves.
    • There is a greater than 10% burden of ventricular ectopy on ambulatory ECG monitoring.

How should I manage a person with a history of palpitations in primary care?

• If a person with a history of palpitations does not need cardiology referral, or is awaiting cardiology assessment following referral:
  
  • Carry out a cardiovascular risk assessment and manage risk factors as appropriate. See the CKS topic on CVD risk assessment and management for more information.
  • Advise on lifestyle measures such as reducing or avoiding stress, caffeine, alcohol, smoking, and drugs that can precipitate or exacerbate palpitations.
  • If the person has sinus tachycardia, assess for and manage any underlying cause where possible.
  • If the person has atrial or ventricular extrasystoles (ectopics), if there are no features of underlying heart disease and palpitations are infrequent, reassure that the palpitations are unlikely to be a cause for concern.
• Arrange referral to cardiology if heart failure or valve disease is confirmed on echocardiogram or if there is uncertainty about the underlying cause, especially if palpitations are sustained, recurrent, and/or distressing.
• Give advice about safe driving, work, and leisure activities, if appropriate.
  • The Driver and Vehicle Licensing Agency (DVLA) guidance Assessing fitness to drive: a guide for medical professionals provides information on driving restrictions and when to notify the DVLA for Group 1 and Group 2 entitlement drivers with arrhythmia and/or associated symptoms.
  • Advise that certain occupations, such as those working at height, underwater, or with potentially dangerous machinery, will need to stop work until a diagnosis is confirmed or the underlying condition is treated, and may need an Occupational Health assessment.
• Advise about sources of information and support, such as:
  • The NHS (website www.nhs.uk) information on Heart palpitations and Heart rhythm problems (arrhythmia).
  • The British Heart Foundation (website www.bhf.org.uk) patient information on Palpitations and Arrhythmias.
  • The Arrhythmia Alliance (website www.heartrhythmalliance.org/aa/uk) patient information on Conditions.