palpitations & suspected svt: primary care assessment and escalation

Palpitations are common and usually benign, but a structured approach prevents missed arrhythmia. Focus on (1) haemodynamic stability, (2) red flags, (3) capturing rhythm (ECG/monitor), and (4) targeted referral.

• Palpitations with syncope/presyncope, chest pain, severe breathlessness, hypotension, or heart failure symptoms.
• Family history of sudden cardiac death, known structural heart disease, or inherited arrhythmia syndromes.
• Very rapid rate with instability, or suspected WPW features.

Action: if unstable (shock, chest pain, pulmonary oedema, syncope), treat as emergency and arrange ED/999.

• Onset/offset: sudden start/stop suggests SVT; irregularly irregular suggests AF.
• Duration/frequency: helps choose monitor (daily vs weekly episodes).
• Triggers: caffeine, alcohol, stimulants, anxiety, exertion; consider hyperthyroidism.
• Associated symptoms: dizziness, syncope, dyspnoea, chest pain.
• Examination: pulse regularity, murmurs, signs of heart failure; check BP.

Initial tests: 12-lead ECG (even if asymptomatic), FBC, U&E, TFTs where appropriate.

• Daily symptoms: 24–48h Holter often sufficient.
• Weekly symptoms: 7–14 day patch monitor/event recorder is usually higher yield.
• Rare symptoms: consider longer-term monitors via cardiology if high suspicion.

Patient tip: smartphone ECG devices can help symptom-rhythm correlation, but confirmatory clinical ECG/monitoring is still needed for diagnosis and coding.

• If stable and narrow-complex regular tachycardia: consider vagal manoeuvres (modified Valsalva) and arrange urgent assessment if persistent.
• If unstable or broad-complex tachycardia: emergency care (ED/999).
• Avoid AV-nodal blockers if pre-excited AF is suspected; specialist protocols apply.