© FRCEM Study Zone | Where Preparation Meets Precision
Palpitations are one of the most common cardiovascular complaints presenting to both Emergency Departments and primary care. While often benign, they may represent serious arrhythmias, structural heart disease, or high-risk systemic conditions.
For clinicians preparing for the Final FRCEM SBA examination, mastering the structured, guideline-based assessment of palpitations is essential.
This comprehensive guide integrates the latest NICE Clinical Knowledge Summary (CKS) recommendations on palpitations assessment, alongside Emergency Medicine considerations drawn from RCEM curriculum standards.
Primary source:
🔗 NICE CKS – Palpitations (Assessment & Diagnosis)
https://cks.nice.org.uk/topics/palpitations/diagnosis/assessment/
What Are Palpitations?
Palpitations describe an abnormal awareness of the heartbeat—whether fast, slow, irregular, forceful, or “fluttering.” They may occur in isolation or be associated with life-threatening cardiovascular pathology.
1. Taking a High-Value Clinical History (NICE CKS Guidance)
A structured, focused history is the most powerful diagnostic tool. NICE emphasises exploring:
✔ Circumstances before and during the episode
Onset during exercise is a red flag—consider malignant arrhythmias or structural heart disease.
Sudden onset/offset suggests SVT.
Irregular onset may suggest atrial fibrillation.
✔ Duration and frequency
Short, recurrent episodes often reflect SVT; prolonged episodes suggest AF, flutter, or sinus tachycardia.
✔ Nature of the rhythm
Ask the patient to tap out the rhythm—a simple, effective NICE-recommended method.
✔ Associated high-risk symptoms
Chest pain
Dyspnoea
Syncope or presyncope
Severe dizziness
These mandate urgent assessment and possible hospital referral.
✔ Past medical history
Conditions increasing arrhythmia risk include:
Ischaemic heart disease
Cardiomyopathy
Heart failure
Valve disease
✔ Family history
Sudden cardiac death <40 years is a major red flag (e.g., channelopathies).
✔ Lifestyle and drug factors
Palpitations may be triggered by:
Caffeine
Alcohol
Cocaine, amphetamines, cannabis
Nicotine
Prescribed & OTC medications (including β-agonists, decongestants, thyroxine)
✔ Systemic contributors
Thyrotoxicosis
Sepsis
Anaemia
Fever
Sleep deprivation
For full official guidance:
🔗 NICE CKS – Palpitations History Taking
https://cks.nice.org.uk/topics/palpitations/diagnosis/assessment/
2. Essential Examination (NICE & RCEM Standards)
A focused examination should include:
Cardiovascular assessment
Measure heart rate & rhythm
Blood pressure
Presence of murmurs
Signs of heart failure (JVP, basal crepitations, oedema)
Systemic assessment
Thyrotoxicosis (tremor, goitre, sweating)
Anaemia (pallor)
Sepsis indicators
If palpitations are ongoing, an immediate ECG is recommended.
3. ECG: Core to Diagnosis (NICE CKS & RCEM Curriculum)
Obtaining a 12-lead ECG is mandatory in current palpitations and recommended for all historical episodes.
Immediate ECG red flags
Ventricular tachycardia (VT) – Broad complex, rate >160 bpm
SVT – Narrow complex, regular, rate 140–280 bpm
Atrial fibrillation – Irregular, absent P-waves
Atrial flutter – Saw-tooth waves (≈300 bpm atrial rate)
WPW (pre-excitation) – Short PR, delta wave
Long QT syndrome – QTc >450 ms
Full ECG examples are available via NICE:
🔗 NICE ECG Library
https://cks.nice.org.uk/topics/palpitations/diagnosis/ecg-ft/
4. When to Admit – Emergency Red Flags (NICE)
Arrange emergency hospital admission if any of the following are present:
Current palpitations with:
Ventricular tachycardia
Persistent SVT
Haemodynamic instability
Chest pain or severe dyspnoea
High-risk ECG features (e.g., AV block, ischemic changes)
Palpitations triggered by exercise
Strong suspicious family history (e.g., SCD under age 40)
If trained, NICE advises attempting SVT termination manoeuvres before admitting:
Modified Valsalva
Carotid sinus massage (with continuous ECG monitoring and resuscitation facilities)
5. When to Refer to Cardiology
Urgent referral if:
Syncope or near syncope
Exercise-induced palpitations
Family history of sudden cardiac death (<40 years)
2nd- or 3rd-degree AV block
Routine referral for:
Episodes associated with chest pain or lightheadedness
Structural heart disease
Hypertension or heart failure
Recurrent SVT symptoms
Frequent ventricular ectopics
Suspected paroxysmal AF
6. Investigations in Primary Care
If admission is not indicated, NICE recommends:
Blood tests
FBC
U&E
Thyroid function
HbA1c
Liver function tests
Ambulatory monitoring
Daily symptoms → 24–48h Holter
Less frequent → event recorder
Rare, brief → patient instructed to obtain ECG at onset
Echocardiogram if:
Murmur present
HF suspected
ECG shows LVH, LBBB, pathological Q waves
7. Management Following Assessment
Benign palpitations
Reassure and provide lifestyle advice:
Reduce caffeine
Limit alcohol
Stop smoking
Reduce stress
Avoid recreational drugs
Atrial fibrillation or flutter
Refer to NICE AF guideline:
🔗 NICE AF Guideline
https://www.nice.org.uk/guidance/ng196
Extrasystoles
Reassure if no underlying heart disease.
Sinus tachycardia
Identify and treat the cause—fever, dehydration, anxiety, anaemia, pain.
8. Driving Advice (NICE & DVLA)
Group 1 (car/motorcycle)
Stop driving if arrhythmia may cause incapacity. Resume after the cause is controlled for 4 weeks.
Group 2 (bus/lorry)
Must stop driving and may resume only when controlled for 3 months.
🔗 DVLA Guide – Assessing Fitness to Drive
https://www.gov.uk/guidance/assessing-fitness-to-drive-guide-for-medical-professionals
9. Final FRCEM SBA Exam Relevance
This topic directly aligns with the RCEM 2021 Curriculum (SLO 1, SLO 2, SLO 3) and appears frequently in Final FRCEM SBA examinations.
Key examinable areas include:
SVT recognition and management
VT vs SVT with aberrancy
WPW pattern vs syndrome
Long QT causes
AF red flags
ECG interpretation of arrhythmias
Admission criteria based on haemodynamic features
Ambulatory monitoring selection
Clinicians and exam candidates must recognise high-risk presentations promptly and understand when emergency admission is required.
Conclusion
Palpitations remain a challenging yet vital area of emergency and primary care practice. Using a NICE-aligned systematic approach, clinicians can differentiate benign symptoms from critical arrhythmias requiring urgent management.
For FRCEM candidates, mastering this topic ensures not only exam success but also enhanced clinical safety in the Emergency Department.
For more high-quality Final FRCEM resources, visit: