Arrhythmia/ Palpitations including Direct Access to Ambulatory ECG
Most patients with palpitations are at low risk of serious cardiac events. This reflects the most common causes – ectopic beats, sinus tachycardia and supraventricular arrhythmias. However, it is important to identify patients at risk of more serious, life threatening arrhythmia as treatments are available that can lower their risk, such as drugs and implantable devices.
The following patients are considered at high risk and should be referred urgently for cardiology assessment:
- Palpitations associated with syncope/collapse, pre-syncope, persistent breathlessness or chest pain
- Patients known to have history of ventricular arrhythmia
- Previous myocardial infarction, cardiac surgery, percutaneous coronary intervention or pacemaker / device implant fitted within past two months
- Patients with a family history of sudden cardiac death
- Patients with signs or features of structural cardiac disease or heart failure.
Clinical history often points towards the diagnosis:
- An awareness of a ‘missed’ or ‘extra’ beat often at rest or in bed usually reflects an ectopic beat
- A sudden onset tachycardia that abruptly termination suggests SVT (especially if terminated with breatholding/ valsalva-type manoeuvres)
- An awareness of a regular but slightly faster heartbeat with stress or anxiety usually suggests benign causes such as an increased awareness of sinus rhythm.
Smartphone/ smart watch devices
These devices vary in their precision for detecting common cardiac arrhythmias. Unless the patient has cardiac symptoms, palpitations, or the smart device has self diagnosed a specific arrhythmia (e.g. atrial fibrillation) then no further ambulatory monitoring or review is required.
Direct Access Ambulatory ECG
NHS Lothian provides a service for the assessment of patients with new symptoms suggestive of cardiac arrhythmia. This allows direct access to ambulatory ECG monitoring for low risk patients and clinic assessment of patients at higher risk. Patients with an established arrhythmia and a recurrence of previous symptoms should be referred to their previous cardiologist.
For patients referred for direct access ambulatory ECG monitoring, reports will be sent directly back to the referring doctor. Further clinical advice is available on request through SCIgateway, attaching the ambulatory monitor report.
NHS Lothian does not operate specific arrhythmia clinics. Patients not suitable for Direct Access Ambulatory ECG will be assessed in General Cardiology clinics, with priority determined by the clinical details provided.
C.W & C.S 24-01-23
Who to refer for Direct Access Ambulatory ECG:
- Palpitations characterised by a sensation of an abnormally rapid, forceful or irregular heartbeat
- Frequent symptoms (i.e. symptoms > twice/week) with no high risk features
- Patient can comply with monitoring period (confused patients may remove the monitor or electrodes and are likely to produce unclear recording).
These patients should be referred via SCIgateway to the relevant hospital (site based on patient location – RIE, WGH or SJH) > Cardiology > Arrhythmia Referral.
Who not to refer for Direct Access Ambulatory ECG:
- Patients with symptoms less frequently than twice/week. These patients’ symptoms are less likely to be captured by Holter monitoring. See further information below
- Patients with recent syncope or high risk features (see below)
- Patients already known to Cardiology – please refer to existing Consultant.
Who to refer to General Cardiology clinic:
- Recent syncope or high risk features above (urgent)
- Patients with a history of acute coronary syndrome, cardiac surgery, percutaneous coronary intervention or a pacemaker / device implant within the last two months
- Known history of ventricular tachycardia or ventricular fibrillation
- Patients with symptoms less frequently than twice weekly, where an arrhythmia and not simply ectopic beats, is suspected
- Already known to a consultant or has increasing or changing low risk symptoms of a previously identified arrhythmia.
Referrals will be triaged by a Consultant to initial monitoring with advice, or an urgent or routine clinic review.
These patients should be referred via SCIgateway to the relevant hospital (site based on patient location – RIE, WGH or SJH) > Cardiology > General Cardiology.
For information about driving and further assessment please see the following
Assessment of palpitations | The BMJ
Assessment of palpitations – Diagnosis Approach | BMJ Best Practice
