Palpitations in primary care: when should I worry?

A patient tells you their heart's been racing or skipping. Most of the time it's benign, but a few of these are the ones you can't miss. Here's the approach I use in clinic to sort them out fast.

Step 1: Are they symptomatic at the visit?

If they're symptomatic in the office:

• Get an EKG right away and read it.
• EKG normal: this is often PACs or PVCs. Patients usually describe these as skipped beats that do not happen with exercise.
• EKG abnormal (arrhythmia): manage accordingly.

If they're not symptomatic in the office:

• Take a detailed history and do a physical.
• Still get a baseline EKG.

Step 2: Risk stratify

Low-risk palpitations

• Well tolerated
• Not sustained
• No evidence of structural heart disease

Management:

• Lifestyle changes: limit caffeine, hydrate, avoid stimulants.
• Close follow-up in 2 weeks.
• If the patient is highly anxious, an event monitor can be reassuring.

High-risk palpitations

• Sustained or poorly tolerated episodes
• Signs of heart disease on history, exam, or EKG
• Concerning personal or family history: syncope, documented arrhythmia, sudden cardiac death, cardiomyopathy, or long QT syndrome

Management:

• If concerning for VT (ventricular tachycardia), order a Holter monitor.
• If frequent and associated with syncope, send to the ED for urgent evaluation.

Step 3: Labs and diagnostics

Labs

• TSH to rule out thyroid disorders
• CBC to rule out anemia

Echocardiogram when there's:

• Poorly tolerated or sustained palpitations
• Concern for hypertrophic cardiomyopathy
• A murmur on exam
• EKG findings like prior MI, LBBB, or ventricular hypertrophy

Heart monitoring depends on how often symptoms happen:

• 24 to 48 hour Holter monitor for frequent palpitations
• 2 to 4 week event monitor for less frequent episodes

Step 4: When to refer

• Send a cardiology consult for a concerning history, abnormal findings, or diagnostic uncertainty.
• When in doubt, refer. I err on the side of caution here.

Clinical pearls

• Most palpitations are benign, but context matters. History, family history, and risk factors carry the decision.
• PVCs and PACs are common and often benign, especially when they aren't exercise-induced.
• Reassurance can be therapeutic, but balance it with the right workup.
• Rule out metabolic causes like thyroid and anemia before you land on a psychiatric cause.
• Don't miss the red flags: syncope, family history of sudden death, or an abnormal EKG.

Frequently asked questions

Skipped beats with a normal EKG, do I still need a monitor?
Not always. If the patient is well, the episodes aren't sustained, and there's no structural heart disease, lifestyle changes and a 2-week follow-up are reasonable. Use a monitor if they're anxious or you want documentation.

Holter or event monitor, how do I choose?
Match the device to symptom frequency. Frequent symptoms catch on a 24 to 48 hour Holter. Less frequent episodes need a 2 to 4 week event monitor to capture an event.

When does this go straight to the ED?
Palpitations with syncope, sustained or poorly tolerated episodes, or anything concerning for VT. Those don't wait for an outpatient monitor.

Most of palpitations comes down to one question: benign or not, and the EKG plus the history usually answers it. For a quick bedside version, the Clinical Desk Reference keeps the workup on one page. If you want to build the broader cardiac workup with confidence, the Primary Care Clinical Mastery Program walks through it.

Education only. Use clinical judgment and your local guidelines.

Written by Allison Sowders, MSN, APRN, FNP-BC, a practicing primary care nurse practitioner and founder of Nurse Practitioner Mentor. Reviewed July 2026.