Palpitations in Primary Care: When to Be Concerned

Palpitations are a very common chief complaint in primary care. Causes can range from benign to life-threatening — including cardiac, metabolic, and psychiatric disorders.

Here’s a streamlined, practical approach I use in clinic.

Step 1: Symptomatic vs. Not Symptomatic at the Visit

• If symptomatic in office:

  • Obtain an EKG immediately and assess.

  • EKG normal → Often PACs or PVCs (patients usually describe these as “skipped beats” that do not occur with exercise).

  • EKG abnormal (arrhythmia) → Manage accordingly.

• If not symptomatic in office:

  • Obtain a detailed history and physical.

  • Still get a baseline EKG.

Step 2: Risk Stratification

Low-Risk Palpitations

• Well tolerated

• Unsustained

• No evidence of structural heart disease

Management:

• Lifestyle modification: limit caffeine, hydrate, avoid stimulants.

• Close follow-up in 2 weeks.

• If patient is highly anxious → consider ordering an event monitor for reassurance.

High-Risk Palpitations

• Sustained or poorly tolerated episodes

• Signs of heart disease (history, exam, or EKG)

• Concerning personal or family history:

  • Syncope

  • Documented arrhythmia

  • Sudden cardiac death

  • Cardiomyopathy

  • Long QT syndrome

Management:

• If concerning for VT (ventricular tachycardia) → order a Holter monitor.

• If frequent and associated with syncope → send to ED for urgent evaluation.

Step 3: Labs & Diagnostics

• Labs

  • TSH → rule out thyroid disorders

  • CBC → rule out anemia

• Echocardiogram

  • Poorly tolerated or sustained palpitations

  • Concern for hypertrophic cardiomyopathy

  • Murmur noted on exam

  • EKG findings: prior MI, LBBB, ventricular hypertrophy

• Heart Monitoring (depends on frequency of symptoms)

  • 24–48 hr Holter monitor → frequent palpitations

  • 2–4 week event monitor → less frequent episodes

Step 4: When to Refer

• Cardiology consult if concerning history, abnormal findings, or diagnostic uncertainty.

• I personally err on the side of caution — when in doubt, refer.

Clinical Pearls

• Most palpitations are benign, but the context matters (history, family history, and risk factors).

• PVCs/PACs are common and often benign — especially if not exercise-induced.

• Reassurance can be therapeutic, but always balance with appropriate evaluation.

• Always rule out metabolic causes (thyroid, anemia) before assuming psychiatric cause.

• Don’t miss red flags: syncope, family history of sudden death, or abnormal EKG.

Final Note

This is a general guideline I follow. Each patient is unique, and your clinical judgment always comes first.

👉 Want more practical workflows like this? Check out my Mentorship Program for New NPs  where I share real-world approaches to common primary care complaints.