Palpitations History

Differentials

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself by name and role
• Check the patient’s name and date of birth
• Explain the task and get consent

“I have been asked to speak to you about the sensation you have been experiencing in your chest. I will ask you some questions to help determine what might be causing it. Does that sound all right?”

Presenting Complaint

Begin with an open question to establish the patient’s reason for presentation, for example, “Could you tell me about what’s been going on?”

Try to let the patient speak for 30-60 seconds without interruption. This is referred to as the ‘golden minute’ and can provide valuable information about why the patient has sought medical attention as well as cues surrounding their ideas, concerns, and expectations (ICE) to explore later in the consultation.

History of Presenting Complaint

Next, you need to gather more specific information about the patient’s presenting complaint to establish the differential diagnosis. You can use a mixture of open and closed questions. 

An example of an open question here would be: “How would you describe the sensation in your chest?” or “Have you noticed any other symptoms alongside these palpitations?”. Examples of closed questions include: “Do you get chest pain with the palpitations?” or “Are the palpitations ever brought on by exercise?”

When taking a palpitations history, you may find it useful to use a structured approach to your questioning. For example:

• Character – how would the patient describe the palpitations? Could they tap out the rhythm they feel on the desk? A ‘skipped beat’ or ‘extra beat’ sensation may represent extrasystole. Tapping out an irregular rhythm may indicate atrial fibrillation or flutter.
• Onset – when did the sensation start? What were they doing at the time? Onset of palpitations with exercise is a red flag for more serious pathology and will likely require a cardiology referral. Improvement with exertion common in extrasystole.
• Frequency – how often are the palpitations happening? Is there any pattern to them? This will also help you to determine whether symptoms can be captured on a standard 12-lead ECG or whether 24-hour (or longer) monitoring will be required.
• Timing – how long does the sensation last? What time of the day do the symptoms happen? Any associated triggers? Has the timing of episodes changed since the patient first noticed their symptoms? Does the patient have the symptoms now, or are the palpitations historic?
• Exacerbating and relieving factors – does anything bring the palpitations on, e.g., stress, caffeine, drug use? Does anything make them better, e.g., deep breathing, getting up and moving around, or avoidance of potential triggers?
• Associated symptoms – does the patient experience any other symptoms alongside the palpitations? Try to think not only about other cardiovascular symptoms (discussed further below), but also symptoms that may indicate wider system involvement e.g., tremor, goitre, sweating, and heat intolerance may make you think about thyrotoxicosis as a differential. 
• Previous similar episodes? – has this ever happened to the patient before? Did it feel the same, or different?

System-specific History

After establishing further information about the palpitations, you need to gather any relevant system-specific information. In this case, the system in question is the cardiovascular system. Try to think of symptoms that may occur alongside palpitations and ask about these.

It is important not only to ask these questions, but also to understand how the patient’s answers help narrow down the differential diagnosis. 

Cardiovascular system-specific questions to ask include but are not limited to:

• Chest pain – chest pain associated with palpitations may indicate that there is myocardial ischaemia, which requires urgent investigation and treatment.
• Shortness of breath – breathlessness with palpitations has a broad differential diagnosis, including atrial fibrillation, atrial flutter, and panic attacks. The presence of significant breathlessness and current palpitations should be treated as a red flag and urgent assessment arranged. 
• Lightheadedness – many causes of palpitations may cause lightheadedness, not all of which are cause for concern. However, if there is history of syncope or loss of consciousness, the patient should be referred for urgent assessment.
• Diet – is the patient’s diet contributing to their symptoms? Make sure to ask about caffeine intake, including tea and coffee, as well as less obvious sources, e.g., fizzy drinks, energy drinks, chocolate, green tea.

Red Flags

Features in a palpitations history that should trigger an urgent referral for further assessment include:

• Onset with exercise
• Chest pain, significant breathlessness, or loss of consciousness associated with the palpitations.
• Sudden cardiac death in a family member under 40 years old. 

Relevant Systems Review

A systems review is a useful tool to ensure no important information from the history has been missed. However, it is key to consider which systems to review to keep your questions relevant to the presenting complaint.

Appropriate systems to review when taking a history of palpitations include:

• Endocrine – are there any symptoms of thyrotoxicosis, e.g., tremor, sweating, goitre, heat intolerance, or any thyroid eye disease (Graves’ disease)? Palpitations in a patient with known diabetes, along with confusion, sweating, or loss of consciousness could be a symptom of hypoglycaemia so checking capillary glucose is important for these patients. Palpitations with headache and significant hypertension may indicate pheochromocytoma.
• Psychiatric – palpitations can be a physical symptom of a psychiatric issue such as anxiety or a panic attack, especially if there is an emotional trigger. Palpitations may be associated with chest tightness, shortness of breath, tingling, fear, and panic. 

Ideas, Concerns & Expectations (ICE)

Using the ICE mnemonic, you can gather information about how the patient feels about their symptoms, whether they have any specific worries or concerns, and how they hope to move forward after seeking medical attention. Try to find your own approach to asking about ICE that suits your personal style; some examples are included below:

• Ideas – “Do you have any thoughts about what might be going on?” “What do you think might be causing these symptoms?”
• Concerns – “Is there anything that is worrying you about these palpitations?” ‘Have you read anything or Googled your symptoms that has worried you?”
• Expectations – “Was there anything specific you were hoping we would do today?” “Do you have any ideas about what might happen next?”

Past Medical History

Gather information about previous or existing health conditions that the patient may have. Try to note when an existing condition may be of significance in the context of a presenting complaint of palpitations. The patient who has Graves’ disease which was previously treated but has recently developed symptom recurrence including palpitations may be having a relapse. A patient with known structural heart disease who develops palpitations is at higher risk of a serious underlying condition. Don’t forget to ask about previous similar episodes of palpitations.

Ask about previous surgery or procedures the patient may have undergone, e.g., do they have a pacemaker or implantable cardioverter defibrillator? If so, why was this put in and when was it last checked and confirmed to be functioning correctly?

Drug History

Ask the patient about any regular medication they take, not forgetting to ask specifically about medications that the patient may not think to volunteer, e.g., over the counter medications, herbal or alternative medication, contraception, HRT, injections such as vitamin B12. Check whether the patient is compliant with their medication and taking it as prescribed.

Try to think about whether the information you are given could be relevant to the differential diagnosis, e.g., the patient has presented with palpitations and reports they have not been compliant with their thyroid medication (poor disease control). Remember that certain medications may cause palpitations as a side effect, e.g., salbutamol, antimuscarenics, certain antipsychotics and antidepressants.

Don’t forget preparations patients may buy over the counter which can cause palpitations e.g., caffeine supplements and decongestant medications including pseudoephedrine. Check how much of these products patients are using.

Remember to ask about drug allergies and clarify any reported symptoms to differentiate a true allergy from an intolerance.

Social History

This is the chance to learn more about the patient, beyond their presenting complaint.

• Who do they live with? Do they have a social support network, e.g., if receiving a debilitating diagnosis. Would someone else be at home to witness a symptom episode or to call for help if required?
• Do they work? Are they able to work with their current symptoms, and is it safe to continue working whilst their symptoms are being investigated? This particularly applies to patients who work at height, with dangerous machinery or who drive for a living. 
• Do they drive? Does their condition affect their ability to drive or attend appointments? The DVLA states that patients must inform them about palpitations.
• Have they had contact with someone with similar symptoms?
• Have they recently returned from travelling abroad?
• Do they smoke? Smoking can cause palpitations due to the nicotine content of cigarettes, e-cigarettes and cigars.
• Do they drink alcohol? Alcohol increases palpitations.
• Do they use recreational drugs? Some recreational drugs increase the risk of palpitations, e.g., cocaine, and amphetamine.

Try to think about the relevance of the information you are given, e.g., the patient who is being worked up for palpitations works as a construction manager including at height and with machinery will need to be advised to inform their employer and work with amended duties.

Family History

Does anyone in the family have cardiovascular disease? A family history of structural heart disease may prompt further investigations for a patient presenting to you with palpitations. A family history of sudden cardiac death before the age of 40 is a red flag and warrants urgent cardiology assessment. 

Do any other health conditions run in the family, e.g., thyroid or autoimmune conditions which may increase a patient’s risk of developing thyrotoxicosis themselves?

Finishing

Thank the patient and wash your hands. Consider your differential diagnosis and how you might narrow this down further through examination, bedside tests or further investigation/imaging. 

Last updated Feb 2025

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