Clinical Topic A-Z Clinical Speciality

Palpitations

Palpitations
D001145Arrhythmias, Cardiac
D001282Atrial Flutter
Cardiovascular
2009-03-02Last revised in March 2009

Palpitations - Summary

Palpitation is the sensation of rapid, irregular, or forceful heart beats. They are most commonly caused by:

Tachycardias (heart rate more than 100 beats per minute).

Atrial fibrillation or flutter.

Extrasystoles (ventricular or atrial).

Recording an electrocardiogram (ECG) during an episode of palpitations is the gold standard for diagnosis.

Assessment of a person who currently has palpitations involves:

Checking for a history of ischaemic heart disease, heart failure, cardiomyopathy, or valve disease, that could predispose to a dangerous arrhythmia.

Assessing for symptoms suggestive of a serious complication of an arrhythmia, such as breathlessness, chest pain, syncope or near syncope.

Asking about sudden cardiac death of a first degree relative younger than 40 years of age.

Checking the person’s blood pressure.

Taking an electrocardiogram (ECG) immediately.

If there is uncertainty about excluding ventricular tachycardia (VT) or supraventricular tachycardia (SVT) from the ECG result:

Immediate expert interpretation of the ECG should be requested, or

Emergency admission should be arranged, with a copy of the ECG.

Emergency admission should be arranged for anyone with current palpitations with:

Ventricular tachycardia (VT).

Persistent supraventricular tachycardia (SVT) — an attempt should be made to terminate the SVT before admission using the Valsalva manoeuvre or carotid sinus massage, if appropriate.

Symptoms of breathlessness, chest pain, or syncope or near syncope.

Hypotension.

If the person has current palpitations due to other arrhythmias such as sinus tachycardia, atrial fibrillation or flutter, atrial or ventricular extrasystoles, or SVT terminated successfully in primary care:

Assessment should be carried out for an underlying cause and management initiated accordingly.

Referral to cardiology should be arranged, if appropriate.

Rate-controlling drugs such as atenolol or metoprolol should be considered, if appropriate.

People who have a normal ECG and no history suggestive of heart disease can be reassured that palpitations are unlikely to be due to a serious underlying cardiac cause.

Referral (urgency depends on clinical judgement) should be arranged for all people who have a history of palpitations and:

Symptoms suggestive of VT or SVT (urgent referral).

Symptoms suggestive of a serious complication of an arrhythmia, such as breathlessness, chest pain, syncope or near syncope.

Risk factors for a serious arrhythmia, such as family history of sudden cardiac death or evidence of structural heart disease.

A major ECG abnormality.

If paroxysmal atrial fibrillation is suspected or the cause of palpitations is unclear:

Ambulatory monitoring should be arranged to document the rhythm during a symptomatic episode.

Assessment should be carried out to determine an underlying cause and management initiated accordingly.

Have I got the right topic?

192months3060monthsBoth

This CKS topic is based on the Recommended protocol for palpitations by the Thames Valley Cardiac Network [Arrhythmia & Sudden Cardiac Death Subgroup, 2007].

This CKS topic covers the management of people presenting with palpitations caused by extrasystoles and various types of tachycardia, including atrial fibrillation.

This CKS topic does not cover the management of people presenting with bradycardia.

There is a separate CKS topic on Atrial fibrillation.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in March 2009

November 2008 to March 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

There are no major changes to the recommendations.

Previous changes

September 2008 — minor correction to the Changes section. Issued September 2008.

October 2005 — minor technical update. Issued in November 2005.

March 2005 — rewritten. Validated in June 2005 and issued in July 2005.

January 2002 — reviewed. Validated in March 2002 and issued in April 2002.

December 1998 — rewritten replacing guidance on Paroxysmal supraventricular tachycardia. Validated in March 1999 and issued in May 1999.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 November 2008.

HTAs (Health Technology Assessments)

No new HTAs since 1 November 2008.

Economic appraisals

No new economic appraisals relevant to England since 1 November 2008.

Systematic reviews and meta-analyses

Systematic reviews published since the last revision of this topic:

Thavendiranathan, P., Bagai, A., Khoo, C., et al. (2009) Does this patient with palpitations have a cardiac arrhythmia? JAMA 302(19), 2135-2143. [Abstract]

Primary evidence

No new randomized controlled trials published in the major journals since 1 November 2008.

New policies

No new national policies or guidelines since 1 November 2008.

New safety alerts

No new safety alerts since 1 November 2008.

Changes in product availability

No changes in product availability since 1 November 2008.

Goals and outcome measures

Goals

To appropriately assess and manage someone with palpitations during the consultation

To appropriately assess and manage someone complaining of palpitations which are not present during the consultation

Background information

Definition

What is it?

Palpitation is the sensation of rapid, irregular, or forceful heart beats [Simon and RCGP, 2008].

Palpitations are most commonly caused by [Camm and Bunce, 2005]:

Various types of tachycardia (heart rate more than 100 beats per minute).

Atrial fibrillation (rate is fast or slow).

Extrasystoles (ventricular or atrial).

Bradycardia (heart rate less than 60 beats per minute) may cause an increased awareness of the heart beat, but is predominantly associated with syncope and pre-syncope [Hampton, 2008b].

Recording an electrocardiogram (ECG) during an episode of palpitations is the gold standard for diagnosis [Arrhythmia & Sudden Cardiac Death Subgroup, 2007].

Management

Management

Scenario: Palpitations present now : covers the management of people with palpitations that are present at the time of the consultation.

Scenario: Palpitations not present now : covers the management of people complaining of palpitations that are not present at the time of the consultation.

Scenario: Palpitations present now

Scenario: Palpitations present during consultation

192months3060monthsBoth

Assessment

How should I assess someone who has palpitations during the consultation?

Check for a history of heart disease that could predispose to a dangerous arrhythmia; including ischaemic heart disease, heart failure, cardiomyopathy, or valve disease.

Assess for symptoms that could indicate a serious complication of an arrhythmia, including:

Breathlessness.

Chest pain.

Syncope or near syncope (for example, dizziness).

Check blood pressure.

Take an electrocardiogram (ECG) immediately, including a long rhythm strip.

Distinguish:

Ventricular tachycardia (VT) — assume any broad complex tachycardia is VT unless proven otherwise.

Supraventricular tachycardia.

Sinus tachycardia.

Atrial fibrillation.

Atrial flutter.

Extrasystoles (atrial and ventricular).

See Additional information for the characteristic ECG features of the common arrhythmias, with examples.

If there is uncertainty about excluding ventricular tachycardia or supraventricular tachycardia, seek help urgently. Consider:

Sending the ECG by fax, e-mail, or other electronic methods of transmission for immediate expert interpretation, or

Arrange emergency admission, ensuring that the ECG, or a good quality copy of it, is included with the letter of referral.

Additional information

Additional information

Characteristic ECG features of the common rhythms that cause palpitations

Sinus tachycardia. See a typical trace from the ECG Library.

Rate over 100 beats per minute (bpm), normal sinus rhythm.

Supraventricular tachycardia. See a typical trace from Wikimedia Commons.

P-waves are usually not identifiable.

Regular narrow QRS complex tachycardia (unless the person has a bundle branch block as well).

Rate usually between 130 and 250 bpm.

Ventricular tachycardia. See a typical trace from the ECG library.

P-waves may not be visible, may be visible but out of phase with the QRS complex, or visible immediately after the QRS complexes.

Regular broad QRS complex.

Rate usually greater than 160 bpm.

Atrial fibrillation. See a typical trace from the ECG library.

No distinct P-waves visible. The baseline, best seen in V1, is variable and completely irregular.

Irregularly spaced narrow QRS complexes (unless the person has a bundle branch block as well).

Rate usually over 160 bpm but may be slower, particularly in the elderly. Less commonly, the rate may be normal.

Atrial flutter. See a typical trace from the ECG library.

P-wave rate 300 bpm producing a saw-tooth pattern. Best seen in leads III and aVF.

Narrow QRS complex (unless the person has a bundle branch block as well).

2:1, 3:1, or 4:1 block resulting in QRS rate of approximately 150 bpm, 100 bpm, or 75 bpm. The rhythm is irregular if the block is variable, and may resemble atrial fibrillation.

Ventricular extrasystoles (ectopics). See a typical trace from the ECG library.

Early QRS complex which is wide and abnormal in shape and is not preceded by a P-wave. P-waves may sometimes be seen immediately after the QRS complex.

Abnormal T-wave associated with abnormal QRS.

When these alternate with normal QRS complexes, the rhythm is called bigeminy. See a typical trace from the ECG library.

When extrasystoles occur with every third beat, the rhythm is called trigeminy.

Atrial extrasystoles. See a typical trace from the ECG library.

Abnormally shaped P-wave (compared with normal sinus complexes) precedes QRS complex.

Early QRS complex of similar morphology to normal sinus beats.

[Hampton, 2008a]

Basis for recommendation

Basis for recommendation

These recommendations are based on the Thames Valley Cardiac Network protocol for the management of palpitations in primary care, and represent the consensus opinion of 16 experts [Arrhythmia & Sudden Cardiac Death Subgroup, 2007]. They are also in line with recommendations published by the Department of Health; National service framework on arrhythmias and sudden cardiac death [DH, 2005], and expert opinion representing the Royal College of General Practitioners [Simon and RCGP, 2008].

These recommendations are intended to distinguish people known to be at increased risk of immediate serious harm from an arrhythmia, who require management in secondary care. This includes people:

With ventricular tachycardia, who are at risk of death from an arrhythmia.

With any tachycardia precipitating acute heart failure, angina, or collapse.

Who to admit

When is admission advised for people with palpitations?

Arrange emergency admission for anyone with palpitations with:

Ventricular tachycardia (VT). Assume any broad complex tachycardia is VT unless you can confidently identify another cause, such as established left bundle branch block with sinus tachycardia.

Persistent supraventricular tachycardia (SVT). Before deciding to admit, attempt to terminate the SVT. Recommended methods include:

Valsalva manoeuvre: ask the person to breathe out against a closed nose and mouth.

Carotid sinus massage — do not attempt if the person is elderly, or has ischaemic heart disease, a carotid bruit, or a history of stroke or transient ischaemic attack. Only attempt one side at a time. Ensure that a defibrillator is available, as (very rarely) terminating an SVT can provoke other arrhythmias. Ideally, record an electrocardiogram (ECG) continuously during the procedure as well as afterwards.

Symptoms of:

Breathlessness (unless it is mild breathlessness caused by SVT that resolves with treatment of the SVT)

Chest pain

Syncope or near syncope

Hypotension.

Basis for recommendation

Basis for recommendation

These recommendations are based on the Thames Valley Cardiac Network protocol for the management of palpitations in primary care, and represent the consensus opinion of 16 experts [Arrhythmia & Sudden Cardiac Death Subgroup, 2007]. They are also in line with recommendations published by the Department of Health; National service framework on arrhythmias and sudden cardiac death [DH, 2005], and expert opinion representing the Royal College of General Practitioners [Simon and RCGP, 2008].

These recommendations are intended to distinguish people known to be at increased risk of immediate serious harm from an arrhythmia, who require management in secondary care. This includes people:

With ventricular tachycardia, who are at risk of death from a fatal arrhythmia.

With any tachycardia precipitating acute heart failure, angina, or collapse.

Management

How do I manage people following initial assessment?

For people with:

Sinus tachycardia: undertake a systems review, examination, appropriate investigations to look for the underlying cause, and manage accordingly. Causes include:

Anxiety.

Pregnancy.

Fever.

Hypovolaemia.

Menopause.

Drugs — ask about caffeine intake and stimulant recreational drugs (such as amphetamines), and review prescribed medications that are known to cause palpitations (such as bronchodilators and aminophylline-type drugs).

Anaemia — if suspected, do a full blood count. For further information, see the CKS topics on Anaemia - B12 and folate deficiency and Anaemia - iron deficiency.

Cardiac failure — see the CKS topic on Heart failure - chronic.

Chronic lung disease — if chronic obstructive pulmonary disease is suspected, see the CKS topic on Chronic obstructive pulmonary disease.

Thyrotoxicosis — see the CKS topic on Hyperthyroidism.

Atrial fibrillation — see the CKS topic on Atrial fibrillation.

Atrial flutter — refer to cardiology. If the heart rate is uncontrolled:

Control the rate with atenolol or metoprolol, or

Arrange admission for treatment.

Supraventricular tachycardia terminated by carotid sinus massage (or other techniques) — refer to cardiology. While awaiting referral:

Advise the person to avoid caffeine, excess alcohol intake, and smoking as occasionally these can provoke attacks.

If episodes are frequent, distressing, or disabling consider prescribing atenolol or metoprolol.

Atrial extrasystoles — provide reassurance. If symptoms are still causing the person distress, consider treatment with atenolol or metoprolol if these are not contraindicated.

Ventricular extrasystoles:

If underlying heart disease is suspected from the clinical assessment and electrocardiogram (ECG), refer the person to cardiology.

If clinical assessment and ECG is otherwise normal, provide reassurance. If symptoms are still causing the person distress, consider treatment with atenolol or metoprolol if these are not contraindicated.

Reassure people who do not have a history suggestive of heart disease and a normal ECG that palpitations are unlikely to represent a serious problem with their heart. Treatment to reduce risk is rarely needed and is usually given predominantly for symptomatic benefit.

Basis for recommendation

Basis for recommendation

These recommendations are based on the Thames Valley Cardiac Network protocol for the management of palpitations in primary care, and represent the consensus opinion of 16 experts [Arrhythmia & Sudden Cardiac Death Subgroup, 2007]. They are also in line with recommendations published by the Department of Health; National service framework on arrhythmias and sudden cardiac death [DH, 2005], and expert opinion representing the Royal College of General Practitioners [Simon and RCGP, 2008].

Scenario: Palpitations not present now

Scenario: Palpitations not present during consultation

192months3060monthsBoth

Initial assessment

How do I assess people who do not have palpitations during the consultation?

Assess palpitations for characteristics of the following rhythms. Bear in mind the difficulty many people have in accurately describing their symptoms, limiting the value of the history in identifying the rhythm:

Sinus tachycardia:

Usually has a gradual onset and termination.

Rate is usually countable, and the rhythm regular.

Ectopic beats:

Sensation of intermittent missed beats, often followed by a strong beat.

Often most noticeable at rest.

Paroxysmal atrial fibrillation:

May have an abrupt onset; termination may be abrupt or apparently gradual.

Usually associated with a fast heart rate and irregularly irregular rhythm.

Often no specific provocation. Onset at night is common.

Ventricular or supraventricular tachycardia:

Abrupt onset. May terminate abruptly or apparently gradually.

Rate varies from person to person (130–250 beats per minute). Regular rhythm.

Assess for symptoms that may indicate a serious complication of an arrhythmia including, breathlessness, chest pain, or syncope.

Identify risk factors for a serious arrhythmia:

Sudden cardiac death of a first degree relative younger than 40 years of age.

Major structural heart disease including previous history, or symptoms and signs of ischaemic heart disease, heart failure, cardiomyopathy, or valve disease.

Record an electrocardiogram (ECG).

Identify major ECG abnormalities including:

Evidence of ischaemic heart disease.

Left or right ventricular hypertrophy.

P-wave abnormalities.

Evidence of Wolff–Parkinson–White syndrome.

Long QT syndrome.

For the characteristic features of these ECG abnormalities, see Additional information.

Consider requesting an ECG report if there is uncertainty about the presence or absence of relevant abnormalities.

Additional information

Additional information

Characteristic features of major ECG abnormalities associated with an increased risk of an arrhythmia

Evidence of an old myocardial infarction (MI). See a typical trace from the ECG library.

Pathological Q-waves.

Inversion of T-waves.

Loss of R-wave progression across the chest leads following an anterior MI.

Left bundle branch block following a previous MI.

Left ventricular hypertrophy. See a typical trace from the ECG library.

R-wave in V6 greater than 25 mm.

R-wave in V6 plus S-wave in V1 greater than 35 mm.

R-wave in I plus S-wave in III greater than 25 mm.

Inverted T-wave in VL, V5–V6.

Axis normal or deviated to the left.

Right ventricular hypertrophy. See a typical trace from the ECG library.

Tall R-wave in V1.

T-wave inversion in V1–V3 or V4.

Deep S-wave in V6.

Right axis deviation.

P-wave abnormalities.

Peaked P-waves occur with right atrial overload caused by pulmonary or tricuspid valve stenosis, or pulmonary hypertension. See a typical trace from the ECG library.

Broad and bifid P-waves occur with left atrial overload, most commonly caused by hypertension, but classically seen with mitral valve disease.

Evidence of Wolff–Parkinson–White syndrome. See a typical trace from the ECG library.

Short PR interval.

Slight widening of the QRS complex: slurred upstroke (delta wave) with normal terminal portion of the QRS segment.

Sometimes appearances in leads II, III, and aVF mimic a previous inferior MI.

Various possible T-wave abnormalities.

Long QT syndrome.

Measure from the start of the QRS complex to the end of the T-wave.

The precise relationship between the QT interval and the risk of fatal arrhythmias is unknown.

Fatal arrhythmias are rare when the QT interval is less than 500 milliseconds.

[Hampton, 2008b]

Basis for recommendation

Basis for recommendation

These recommendations are based on the Thames Valley Cardiac Network protocol for the management of palpitations in primary care, and represent the consensus opinion of 16 experts [Arrhythmia & Sudden Cardiac Death Subgroup, 2007]. They are also in line with recommendations published by the Department of Health; National service framework on arrhythmias and sudden cardiac death [DH, 2005], and expert opinion representing the Royal College of General Practitioners [Simon and RCGP, 2008].

These recommendations are intended to identify people who are, or who maybe, at increased risk of immediate serious harm from a recurrent arrhythmia. This includes people:

With possible recurrent ventricular tachycardia, who are at risk of death from ventricular fibrillation.

With any recurrent arrhythmia precipitating acute heart failure, angina, or collapse.

Who to refer

Which people with palpitations should I refer?

Following initial assessment, refer all people with:

Symptoms suggestive of ventricular tachycardia or supraventricular tachycardia.

Symptoms indicating serious complications of an arrhythmia.

Risk factors for a serious arrhythmia:

A family history of sudden cardiac death before 40 years of age.

Evidence of major structural heart disease.

A major electrocardiogram (ECG) abnormality.

Following ambulatory monitoring, refer people with proven:

Ventricular tachycardia.

Supraventricular tachycardia.

Atrial flutter.

Tachy-brady syndrome.

Urgency of referral:

Refer urgently all those people with suspected or proven ventricular tachycardia.

For other people, the urgency of referral will depend on clinical judgement, based on:

The frequency and duration of symptoms.

Symptoms of a serious complication from an arrhythmia associated with previous episodes of palpitations, including syncope, chest pain, or breathlessness.

Basis for recommendation

Basis for recommendation

These recommendations are based on the Thames Valley Cardiac Network protocol for the management of palpitations in primary care, and represent the consensus opinion of 16 experts [Arrhythmia & Sudden Cardiac Death Subgroup, 2007]. They are also in line with recommendations published by the Department of Health; National service framework on arrhythmias and sudden cardiac death [DH, 2005], and expert opinion representing the Royal College of General Practitioners [Simon and RCGP, 2008].

These recommendations are intended to identify people who are, or who maybe, at increased risk of immediate serious harm from a recurrent arrhythmia, who require specialist management. This includes people:

With possible recurrent ventricular tachycardia, who are at risk of death from ventricular fibrillation.

With any recurrent arrhythmia precipitating acute heart failure, angina, or collapse.

Who to investigate

Who requires further investigation?

For people who do not require referral following initial assessment:

If characteristic symptoms of extrasystoles are described, further investigations are not necessary if there is no evidence of ischaemic heart disease, major structural heart disease, or any major electrocardiogram (ECG) abnormalities.

If characteristic symptoms of sinus tachycardia are clearly described:

Ambulatory monitoring is not necessary.

Undertake a systems review, examination, and appropriate investigations to look for underlying causes including:

Anxiety.

Fever.

Pregnancy.

Menopause.

Drugs — ask about caffeine intake and stimulant recreational drugs (such as amphetamines), and review prescribed medications that are known to cause palpitations (such as bronchodilators and aminophylline-type drugs).

Hypovolaemia, including blood loss and dehydration.

Anaemia.

Heart failure.

Chronic lung disease.

Thyrotoxicosis.

If atrial fibrillation is suspected from the assessment:

Arrange ambulatory monitoring to document the rhythm during a symptomatic episode. The type of monitoring required is dependent on the frequency and duration of symptoms — see Additional information for the most appropriate method.

Undertake a systems review, examination, and appropriate investigations to look for underlying causes including:

Hypertension.

Obesity.

Heart failure.

Alcohol excess.

Ischaemic heart disease.

Valvular disease.

Thyrotoxicosis.

Acute and chronic pulmonary disease.

Electrolyte abnormality (especially hypokalaemia).

If the cause of the palpitations is unclear, undertake a systems review, examination, and

Arrange ambulatory monitoring. The type of monitoring required is dependent on the frequency and duration of symptoms — see Additional information for the most appropriate method.

Do a full blood count, thyroid function tests, and urea and electrolytes to exclude anaemia, thyrotoxicosis and electrolyte imbalance.

Additional information

Additional information

Ambulatory monitoring

If symptoms are relatively infrequent and last for an hour or more advise the person to attend an Accident and Emergency department, or their GP surgery, for an ECG during the next episode. Provide a letter for the person to give to these healthcare professionals requesting that they have an ECG immediately upon presentation during an episode.

If symptoms are short lived but frequent (for example, more than two or three times per week) arrange a 24 hour or 48 hour Holter monitor.

If symptoms are short lived and infrequent (for example, less than once a week) arrange monitoring with a self-activated recorder, or an event monitor, as appropriate.

Basis for recommendation

Basis for recommendation

These recommendations are based on the Thames Valley Cardiac Network protocol for the management of palpitations in primary care, and represent the consensus opinion of 16 experts [Arrhythmia & Sudden Cardiac Death Subgroup, 2007]. They are also in line with recommendations published by the Department of Health; National service framework on arrhythmias and sudden cardiac death [DH, 2005], and expert opinion representing the Royal College of General Practitioners [Simon and RCGP, 2008].

These recommendations are intended to identify people who are, or who maybe, at increased risk of immediate serious harm from a recurrent arrhythmia, who require specialist management. This includes people:

With possible recurrent ventricular tachycardia, who are at risk of death from ventricular fibrillation.

With any recurrent arrhythmia precipitating acute heart failure, angina, or collapse.

Management

How do I manage people diagnosed with an arrhythmia?

For people who do not require referral following initial assessment, arrange investigations if indicated.

Refer people diagnosed with:

Supraventricular tachycardia following electrocardiogram (ECG) monitoring.

Ventricular tachycardia following ECG monitoring.

Intermittent atrial flutter following ECG monitoring.

For people diagnosed with:

Paroxysmal atrial fibrillation following ECG monitoring, see the CKS topic on Atrial fibrillation.

Sinus tachycardia, manage the underlying cause where possible. For further information on the management of people with:

Anaemia — see the CKS topics on Anaemia - B12 and folate deficiency and Anaemia - iron deficiency.

Cardiac failure — see the CKS topic on Heart failure - chronic.

Thyrotoxicosis — see the CKS topic on Hyperthyroidism.

Symptomatic ventricular or atrial extrasystoles, provide reassurance if the person does not have any evidence of ischaemic heart disease, major structural heart disease, or any major ECG abnormalities. If the symptoms are distressing, consider treatment with a atenolol or metoprolol if there are no contra-indications to these.

Reassure people who do not have a history suggestive of heart disease and a normal ECG that palpitations are unlikely to represent a serious problem with their heart. Treatment to reduce risk is rarely needed and is usually given predominantly for symptomatic benefit.

Basis for recommendation

Basis for recommendation

These recommendations are based on the Thames Valley Cardiac Network protocol for the management of palpitations in primary care, and represent the consensus opinion of 16 experts [Arrhythmia & Sudden Cardiac Death Subgroup, 2007]. They are also in line with recommendations published by the Department of Health; National service framework on arrhythmias and sudden cardiac death [DH, 2005], and expert opinion representing the Royal College of General Practitioners [Simon and RCGP, 2008].

Evidence

Evidence

Supporting evidence

Evidence for the management of people with palpitation

There is a lack of relevant trial evidence to support recommendations for the management of people with palpitations in primary care. Recommendations are therefore based entirely on expert opinion.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of Palpitations, with additional searches for evidence in the following areas:

ECG - specificity and sensitivity of automatic diagnosis

Atrial flutter - primary care management

Search dates

Dates not restricted to November 2008

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.

palpitation$.tw, arrhythmias,cardiac/, atrial flutter/, atrial flutter$.tw.

primary health care/ or primary care.tw. or primary healthcare.tw. or primary health care.tw. or general practice.tw. or gp.tw. or general practitioner.tw. or family practice/ or physicians, family/

electrocardiography/, electrocardiography.tw, ecg.tw.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

National Guidelines Clearinghouse

New Zealand Guidelines Group

British Columbia Medical Association

Canadian Medical Association

Institute for Clinical Systems Improvement

Guidelines International Network

National Library of Guidelines

National Health and Medical Research Council (Australia)

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Royal College of Nursing

Singapore Ministry of Health

Health Protection Agency

National Resource for Infection Control

CREST

World Health Organization

NHS Scotland National Patient Pathways

Agency for Healthcare Research and Quality

TRIP database

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Bandolier

Drug & Therapeutics Bulletin

MeReC

NPCi

BMJ Clinical Evidence

DynaMed

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

References

Arrhythmia & Sudden Cardiac Death Subgroup (2007) Recommended protocol for palpitations. ..Thames Valley Cardiac Network.www.oxfordradcliffe.nhs.uk [Free Full-text]

Camm, A.J. and Bunce, N.H. (2005) Cardiovascular disease. In: Kumar, P. and Clark, M. (Eds.) Kumar & Clark Clinical Medicine. 6th edn. London: Elsevier Saunders. 725-871.

DH (2005) National service framework for coronary heart disease. Chapter 8: arrhythmias and sudden cardiac death. ..Department of Health.www.dh.gov.uk [Free Full-text]

Hampton, J.R. (2008a) The ECG made easy. 7th edn. Edinburgh: Churchill Livingstone.

Hampton, J.R. (2008b) The ECG in practice. 5th edn. Edinburgh: Churchill Livingstone.

Simon, C. and RCGP (2008) Palpitations and arrhythmia. InnovAiT 1(1), 25-34.