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. Recording from smart devices to be reviewd by GP and forwarded to Cardiology if necessary.
Direct Access Ambulatory ECG
NHS Borders provides a service for the assessment of patients with new symptoms suggestive of cardiac arrhythmia. This allows direct access to 24-hour ambulatory ECG monitoring for frequent symptoms and cardio memo for patients with intermittent symptoms. These are for low-risk patients with normal sinus rhythm ECG and no previous history of cardiac disease or sudden cardiac death in family. Patients with an established arrhythmia and a recurrence of previous symptoms and significant cardiac history should be referred to their previous cardiologist via Sci store referral.
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 Borders 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.
Who to refer, who not to refer, how to refer
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 order comms
Who not to refer for Direct Access Ambulatory ECG:
Patients with recent syncope or high-risk features (see below)
Patients already known to Cardiology – please refer to existing Consultant.
Refer via Sci store with attached ECG
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
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 SCI gateway, and it is essential to have history, examination and an attached ECG at the time of urgent or routine referrals.
Primary care management
For information about driving and further assessment please see the following:
Borders Ref Help Toolkit
