Evaluation and EKG Findings with Palpitations – Primary Care RAP

Copied from Primary Care RAP March podcast – an excellent overview of the workup and “red flags” on EKG.

Palpitations are a common symptom seen in the outpatient setting. While most are benign, it is important to rule out more serious and potentially deadly causes. A family history of sudden cardiac death and certain EKG findings should alert the provider to high risk patients.


  • Palpitations are a common complaint but one that should be taken seriously with further work-up if red flags such as syncope, family history of sudden cardiac death and palpitations with abrupt onset.

  • Work up includes: history and physical, labs, EKG, rhythm monitoring and echo.

  • Things to look out for on EKG (see images below)

    • Brugada syndrome

    • QT prolongation or shortening

    • Wolf-Parkinson-White

    • Lown-Ganong-Levine syndrome

    • Arrhythmogenic right ventricular cardiomyopathy

    • Hypertrophic cardiomyopathy

  • Palpitations: A common complaint but one that should be taken seriously if there are red flags.

    • Family history of sudden death at a young age.

    • Palpitations abrupt onset (not typical for sinus tachycardia)

  • How would you work it up?

    • Thorough history of syncope, presyncope, family history.

    • Physical exam.

    • Labs: CBC, metabolic panel, thyroid studies, EKG.

    • Rhythm monitor: Holter monitor, Zio patch that can stay on for a week or two, event monitor (triggered by patient when they feel palpitations and records 30 seconds prior to flicking the switch and onward), phone app (grip the phone when feeling palpitations and the phone records a crude one lead EKG).

    • Echo to rule out underlying structural disease, probably not in everyone but particularly those you are worried about with a strong family history, murmur on exam or EKG abnormalities.

  • What do you look for in the EKG? You aren’t looking for the arrhythmia (unless you happen to catch it) but underlying abnormalities that can potentially lead to lethal arrhythmias or predispose to arrhythmias.

    • Brugada syndrome: ST elevation in leads V1 and V2 often with right bundle branch pattern.

Source: Wikipedia

  • QT prolongation or shortening: both associated with increased risk of Vtach

Link to image online: BCM Journal

  • Wolf-Parkinson-White (WPW): short PR interval and delta waves

Source: Wikimedia Commons

  • Lown-Ganong syndrome: short PR interval

Link to image: Medscape

  • Arrhythmogenic right ventricular cardiomyopathy: epsilon waves (little spiky waves right after the QRS complex in V1)

Source: Wikimedia

  • Hypertrophic cardiomyopathy: left ventricular hypertrophy, ST wave inversions and Q waves in the inferior and lateral leads that don’t meet criteria for ischemia.

Link to image: Pradub

  • If studies come back normal, then what?

    • If sensation of palpitations but nothing on monitor, reassurance that it is not cardiac issue.

    • If no sensation of palpitations while monitored, watchful waiting unless very concerned given family history, consider referral to cardiology. They will then either get an implantable loop recorder or electrophysiologic studies.

  • If studies come back abnormal?

    • Isolated PVC or PAC in a structurally normal heart is a benign finding.

    • If non-sustained V-tach or SVT, that is more concerning and warrants patient seeing cardiology.

    • If QT prolongation, Brugada syndrome (or others mentioned above), recent syncope or family history of sudden cardiac death, recommend immediate cardiology referral.

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