HNY Policy and Pathway Repository - York

• Palpitations are an unpleasant awareness of the heart beating and may be fast or slow.
• It is a very common symptom and is a normal reaction to exertion or stress
• The majority of people do not have an underlying cardiac abnormality or require treatment
• The purpose of this pathway is to facilitate appropriate and early investigation of people with palpitations
• To identify those people who are at low risk of significant cardiac pathology and can be managed by investigations and then management in primary care without the need for a cardiology outpatient appointment
• To ensure that all appropriate investigations are completed before referral
• On receipt of a completed referral form via the RSS with ECG attached, the patient will be contacted by letter for the appropriate ambulatory assessment within 6 weeks where possible.
• The report will be returned to the referring GP within 1 week of the investigation with advice about cardiology follow up.
• Only patients deemed to be significantly symptomatic or having severe abnormalities will be directly referred to the consultant cardiologist, which will be regarded as an additional new patient referral

Exclude Red Flags

It is important to identify any of the following red flag features and indicate these on the referral form. These patients require urgent assessment and may need consultant follow up

• History of transient loss of consciousness, or blackouts (syncope)
• Known cardiac disease:- previous MI, heart failure, valvular heat disease, congenital heart disease, cardiomyopathy and not under follow up
• Family history of sudden cardiac death under 40 or need for pacemaker or defibrillator stating family members affected
• Abnormal resting ECG, excluding sinus tachycardia, first degree heart block, right bundle branch block and AF, which are not red flag features

Exclude the following

• People already under cardiology follow up at Scarborough or York Hospitals
• People with new onset exertional chest pain should be referred through chest pain protocol
• People with AF should be managed through CAR02 the AF pathway
• People with new Heart Failure should be managed through the CAR01 the Heart Failure pathway
• People under 16yrs
   

The following people are unlikely to benefit from referral (see Palpitations Risk Stratification (‘Traffic Light System’) table)

• People who have only ever had one episode or less frequent than once per month and have no red flag features and normal ECG and blood test

Palpitation Pathway Form

A comprehensive description of the symptoms is very important to enable the physician and cardiac physiologist to arrange the appropriate investigations and follow up. If these details are not completed it may not be possible to arrange the investigations and the referral will be returned

• Symptom date of first onset, frequency and duration. In particular do they occur daily or weekly
• How severe are they, do they need to stop or can they carry on
• Type of onset and end of symptoms if known, gradual or sudden, was this provoked
• Are the palpitations fast or slow, regular or irregular
• Do they occur with exercise or at rest
• Do they occur at a particular time of day
• Associated symptoms of flushing, chest pain, breathlessness for example
• Full list of concurrent medication including over the counter treatments
• Intake of caffeine, alcohol and illicit drugs
   

The following investigations are mandatory

• Good quality 12 lead ECG to be attached
• Examination:- pulse, BP, heart sounds, evidence of heart failure or not and BMI
• FBC, U and E, TFT with values If 24hr ECG has already been arranged also attach
   

Indications for admission with palpitations

• People who are haemodynamically compromised
• People who are known to have Wolf Parkinson White syndrome and have palpitations
• Any broad complex tachycardia on ECG
   

Palpitations and driving

• If the patient has been incapacitated by palpitations they should be advised not to drive and that they should notify the DVLA. Driving may resume when the symptoms are controlled for more than 1 month unless they are a Class 2 licence holder.
   

Referral Pathway

• Not all people who have palpitations require referral to a specialist. They should have a full history, investigations and assessment of risk and potential diagnosis in primary care.
• For people at intermediate and high risk please complete referral form and attach summary of records with PMH, medications and investigations plus 12 lead ECG.
• Please ensure that there are up to date patient contact details on the form.
• Send via RSS clearly indicating the presence of Red Flag features as an URGENT referral if appropriate.
• Where mandatory items and a clear history are not included the referral will be returned to the practice for completion and return.
• Where there are urgent features, the patient will be contacted for ambulatory assessment within 2 weeks and Cardiology follow up may be arranged by the Cardiac Physiology Department and the Consultant Cardiologists.
• Where there are no urgent features, the patient will be contacted by letter to attend for the appropriate investigation within 6 weeks and the report returned to the GP for action unless significant abnormalities are found. The majority of these reports will be produced by an experienced cardiac physiologist as this provides the most efficient service for the patient.
• Any cardiology clinic appointment will be regarded as a new patient assessment.

Ref: Gale C.P. and Camm A.J. Assessment of palpitations BMJ 2015;351:h5649

Palpitations Risk Stratification (‘Traffic Light System’)

Skipped beats   Thumping beats   Short fluttering   Slow pounding AND Normal ECG AND No family history AND No structural heart disease	History suggests recurrent tachyarrhythmia   Palpitations with associated symptoms AND/OR Abnormal ECG AND/OR Structural heart disease	Palpitation during exercise   Palpitations with near syncope / near syncope   High risk structural heart disease   Family history of inheritable heart disease / SADS   High degree atrioventricular block
Low risk: manage in primary care	Refer to cardiology / arrhythmia care co-ordinator	Refer to cardiology with urgency

Ref: Wolff A. and Cowan C. 10 Steps Before you refer for Palpitations The British Journal of Cardiology 2006; 16 p 182-186

Referral forms

• SystmOne Referral Form
• SystmOne Referral Form (word format)
• EMIS Web Referral Form