Patient

1
Palpitations / Suspected Clinically Significant
Arrhythmia Patient Pathway June 2006
Patient Presentation
Palpitations
Primary Care
GP
Medical Consultant
Perform 12 lead electrocardiogram (ECG).
Interpretation of ECG should be performed by
suitably trained personnel. Blood tests on all
patients TFT, FBC, Ca, UE, lipids, blood sugar

• Are there any red flag symptoms
• Loss of consciousness
• Palpitations associated with chest pain
• Severe lightheadedness, nausea or breathlessness
  (consider panic attacks).

Refer for appropriate investigations within 72
hours With ECG Appointment triage by Medical
Consultant
Yes
No
Intermediate Specialist Service may be Open
Access, Primary Care or Hospital
See ambulatory ECG algorithm on next page
Primary Care
Normal ECG
Perform 12 lead electrocardiogram (ECG).
Interpretation of ECG should be performed by
suitably trained personnel. Blood tests on all
patients TFT, FBC, Ca, UE, lipid, blood sugar
Cardiology Consultant
Refer to be assessed within 1 month
Abnormal ECG e.g. long QT interval, delta wave
See Atrial Fibrillation algorithm on next page
Atrial Fibrillation (AF)
left bundle branch block (LBBB), left ventricular
hypertrophy (LVH), old myocardial infarction (MI)
See ambulatory ECG algorithm on next page
Patient
Primary Care
Secondary Care
Based on www.cci.scot.nhs.uk
Page 1 of 3
2
Palpitations / Suspected Clinically Significant
Arrhythmia Patient Pathway June 2006
Ambulatory ECG monitoring by Intermediate
Specialist Service
Atrial Fibrillation Algorithm
GP
daily symptoms (gt1 episode per day)
less than daily symptoms

• Control Ventricular Rate target lt80/min see
  page 3
• Assess need for anti-coagulation (CHADS2 score
  see page 3)
• Consider referral criteria for specialist
  assessment

24 hour ambulatory ECG
48 hour ambulatory monitoring

• Young age (lt50 years)
• Reversible precipitating cause of AF (e.g.
  alcohol binge, thyrotoxicosis, pneumonia, recent
  surgery) and no major structural or functional
  heart disease
• Difficulty with ventricular rate control
• AF causing symptomatic limitation despite rate
  limiting treatment e.g. heart failure, excessive
  exertional breathlessness, undue fatigue.

Had typical symptoms during ambulatory recording?
Red Flag arrhythmia
PMO informs consultant
No
Yes
Consider referring again if symptoms cause
clinical concern.
Clinically significant arrhythmia?
Obtain echocardiogram by the fastest local means.
Echocardiogram should be arranged once rate is
controlled (if no echocardiogram in past year and
no relevant intercurrent clinical event).
Yes
No
Refer results for medical consultant
opinion/triage

• If abnormal
• valve disease
• left ventricular systolic dysfunction / heart
  failure

Normal
Provide GP with patient leaflet / advice on AF
with advice on referral
Medical Consultant
Medical Consultant
GP
Refer for consultant opinion
GP
Reassure patient and provide information
Consultant opinion
Provide patient with information leaflet and
advice on AF .
Based on the Greater Glasgow Health Board Pathway
Page 2 of 3
3
Palpitations / Suspected Clinically Significant
Arrhythmia Patient Pathway June 2006
Ventricular rate control 1. Target ventricular
ECG rate lt80 beats/min 2. Treatments of choice
either - a beta-blocker , Atenolol If
ventricular rate still gt80 beats/min. add
digoxin OR - a rate limiting calcium channel
blocker (CCB) i.e. verapamil or diltiazem (but
avoid if left ventricular systolic dysfunction /
heart failure). Start with verapamil (slow
release) 120mg od and uptitrate to 240mg od if
ventricular rate still gt80 beats/min. Add digoxin
if target ventricular rate still not met. N.B.
beta-blockers and rate limiting CCBs must NOT be
combined except under specialist supervision. 3.
Digoxin has a LIMITED role - mainly in heart
failure, initially, for rapid control of the
ventricular rate but new evidence shows that
beta-blockers are the agents of choice in stable
heart failure - can be used in COMBINATION
with beta-blockers / rate limiting CCB when
control of the ventricular rate is difficult.

• Suitable for cardioversion?
• Persistent AF
• Symptomatic despite ventricular rate control
• Short duration (lt72 hours consider immediate
  referral to hospital)

Page 3 of 3