What is the proper procedure for writing an electrocardiogram (EKG) referral for a patient with arrhythmia?

How to Write an EKG Referral for Arrhythmia

When writing an EKG referral for arrhythmia, obtain a resting 12-lead ECG first, document the detailed clinical history including episode pattern (frequency, duration, onset, triggers), and specify clear indications for specialist referral based on the type of arrhythmia and severity of symptoms. 1

Essential Components to Include in the Referral

Clinical History Documentation

• Document the precise pattern of arrhythmia episodes: number of episodes, duration, frequency, mode of onset (sudden vs gradual), and any identifiable triggers 1
• Record specific symptoms during episodes: palpitations (regular vs irregular), syncope, near-syncope, dyspnea, chest pain, or polyuria (suggests sustained supraventricular arrhythmia) 1
• Note response to vagal maneuvers if attempted, as termination by vagal maneuvers suggests re-entrant tachycardia involving AV nodal tissue 1
• Include precipitating factors: excessive caffeine, alcohol, nicotine intake, recreational drugs, or hyperthyroidism 1

Required Baseline Testing Before Referral

• Obtain a resting 12-lead ECG as the fundamental diagnostic tool—this is mandatory and should be recorded before any referral 1
• Strongly encourage obtaining a 12-lead ECG during the arrhythmia if the patient has a history of sustained arrhythmia, as this provides definitive diagnostic information 1
• Do not rely on automatic ECG analysis systems, as they are unreliable and commonly suggest incorrect arrhythmia diagnoses 1

Absolute Indications for Urgent Specialist Referral

These patients require immediate referral to a cardiac arrhythmia specialist:

• Wide complex tachycardia of unknown origin 1
• All patients with Wolff-Parkinson-White (WPW) syndrome (pre-excitation combined with arrhythmias) due to potential for lethal arrhythmias 1
• Patients with severe symptoms during palpitations: syncope or dyspnea 1
• Irregular and paroxysmal palpitations with baseline pre-excitation on ECG, which suggests atrial fibrillation episodes and carries risk of significant morbidity and possibly sudden death 1

Relative Indications for Specialist Referral

For narrow complex tachycardias, refer when:

• Drug resistance or intolerance to antiarrhythmic therapy 1
• Patient desires to be free of drug therapy and may be candidate for catheter ablation 1
• Paroxysmal regular palpitations with pre-excitation on resting ECG, which is sufficient for presumptive diagnosis of AVRT and does not require documentation of spontaneous episodes before referral 1

Additional Diagnostic Information to Include

Structural Heart Disease Assessment

• Consider echocardiographic examination in patients with documented sustained SVT to exclude structural heart disease, which cannot be detected by physical examination or 12-lead ECG alone 1
• Note any known cardiovascular disease: coronary artery disease, cardiomyopathy, valvular disease, congenital heart disease, or conduction disturbances 1

Ambulatory Monitoring Results (if available)

• 24-hour Holter recording results for patients with frequent (several episodes per week) but transient tachycardias 1
• Event or wearable loop recorder data for less frequent arrhythmias 1
• Implantable loop recorder consideration for rare symptoms (fewer than two episodes per month) associated with severe symptoms of hemodynamic instability 1

Critical Pitfalls to Avoid

• Never initiate class I or class III antiarrhythmic drugs without documented arrhythmia due to risk of proarrhythmia 1
• Do not delay referral waiting for arrhythmia documentation if symptoms and clinical history indicate paroxysmal arrhythmia and the resting 12-lead ECG gives no clue to mechanism—further diagnostic tests may not be necessary before referral for invasive electrophysiological study 1
• Avoid relying solely on monitor strips—a full 12-lead ECG provides essential diagnostic information that single-lead monitoring cannot 1

Specific Referral Language

State clearly in the referral:

• The type of arrhythmia suspected (if known from ECG)
• Whether wide or narrow complex tachycardia
• Presence or absence of pre-excitation
• Severity and frequency of symptoms
• Any hemodynamic instability during episodes
• Response to any attempted interventions (vagal maneuvers, medications)
• Urgency level based on the absolute indications listed above 1