Can an EKG be Ordered for Palpitations?
Yes, a 12-lead electrocardiogram (EKG/ECG) is mandatory and should be obtained immediately in all patients presenting with palpitations. 1, 2, 3
Why the 12-Lead ECG is Essential
The resting 12-lead ECG serves multiple critical diagnostic functions that directly guide management decisions:
- Identifies baseline rhythm abnormalities including pre-excitation patterns (Wolff-Parkinson-White syndrome), conduction defects, and signs of structural heart disease 2, 3
- Detects life-threatening patterns such as QT prolongation, Brugada pattern, signs of hypertrophic cardiomyopathy, prior infarction, or ventricular hypertrophy 3
- Determines if immediate specialist referral is needed: The presence of pre-excitation on resting ECG with a history of paroxysmal regular palpitations is sufficient for presumptive diagnosis of atrioventricular reentrant tachycardia (AVRT) and warrants immediate referral to cardiac electrophysiology without needing to document the arrhythmia first 1, 2
Critical Pitfall to Avoid
Do not rely on automatic ECG analysis systems - they are unreliable and commonly suggest incorrect arrhythmia diagnoses. 1, 2 Manual interpretation by a physician is required.
When the Initial ECG Shows Pre-Excitation
This finding changes everything:
- Regular palpitations + pre-excitation = presumptive AVRT → immediate electrophysiology referral 1, 2
- Irregular palpitations + pre-excitation = atrial fibrillation with accessory pathway → requires immediate electrophysiological evaluation due to risk of sudden death 1, 2
Beyond the Initial ECG
If the resting 12-lead ECG doesn't capture the arrhythmia, ambulatory monitoring is the next step:
- For frequent/daily palpitations: 24-48 hour Holter monitoring 1, 3
- For weekly episodes: External event recorder or wearable loop recorder for 2-4 weeks 3
- For infrequent episodes (monthly or less): Implantable loop recorder should be considered when no cause is identified after prolonged ECG monitoring 1, 3
The European Society of Cardiology specifically recommends 48-hour ambulatory ECG monitoring as first-line for patients with frequent or sustained palpitations to identify the likely cause. 1, 3
What to Look for on the ECG
Examine specifically for: