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Cited by 149Cardiac Arrhythmias and TreatmentsCardiac electrophysiology and arrhythmiasAtrial Fibrillation Management and Outcomes

Management of patients with palpitations: a position paper from the European Heart Rhythm Association

Open access
Raviele, Antonio, Giada, Franco, Bergfeldt, Lennart, Blanc, Jean Jacques, Blomstrom-Lundqvist, Carina, Mont, Lluis, Morgan, John M., Raatikainen, M.J. Pekka +9 more·2011·Europace
DOI 10.1093/europace/eur130
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Abstract

### Aim of the document Palpitations are among the most common symptoms that prompt patients to consult general practitioners, cardiologists, or emergency healthcare services.1–4 Very often, however, the diagnostic and therapeutic management of this symptom proves to be poorly efficacious and somewhat frustrating for both the patient and the physician. Indeed, in many cases a definitive, or at least probable, diagnosis of the cause of palpitations is not reached and no specific therapy is initiated.5,6 This means that many patients continue to suffer recurrences of their symptoms, which impair their quality of life and mental balance, lead to the potential risk of adverse clinical events, and induce continual recourse to healthcare facilities. These difficulties stem from the fact that palpitations are generally a transitory symptom. Indeed, at the moment of clinical evaluation, the patient is often asymptomatic and the diagnostic evaluation focuses on the search for pathological conditions that may be responsible for the symptom. This gives rise to some uncertainty in establishing a cause–effect relationship between any anomalies that may be detected and the palpitations themselves. Moreover, as palpitations may be caused by a wide range of different physiological and pathological conditions, clinicians tend to apply a number of instrumental investigations, laboratory tests, and specialist examinations, which are both time-consuming and costly. Comparable, for example, to syncope, such an approach is warranted in selected patients, whereas other patients with palpitations may not require such careful follow-up. The initial clinical assessment should, therefore, include an educated estimation of the likelihood of a relevant underlying arrhythmia in a patient with palpitations (‘gatekeeper' function). The current management of patients with palpitations is guided chiefly by the clinical experience of the physician. Indeed, the literature lacks specific policy documents or recommendations regarding the most appropriate diagnostic work-up to be adopted in individual …

Verified 2026-10-09 · 1 reference not checked yet

AI snapshot

Written from the paper’s full text.

TL;DR

This European Heart Rhythm Association position paper provides expert advice for diagnosing and managing palpitations, emphasizing initial history, physical examination, and 12-lead ECG, with targeted second-level monitoring when arrhythmic cause is suspected. It synthesizes available evidence and clinical experience, noting that many recommendations lack strong scientific documentation.

Key findings

  • Palpitations are very common: in primary care they account for 16% of symptoms prompting a general practitioner visit and are second only to chest pain as the presenting complaint for specialist cardiologic evaluation.
  • In a prospective study of 190 patients by Weber and Kapoor, palpitations were due to arrhythmias in 41% (16% atrial fibrillation/flutter, 10% supraventricular tachycardia, 2% ventricular tachycardia), structural heart disease in 3%, psychosomatic disorders in 31%, systemic causes in 4%, and medication/illicit substances/stimulants in 6%; no specific cause was identified in 16%, 1-year mortality was 1.6%, and 77% had at least one recurrence.
  • Recurrence affects quality of life: one-third reported impaired ability to attend to household chores, 19% reported diminished working capacity, and 12% had taken days off work.
  • Diagnostic yield varies by monitoring: Holter sensitivity was 33–35% in patients with palpitations of unknown origin and 22% in a meta-analysis of seven studies; external loop/event recorders showed 66–83% diagnostic value; the RUP study found implantable loop recorders superior to conventional strategy (73% vs. 21%) with better cost/effectiveness.

Methods

  • This is an EHRA position paper offering expert advice for diagnostic evaluation and management of palpitations, not a primary study or systematic review.
  • It narratively synthesizes literature and clinical experience, includes a diagnostic flow-chart and tables, and cites studies such as Weber and Kapoor (190 patients), Barsky et al. (145 patients), and the RUP study.
  • Main analysis is consensus-based narrative synthesis; no formal meta-analysis, systematic search, or evidence-grading method is described.

Limitations

  • The paper states that the literature lacks specific policy documents or recommendations for the diagnostic work-up of palpitations, that many suggestions are based on clinical experience without scientific documentation, and that data on long-term prognosis, age/gender distribution, and clinical features are scarce or from small samples.
  • It also notes limitations of ambulatory ECG monitoring: single-lead devices may not allow precise arrhythmia diagnosis, reflex bradyarrhythmias cannot always be distinguished from conduction-system disorders, and monitoring requires symptom recurrence.
  • Evident from the text: as a position paper, recommendations reflect expert consensus rather than a systematic, graded evidence review.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1093/europace/eur130

Cites

128 of 129 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 157 cited sources checked · 0 supported · 0 flagged

  • Premisecitation

    Palpitations are among the most common symptoms that prompt patients to consult general practitioners, cardiologists, or emergency healthcare services.

    “Palpitations are among the most common symptoms that prompt patients to consult general practitioners, cardiologists, or emergency healthcare services.1 -4”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [1] Mayou, 1998, Chest pain, palpitations and panic, J Psychosom Res source

      Not checked in the free run.

    • cites [2] Messineo, 1989, Ventricular ectopic activity: prevalence and risk, Am J Cardiol source

      Not checked in the free run.

    • cites [3] Kroenke, 1990, The prevalence of symptoms in medical outpatients and the adequacy of therapy, Arch Intern Med source

      Not checked in the free run.

    • cites [4] Knudson, 1987, The natural history of palpitations in a family practice, J Fam Pract

      Not checked in the free run.

  • Premisecitation

    The causes of palpitations can be subdivided into five main groups: cardiac arrhythmias, structural heart diseases, psychosomatic disorders, systemic diseases, and effects of medical and recreational drugs.

    “From the aetiological point of view, the causes of palpitations can be subdivided into five main groups (Table 1): cardiac arrhythmias, structural heart diseases, psychosomatic disorders, systemic diseases, and effects of medical and recreational drugs.3 -9”
    Quote in the paperSubstantial claim0 of 7 sources checked
    • cites [3] Kroenke, 1990, The prevalence of symptoms in medical outpatients and the adequacy of therapy, Arch Intern Med source

      Not checked in the free run.

    • cites [4] Knudson, 1987, The natural history of palpitations in a family practice, J Fam Pract

      Not checked in the free run.

    • cites [5] Zimetbaum, 1998, Evaluation of patients with palpitations, New Engl J Med source

      Not checked in the free run.

    • cites [6] Giada, 2004, Diagnostic management of patients with palpitations of unknown origin, Ital Heart J

      Not checked in the free run.

    • cites [7] Brugada, 1993, Investigation of palpitations, Lancet source

      Not checked in the free run.

    • cites [8] Pickett, 2005, Palpitations: a proper evaluation and approach to effective medical therapy, Curr Cardiol Rep source

      Not checked in the free run.

    • cites [9] Abbott, 2005, Diagnostic approach to palpitations, Am Fam Physician

      Not checked in the free run.

  • Interpretationcitation

    In patients with asymptomatic arrhythmias, relevant arrhythmias might not be adequately diagnosed and managed.

    “Thus, in such patients, relevant arrhythmias might not be adequately diagnosed and managed.15”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [15] Flaker, 2005, Asymptomatic atrial fibrillation: demographic features and prognostic information from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study, Am Heart J source

      Not checked in the free run.

  • Premisecitation

    Some structural heart diseases can give rise to palpitations in the absence of true rhythm disorders, including mitral valve prolapse, severe mitral and aortic regurgitation, congenital heart disease with significant shunt, hypertrophic cardiomyopathy, and mechanical prosthetic valves.

    “Some structural heart diseases can give rise to palpitations in the absence of true rhythm disorders.These include, among others, mitral valve prolapse, severe mitral and aortic regurgitation, congenital heart disease with significant shunt, hypertrophic cardiomyopathy, and mechanical prosthetic valves.18,19”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [18] Braunwald, 1992, Valvular heart disease

      Not checked in the free run.

    • cites [19] Deveraux, 1989, Mitral valve prolapse: causes, clinical manifestations, and management, Ann Int Med source

      Not checked in the free run.

  • Premisereasoning

    When it is not possible to document the cardiac rhythm during palpitations, non-arrhythmic causes are regarded as probable, but not definitive.

    “When it is not possible to document the cardiac rhythm during palpitations, non-arrhythmic causes are regarded as probable, but not definitive.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 21
  • The quote only partly states this claim. 1
  • May combine two claims. 41

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    Holter monitoring is low cost.

    “Low cost”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    Event recorders are low cost.

    “Low cost; easy to use”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Implantable loop recorders are invasive.

    “Invasiveness”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    Event recorders produce poor ECG records.

    “poor ECG records”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). The quote only partly states this claim.

    Findingnone given

    Pacemakers/ICDs have high costs.

    “high costs”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Pacemakers/ICDs are invasive.

    “Invasiveness”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Event recorders are easy to use.

    “Low cost; easy to use”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Uncertainty arises in establishing a cause-effect relationship between any anomalies detected and the palpitations themselves because palpitations are transitory and the patient is often asymptomatic at evaluation.

    “This gives rise to some uncertainty in establishing a cause -effect relationship between any anomalies that may be detected and the palpitations themselves.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Palpitations are generally a transitory symptom.
    • Rests on an assumption: At the moment of clinical evaluation, the patient is often asymptomatic.

  • May combine two claims.

    Premisecitation

    Although cardiac rhythm disorders generally give rise to palpitations, in some subjects arrhythmias including prognostically relevant disorders such as non-sustained ventricular tachycardias and atrial fibrillation may remain completely asymptomatic.

    “It is important to underline the fact that, although cardiac rhythm disorders generally give rise to palpitations (or other related symptoms, such as fatigue, dyspnoea, dizziness, syncope, and angina), in some subjects, for reasons not entirely known but probably linked to some clinical characteristics (long-standing arrhythmias with relatively low maximum ventricular rate, male sex, absence of”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [11] Sugishita, 2003, Diabetes influences the cardiac symptoms related to atrial fibrillation, Circ J source

      Not checked in the free run.

    • cites [13] Kirchhof, 2007, Outcome parameters for trials in atrial fibrillation, Europace source

      Not checked in the free run.

    • cites [14] Camm, 2010, Guidelines for the management of atrial fibrillation. The task force for the management of atrial fibrillation of the European Society of Cardiology, Eur Heart J

      Not checked in the free run.

    • cites [15] Flaker, 2005, Asymptomatic atrial fibrillation: demographic features and prognostic information from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study, Am Heart J source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In many cases, a definitive or at least probable diagnosis of the cause of palpitations is not reached and no specific therapy is initiated.

    “Indeed, in many cases a definitive, or at least probable, diagnosis of the cause of palpitations is not reached and no specific therapy is initiated.5,6”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [5] Zimetbaum, 1998, Evaluation of patients with palpitations, New Engl J Med source

      Not checked in the free run.

    • cites [6] Giada, 2004, Diagnostic management of patients with palpitations of unknown origin, Ital Heart J

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    Palpitations may be caused by a wide range of different physiological and pathological conditions.

    “Moreover, as palpitations may be caused by a wide range of different physiological and pathological conditions, clinicians tend to apply a number of instrumental investigations, laboratory tests, and specialist examinations, which are both time-consuming and costly.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Many patients with palpitations continue to suffer recurrences of symptoms, which impair quality of life and mental balance, lead to potential risk of adverse clinical events, and induce continual recourse to healthcare facilities.

    “This means that many patients continue to suffer recurrences of their symptoms, which impair their quality of life and mental balance, lead to the potential risk of adverse clinical events, and induce continual recourse to healthcare facilities.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisereasoning

    Electrocardiographic documentation of a rhythm disorder during spontaneous symptoms provides the strongest evidence of causality; whenever this proves possible, the palpitations are classified as being of arrhythmic origin.

    “Electrocardiographic documentation of a rhythm disorder during spontaneous symptoms provides the strongest evidence of causality; whenever this proves possible, therefore, the palpitations are classified as being of arrhythmic origin.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Electrocardiographic documentation of a rhythm disorder during spontaneous symptoms provides the strongest evidence of causality.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    It is not uncommon for a patient to have more than one potential cause or type of palpitation.

    “It is not uncommon, however, for the patient to have more than one potential cause or type of palpitation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Psychosomatic disorders most frequently associated with palpitations include anxiety, panic attacks, depression, and somatization, which can either induce sinus tachycardia or modify the patient's subjective perception of a heartbeat that is otherwise normal or presents minimal irregularities.

    “Psychosomatic disorders that are most frequently associated with palpitations include anxiety, panic attacks, depression, and somatization, which can either induce sinus tachycardia or modify the patient's subjective perception of a heartbeat that is otherwise normal or presents minimal irregularities.20 -23”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [20] Chignon, 1993, Panic disorder in cardiac outpatients, Am J Psychiatry source

      Not checked in the free run.

    • cites [21] Barsky, 1994, Psychiatric disorders in medical outpatients complaining of palpitations, J Gen Intern Med source

      Not checked in the free run.

    • cites [22] Barsky, 1994, Panic disorder, palpitations and awareness of cardiac activity, J Nerv Ment Dis source

      Not checked in the free run.

    • cites [23] Jeejeebhoy, 2000, Panic disorder and the heart: a cardiology perspective, J Psychosom Res source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisereasoning

    Palpitations are considered to be of non-arrhythmic origin when the underlying heart rhythm exhibits sinus rhythm or sinus tachycardia.

    “By contrast, they are considered to be of non-arrhythmic origin when the underlying heart rhythm exhibits sinus rhythm or sinus tachycardia.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Some studies suggest that anxiety exerts a facilitating effect on arrhythmogenesis as well as on the patient's perception of the arrhythmia.

    “Indeed, in the last few years, some studies investigating the correlation between anxiety syndrome and the appearance of arrhythmias have suggested that anxiety exerts a facilitating effect on arrhythmogenesis 28 as well as on the patient's perception of the arrhythmia.29”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [28] Tavazzi, 1986, The role of psychologic stress in the genesis of lethal arrhythmias in patients with coronary artery disease, Eur Heart J

      Not checked in the free run.

    • cites [29] Domschke, 2010, Coincidence of paroxysmal supraventricular tachycardia and panic disorders: two case reports, Ann Gen Psych source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    A sensation of palpitation may stem from sinus tachycardia and/or increased cardiac contractility, both of which may have various causes: fever, anaemia, orthostatic hypotension, hyperthyroidism/thyreotoxicosis, postmenopausal syndrome, pregnancy, hypoglycaemia, hypovolaemia, pheochromocytoma, arteriovenous fistula, postural orthostatic tachycardia syndrome, among others.

    “A sensation of palpitation may stem from sinus tachycardia and/or increased cardiac contractility, both of which may have various causes: fever, anaemia, orthostatic hypotension, hyperthyroidism/ thyreotoxicosis, postmenopausal syndrome, pregnancy, hypoglycaemia, hypovolaemia, pheochromocytoma, arteriovenous fistula, postural orthostatic tachycardia syndrome, among others.31 -39”
    Quote in the paperNot a substantial claim0 of 9 sources checked
    • cites [31] Cryer, 1985, Glucose counterregulation, hypoglycemia, and intensive insulin therapy in diabetes mellitus, N Engl J Med source

      Not checked in the free run.

    • cites [32] Klein, 1990, Thyroid hormone and the cardiovascular system, Am J Med source

      Not checked in the free run.

    • cites [33] Bravo, 1984, Pheocromocitoma: diagnosis, localization and management, N Engl J Med source

      Not checked in the free run.

    • cites [34] Rosenthal, 1992, Hematological–oncological disorders and heart disease

      Not checked in the free run.

    • cites [35] Elkayam, 1992, Pregnancy and cardiovascular disease

      Not checked in the free run.

    • cites [36] Dinardello, 1990, Fever

      Not checked in the free run.

    • cites [37] Holman, 1966, Abnormal arteriovenous communications. Great variability of effects with particular reference to delayed development of cardiac failure, Circulation source

      Not checked in the free run.

    • cites [38] Moya, 2009, Guidelines for the diagnosis and management of syncope. The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Developed in collaboration with European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), and Heart Rhythm Society (HRS), Eur Heart J source

      Not checked in the free run.

    • cites [39] Thomas, 1981, Orthostatic hypotension, Mayo Clin Proc source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In a study conducted on patients with documented supraventricular tachycardia, two-thirds had previously been wrongly diagnosed as suffering from panic attack disorder, and the diagnosed 'psychosomatic disease' could be cured by catheter ablation in most of these patients.

    “Finally, in a study conducted on patients with documented supraventricular tachycardia, it was found that two-thirds had previously been wrongly diagnosed as suffering from panic attack disorder, and that the diagnosed 'psychosomatic disease' could be cured by catheter ablation in most of these patients.30”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [30] Lessmeier, 1997, Unrecognized paroxysmal supraventricular tachycardia. Potential for misdiagnosis as panic disorder, Arch Intern Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    The prevalence of palpitations is dependent on definitions and diagnostic methods used and varies substantially in different populations.

    “The prevalence of palpitations is dependent on definitions and diagnostic methods used and varies substantially in different populations.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In studies in primary care settings, palpitations account for 16% of the symptoms that prompt patients to visit their general practitioner, and are second only to chest pain as the presenting complaint for specialist cardiologic evaluation.

    “In studies in primary care settings, palpitations account for 16% of the symptoms that prompt patients to visit their general practitioner, and are second only to chest pain as the presenting complaint for specialist cardiologic evaluation.1,3,4”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [1] Mayou, 1998, Chest pain, palpitations and panic, J Psychosom Res source

      Not checked in the free run.

    • cites [3] Kroenke, 1990, The prevalence of symptoms in medical outpatients and the adequacy of therapy, Arch Intern Med source

      Not checked in the free run.

    • cites [4] Knudson, 1987, The natural history of palpitations in a family practice, J Fam Pract

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In cases of drug-induced palpitations, palpitations may be linked to sinus tachycardia; drugs involved include sympathomimetics, anticholinergics, vasodilators, and hydralazine.

    “In such cases, palpitations may be linked to sinus tachycardia; drugs involved include sympathomimetics, anticholinergics, vasodilators, and hydralazine.40”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [40] Naranjo, 1981, A method for estimating the probabilty of adverse drug reaction, Clin Pharmacol Ther source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    There is evidence that palpitations are a very frequent symptom in the general population and, in particular, in patients suffering from hypertension or heart disease.

    “Nevertheless, there is evidence that palpitations are a very frequent symptom in the general population 2,9 and, in particular, in patients suffering from hypertension or heart disease.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [2] Messineo, 1989, Ventricular ectopic activity: prevalence and risk, Am J Cardiol source

      Not checked in the free run.

    • cites [9] Abbott, 2005, Diagnostic approach to palpitations, Am Fam Physician

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In a prospective study by Weber and Kapoor in 190 patients presenting with a complaint of palpitations at a university medical centre, palpitations were due to arrhythmias in 41% (16% atrial fibrillation/flutter, 10% supraventricular tachycardia, 2% ventricular tachycardia), to structural heart disease in 3%, to psychosomatic disorders in 31% (mainly panic and anxiety disorders), to systemic cases

    “In a prospective study by Weber and Kapoor 47 in 190 patients presenting with a complaint of palpitations at an university medical centre, palpitations were due to arrhythmias in 41% of these patients (16% of whom had atrial fibrillation/flutter, 10% had supraventricular tachycardia, and 2% had ventricular tachycardia), to structural heart disease in 3%, to psychosomatic disorders in 31% (mainly”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [47] Weber, 1996, Evaluations and outcomes of patients with palpitations, Am J Med source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    It is not always possible to establish a definite cause of palpitations; often, only a likely cause can be given, and, in some cases, several possible causes have to be taken into consideration.

    “Indeed, it is not always possible to establish a definite cause of palpitations; often, only a likely cause can be given, and, in some cases, several possible causes have to be taken into consideration.8,42”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [8] Pickett, 2005, Palpitations: a proper evaluation and approach to effective medical therapy, Curr Cardiol Rep source

      Not checked in the free run.

    • cites [42] Lange, 2001, Cardiovascular complications of cocaine use, N Engl J Med source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In general, older patients and men are more likely to have an arrhythmic cause of palpitations and younger patients and women a psychosomatic cause.

    “In general, however, older patients and men are more likely to have an arrhythmic cause of palpitations and younger patients and women a psychosomatic cause.47 -51”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [47] Weber, 1996, Evaluations and outcomes of patients with palpitations, Am J Med source

      Not checked in the free run.

    • cites [48] Thavendiranathan, 2009, Does this patient with palpitations have a cardiac arrhythmia?, JAMA source

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    • cites [49] Hoefman, 2007, Predictive value of history taking and physical examination in diagnosing arrhythmias in general practice, Fam Pract source

      Not checked in the free run.

    • cites [50] Summerton, 2001, New-onset palpitations in general practice: assessing the discriminant value of items within the clinical history, Fam Pract source

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    • cites [51] Mayou, 2003, Characteristics of patients presenting to a cardiac clinic with palpitations, Q J Med source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    In athletes, palpitations are not uncommon.

    “In athletes, palpitations are not uncommon.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Even in patients without severe heart disease, palpitations may be due to significant arrhythmias, such as atrial fibrillation, atrial flutter, or ventricular ectopic beats, all of which require adequate investigation and treatment.

    “However, even in patients without severe heart disease, palpitations may be due to significant arrhythmias, such as atrial fibrillation, atrial flutter, or ventricular ectopic beats, all of which require adequate investigation and treatment.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In the study by Weber and Kapoor, 77% of patients experienced at least one recurrence of palpitations, and the effect on their quality of life was unfavourable: one-third reported impairment of ability to attend to household chores, 19% claimed working capacity diminished, and 12% said they had taken days off work.

    “In the study by Weber and Kapoor, 47 77% of patients experienced at least one recurrence of palpitations, and the effect on their quality of life was unfavourable: one-third of patients reported an impairment of their ability to attend to household chores, 19% claimed that their working capacity had diminished, and 12% said that they had taken days off work.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [47] Weber, 1996, Evaluations and outcomes of patients with palpitations, Am J Med source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Sudden death, in particular in younger athletes, is rare and mostly associated with underlying structural heart disease or primary arrhythmic disorders, and palpitations may be the initial clinical symptom or an incidental finding possibly leading to the recognition of a previously undiagnosed relevant heart disease.

    “Sudden death, in particular in younger athletes, is rare and mostly associated with underlying structural heart disease or primary arrhythmic disorders, and palpitations may be the initial clinical symptom or an incidental finding possibly leading to the recognition of a previously undiagnosed relevant heart disease.55,56”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [55] Pelliccia, 2005, Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology, Eur Heart J source

      Not checked in the free run.

    • cites [56] Delise, 2005, Cardiological guidelines for competitive sports eligibility, Ital Heart J

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Although palpitations display a low mortality rate, the recurrence of symptoms is very frequent.

    “Although palpitations display a low mortality rate, the recurrence of symptoms is, however, very frequent.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Patients are not always able to describe the characteristics of their symptoms precisely; it may therefore be difficult to identify the type of palpitation accurately, especially in the case of normal-rate palpitations.

    “It should, however, be stressed that patients are not always able to describe the characteristics of their symptoms precisely.It may therefore be difficult to identify the type of palpitation accurately, especially in the case of normalrate palpitations.5,9,61”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [5] Zimetbaum, 1998, Evaluation of patients with palpitations, New Engl J Med source

      Not checked in the free run.

    • cites [9] Abbott, 2005, Diagnostic approach to palpitations, Am Fam Physician

      Not checked in the free run.

    • cites [61] Leitch, 1991, Can patients discriminate between atrial fibrillation and regular supraventricular tachycardia?, Am J Cardiol source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In many respects, palpitations seem to behave like a chronic disorder that has a favourable prognosis, but with periodic attacks followed by transitory remission.

    “In many respects, palpitations seem to behave like a chronic disorder that has a favourable prognosis, but with periodic attacks followed by transitory remission.3,4”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [3] Kroenke, 1990, The prevalence of symptoms in medical outpatients and the adequacy of therapy, Arch Intern Med source

      Not checked in the free run.

    • cites [4] Knudson, 1987, The natural history of palpitations in a family practice, J Fam Pract

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Frequent and recurrent palpitations can impair the patient's quality of life, giving rise to anxiety and frequent visits to the emergency department.

    “Frequent and recurrent palpitations, therefore, can impair the patient's quality of life, giving rise to anxiety and frequent visits to the emergency department.3”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] Kroenke, 1990, The prevalence of symptoms in medical outpatients and the adequacy of therapy, Arch Intern Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Pulsation palpitations tend to be persistent and are generally linked to structural heart diseases, such as aortic regurgitation, or to systemic causes involving a high stroke volume, such as fever and anaemia.

    “They tend to be persistent and are generally linked to structural heart diseases, such as aortic regurgitation, or to systemic causes involving a high stroke volume, such as fever and anaemia.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Tachycardiac palpitations are generally linked to supraventricular or ventricular tachyarrhythmias, which begin and usually end suddenly, or to sinus tachycardia due to systemic causes or to the use of drugs or illicit substances (in these cases, palpitations begin and end gradually).

    “These palpitations are generally linked to supraventricular or ventricular tachyarrhythmias, which begin and usually end suddenly (sometimes the termination is gradual due to the increase in sympathetic tone during tachycardia that tends to persist and declines slowly after its interruption), or to sinus tachycardia due to systemic causes or to the use of drugs or illicit substances (in these”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Episodes of paroxysmal atrial fibrillation may occur in the phase immediately following the cessation of physical effort, during which a sudden reduction in sympathetic tone is accompanied by an increase in vagal tone.

    “Finally, episodes of paroxysmal atrial fibrillation may occur in the phase immediately following the cessation of physical effort, during which a sudden reduction in sympathetic tone is accompanied by an increase in vagal tone.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Palpitations that arise in situations of anxiety or during panic attacks are generally due to episodes of more or less rapid sinus tachycardia secondary to the mental disturbance.

    “Palpitations that arise in situations of anxiety or during panic attacks are generally due to episodes of more or less rapid sinus tachycardia secondary to the mental disturbance.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisereasoning

    During physical exercise, due to an increase in the sympathetic drive, patients may experience, in addition to the normal sensation of a rapid heart rate elicited by intense effort, palpitations due to various types of arrhythmia, such as right ventricular outflow tract tachycardia, atrioventricular node reentrant tachycardia, and polymorphic catecholaminergic ventricular tachycardia.

    “During physical exercise, due to an increase in the sympathetic drive, patients may experience, in addition to the normal sensation of a rapid heart rate elicited by intense effort, palpitations due to various types of arrhythmia, such as right ventricular outflow tract tachycardia, atrioventricular node reentrant tachycardia, and polymorphic catecholaminergic ventricular tachycardia.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Polyuria, which is due to the hypersecretion of natriuretic hormone, is typical of atrial tachyarrhythmias, particularly atrial fibrillation.

    “Polyuria, which is due to the hypersecretion of natriuretic hormone, is typical of atrial tachyarrhythmias, particularly atrial fibrillation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Palpitations arising after sudden changes in posture are frequently due to intolerance to orthostatis or to episodes of atrioventricular nodal reentrant tachycardia.

    “Palpitations arising after sudden changes in posture are frequently due to intolerance to orthostatis or to episodes of atrioventricular nodal reentrant tachycardia.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Extrasystolic palpitations are frequently encountered even in young subjects, often in the absence of heart disease, and generally have a benign prognosis.

    “Linked to the presence of atrial or ventricular extrasystolic beats, this type of palpitation is frequently encountered even in young subjects, often in the absence of heart disease, and generally has a benign prognosis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Anxiety-related palpitations are due to psychosomatic disorders and usually require exclusion of an arrhythmic cause of the symptoms.

    “Anxiety-related palpitations are due to psychosomatic disorders and usually require exclusion of an arrhythmic cause of the symptoms.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The initial clinical evaluation leads to a definitive or probable diagnosis of the cause of the palpitations in about half of patients, and excludes with reasonable certainty the presence of causes that have an unfavourable prognosis.

    “The initial clinical evaluation leads to a definitive or probable diagnosis of the cause of the palpitations in about half of patients, and excludes with reasonable certainty the presence of causes that have an unfavourable prognosis.47”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [47] Weber, 1996, Evaluations and outcomes of patients with palpitations, Am J Med source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisenone given

    A thorough initial clinical evaluation will indicate which specific investigations, if any, are necessary.

    “Moreover, a thorough initial clinical evaluation will indicate which specific investigations, if any, are necessary.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The likelihood ratio of each feature for diagnosing an arrhythmic cause of palpitations is, in general, low and only a few features are really predictive. They include history of cardiac disease, palpitations affected by sleeping, or while the patient is at work.

    “The likelihood ratio of each feature is, in general, low and only a few features are really predictive.They include history of cardiac disease, palpitations affected by sleeping, or while the patient is at work.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [48] Thavendiranathan, 2009, Does this patient with palpitations have a cardiac arrhythmia?, JAMA source

      Not checked in the free run.

  • May combine two claims.

    Premisenone given

    Many of the latest diagnostic systems allow automatic detection of arrhythmias and immediate wireless transmission of ECG data to a central monitoring station.

    “Another major benefit of the latest diagnostic systems is that many of them not only allow automatic detection of the arrhythmias but also allow immediate wireless transmission of pertinent ECG data to a central monitoring station via a mobile telephone line or the Internet.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    ILRs have been successfully used to study syncope and have a better cost/effectiveness ratio than conventional tests.

    “ILRs have been successfully used to study syncope, in which they have shown a better cost/effectiveness ratio than the conventional tests, 86,87”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [86] Krahn, 1999, The high cost of syncope: cost implications of a new insertable loop recorder in the investigation of recurrent syncope, Am Heart J source

      Not checked in the free run.

    • cites [87] Krahn, 2001, Randomized assessment of syncope trial: conventional diagnostic testing versus a prolonged monitoring strategy, Circulation source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In patients with daily or weekly symptoms, external loop recorders and event recorders have higher diagnostic value (66-83%) and better cost/effectiveness than Holter devices.

    “By contrast, in patients in whom the symptoms are quite frequent (i.e.daily or weekly), external loop recorders and event recorders have shown both a higher diagnostic value (66 -83%) and a better cost/effectiveness ratio than Holter devices.71,83”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [71] Scherr, 2008, Prospective comparison of the diagnostic utility of a standard event monitor versus a ‘leadless’ portable ECG monitor in the evaluation of patients with palpitations, J Interv Card Electrophysiol source

      Not checked in the free run.

    • cites [83] Zimetbaum, 1998, Diagnostic yield and optimal duration of continuous-loop event monitoring for the diagnosis of palpitations, Ann Intern Med source

      Not checked in the free run.

  • May combine two claims.

    Interpretationnone given

    Ambulatory ECG monitoring requires the patient to experience a recurrence of symptoms, which delays diagnosis and may expose patients with malignant arrhythmias to adverse events.

    “Finally, ambulatory ECG monitoring requires the patient to experience a recurrence of symptoms.This delays the diagnosis and, should the palpitations be due to malignant arrhythmias, exposes the patient to the potential risk of adverse events.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Once atrial fibrillation has been diagnosed as a cause of palpitations, there is limited data on the importance of assessing atrial fibrillation burden for evaluating thromboembolic risk, and more information is needed.

    “However, it must be underlined that once atrial fibrillation has been diagnosed as a cause of palpitations, there is up to now only limited data on the importance of assessing atrial fibrillation burden for the evaluation of thromboembolic risk, and more information is still needed.67,91”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [67] Botto, 2009, Presence and duration of atrial fibrillation detected by continuous monitoring: crucial implications for the risk of thromboembolic events, J Cardiovasc Electrophysiol source

      Not checked in the free run.

    • cites [91] Glotzer, 2009, The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk. The TRENDS Study, Circ Arrhythm Electrophysiol source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    EPS enables diagnosis and specific therapy to be initiated immediately, whereas ambulatory ECG monitoring requires symptom recurrence.

    “Finally, while EPS enables a diagnosis to be made and specific therapy to be initiated immediately, ambulatory ECG monitoring requires the patient to experience a recurrence of symptoms.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisereasoning

    12-lead ECG during palpitations allows analysis of P and QRS morphologies, their relationship, and heart rhythm frequency and regularity, and provides an accurate diagnosis of concordance between palpitations and presence or absence of arrhythmia.

    “It allows the physician to analyse P and QRS morphologies and the relationship between these two waves, and the frequency and regularity of the heart rhythm, and finally brings an accurate diagnosis on the concordance between palpitations and the presence or absence of arrhythmia.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    In some instances, such as evident pre-excitation with reported rapid regular palpitations, the diagnosis is formal even if tachycardia has never been recorded.

    “In some instances, for example in case of evident pre-excitation when the patient reports rapid regular palpitations, the diagnosis is formal even if tachycardia has never been recorded.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisereasoning

    Precise analysis of ECG during arrhythmia either provides the mechanism or gives important data leading to the diagnosis.

    “Furthermore, precise analysis of ECG during arrhythmia either provides the mechanism or gives important data that lead to this diagnosis.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    Circumstances during which palpitations occur are generally helpful to evaluate their cause.

    “Circumstances during which palpitations have occurred are generally helpful to evaluate their cause.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    P waves during rapid tachycardia are not always visible, making diagnosis difficult.

    “It should be stressed, however, that P waves during rapid tachycardia are not always visible, making the diagnosis difficult.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Vagal manoeuvres such as carotid sinus massage can guide the differential diagnosis of tachycardias: sudden interruption suggests AV junctional tachycardia, while temporary reduction suggests atrial fibrillation, flutter, or atrial tachycardia.

    “The differential diagnosis of various types of tachycardia may be guided by vagal manoeuvres 68 such as carotid sinus massage: sudden interruption of the tachycardia is highly suggestive of a tachycardia involving the atrioventricular junction whereas a temporary reduction of the frequency is suggestive of atrial fibrillation, flutter, or atrial tachycardia (Table 3).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [68] Brembilla-Perrot, 2010, Pharmacological testing in the diagnosis of arrhythmias, Minerva Cardioangiol

      Not checked in the free run.

58 of 58

  • The paper relies on this without support.

    Palpitations are generally a transitory symptom.

    “These difficulties stem from the fact that palpitations are generally a transitory symptom.”

  • The paper relies on this without support.

    At the moment of clinical evaluation, the patient is often asymptomatic.

    “Indeed, at the moment of clinical evaluation, the patient is often asymptomatic and the diagnostic evaluation focuses on the search for pathological conditions that may be responsible for the symptom.”

  • The paper relies on this without support.

    The current management of patients with palpitations is guided chiefly by the clinical experience of the physician.

    “The current management of patients with palpitations is guided chiefly by the clinical experience of the physician.”

  • The paper relies on this without support.

    The literature lacks specific policy documents or recommendations regarding the most appropriate diagnostic work-up to be adopted in individual patients.

    “Indeed, the literature lacks specific policy documents or recommendations regarding the most appropriate diagnostic work-up to be adopted in individual patients.”

  • The paper relies on this without support.

    Electrocardiographic documentation of a rhythm disorder during spontaneous symptoms provides the strongest evidence of causality.

    “Electrocardiographic documentation of a rhythm disorder during spontaneous symptoms provides the strongest evidence of causality; whenever this proves possible, therefore, the palpitations are classified as being of arrhythmic origin.”

  • The paper relies on this without support.

    In patients with palpitations of unknown origin, gradual onset, absence of significant heart disease, and anxiety-related or extrasystolic palpitations indicate a low probability of an arrhythmic cause.

    “In subjects with palpitations of unknown origin who have a low probability of an arrhythmic cause (i.e.patients with gradual onset of palpitations and without significant heart disease and those with anxiety-related or extrasystolic palpitations), further investigations are often not required.”

  • The paper relies on this without support.

    The patient's description of symptoms can reliably establish that they match palpitations and are not confused with other chest manifestations.

    “The first step is to establish that symptoms described by the patient match to palpitations and are not confused with chest pain or other manifestations arising in the chest, but that do not correspond to the definition of palpitations described in this article.”

  • The paper relies on this without support.

    12-lead ECG recorded during palpitations is the diagnostic gold standard.

    “If the patient is examined during palpitations, 12-lead ECG represents the diagnostic gold standard.”

  • The paper relies on this without support.

    The specificity of ambulatory ECG monitoring for diagnosing arrhythmic versus nonarrhythmic palpitations is optimal.

    “The specificity of ambulatory ECG monitoring, at least in formulating a diagnosis of arrhythmic palpitations or nonarrhythmic palpitations, is optimal”

  • The paper relies on this without support.

    Ventricular tachycardia is much less common and is typical of patients with structural or arrhythmogenic heart diseases.

    “Ventricular tachycardia is much less common and is typical of patients with structural or arrhythmogenic heart diseases.”
10 of 10

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Sinus tachycardia classified as both arrhythmic and non-arrhythmic

    Minor

    The paper says palpitations accompanied by sinus tachycardia are considered non-arrhythmic, but later lists sinus tachycardia among the tachyarrhythmias that cause palpitations.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 7

  1. Malliani, 1986, Sensory innervation of the heart, 39
  2. Braunwald, 1992, Valvular heart disease, 1007
  3. Rosenthal, 1992, Hematological–oncological disorders and heart disease, 1742
  4. Dinardello, 1990, Fever, 464
  5. Zipes, 1995, Assessment of patients with cardiac arrhythmia, 1009
  6. Waktare, 2001, Holter and event recordings for arrhythmia detection, 3
  7. Kirchhof, 2009, Giant T-U waves precede torsades de pointes in long QT syndrome, J Am Coll Cardiol, 54, 143, 10.1016/j.jacc.2009.03.043 · DOI · Paper page

Cited by

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Related

Authors
Raviele, A., Giada, F., Bergfeldt, L., Blanc, J. J., Blomstrom-Lundqvist, C., Mont, L., Morgan, J. M., Raatikainen, M. J. P., Steinbeck, G., Viskin, S., reviewers, D., Kirchhof, P., Braunschweig, F., Borggrefe, M., Hocini, M., Bella, P. D., & Shah, D. C.
Affiliations
  • Ospedale dell' Angelo (IT)
  • PF Calvi Hospital 2 Cardiovascular Department , , Noale-Venice ,
  • Sahlgrenska University Hospital (SE)
  • Bretagne University 4 Cardiology Department , , Brest ,
  • Uppsala University Hospital 5 Cardiology Department , , Uppsala ,
  • Hospital Clinic 6 Cardiology Department , , , Barcelona ,
  • University Hospital Southampton NHS Foundation Trust (GB)
  • Tampere University Hospital (FI)
  • Ludwig-Maximilians-Universität München (DE)
  • Tel Aviv University (IL)
  • University Hospital Münster (DE)
  • Karolinska University Hospital (SE)
  • Hôpital Cardiologique du Haut-Lévêque (FR)
  • Pessac 14 Hopital du Haut Leveque , ,
  • Ospedale San Raffaele 15 , Milan ,
  • 16 Cantonal Hospital, Geneva, Switzerland
ORCID
Venue
Europace
Publisher
Oxford University Press (OUP)
Published
2011-01-01
Volume
13
Issue
7
Pages
920-934
ISSN
  • 1099-5129 (ISSN-L)
  • 1532-2092
DOI
10.1093/europace/eur130
OpenAlex
W1989735748
Semantic Scholar
25b0a796effed62d415c4ba59d5f0a2363603639
Cited by
149
References
127
Citations by year
2026: 11 · 2025: 13 · 2024: 9 · 2023: 10 · 2022: 10 · 2021: 19 · 2020: 12 · 2019: 8 · 2018: 11 · 2017: 11 · 2016: 8 · 2015: 9 · 2014: 9 · 2013: 3 · 2012: 6
FWCI
3.96
Type
journal article
Language
en
Open access
Locations
  • EP Europace (publishedVersion)
  • PubMed (publishedVersion)
  • University of Birmingham Research Portal (University of Birmingham) (submittedVersion)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
Keywords
palpitations, arrhythmia diagnosis, diagnostic workup, clinical evaluation, gatekeeper function, symptom management, quality of life, health care utilization, syncope
MeSH terms
Arrhythmias, Cardiac, Electrocardiography, Europe, Heart Diseases, Heart Rate, Humans, Prognosis, Psychophysiologic Disorders, Substance-Related Disorders

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

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