Epidemiology and Age–sex Patterns

While palpitations frequently cause concern among caregivers, the complaint is among the least frequent ones in paediatric emergency departments. In fact, in a study that looked back at data from more than 140,000 paediatric emergency visits, only 0.07% of the patients complained of palpitations, and just 13.5% of these patients had arrhythmic aetiologies verified that necessitated intervention. ^{Reference Bobbo, Amoroso and Tamaro6} Supraventricular tachycardia is the most common type of arrhythmia in children, and it is found in 0.1% to 0.4% of individuals who are otherwise healthy. ^{Reference Balsam, Lodziński and Tymińska7} The incidence of supraventricular tachycardia increases steadily from the time of birth to adolescence when it reaches approximately 1.3 cases per 1,000 patients per year at the age of 15. ^{Reference Balsam, Lodziński and Tymińska7} The age distribution is commonly bimodal with peaks between 6 and 9 years and again in adolescence. This is explained by the changes in autonomic tone, the development of the cardiac conduction system, and the fact that older children become more aware of palpitations and can verbalise symptoms to caregivers. ^{Reference Balsam, Lodziński and Tymińska7}

Paediatric arrhythmias vary greatly between the sexes at different ages. For instance, males tend to have more first episode supraventricular tachycardia due to an accessory pathway, Brugada syndrome, and arrhythmogenic right ventricular cardiomyopathy, whereas females experience atrioventricular nodal reentrant tachycardia and arrhythmias related to a long QT interval more often. ^{Reference Clausen, Theophilos, Jackno and Babl8} It is very important to understand these patterns when selecting the diagnostic tests and determining the risk. Repeated palpitations have a major impact on the choices of long-term care and treatment. It is estimated that about 35% of children with atrioventricular nodal reentrant tachycardia who are treated with supraventricular tachycardia ablation will experience recurrent palpitations. ^{Reference Çınar, Kafalı, Şahin and Ergül9} Previous arrhythmia attacks, younger age at first presentation, and the intensity of the first tachycardia are the factors associated with the recurrence. ^{Reference Bobbo, Amoroso and Tamaro6,Reference Çınar, Kafalı, Şahin and Ergül9} It was pointed out that continuous monitoring by wearable electrocardiogram devices or external event recorders allows the correlation of symptoms with arrhythmias, thus leading to targeted follow-up care and reducing unnecessary hospitalisations. ^{Reference Çınar, Kafalı, Şahin and Ergül9}

Physiologic and benign causes

The most frequent benign cause of palpitations in children is sinus tachycardia. Fever, dehydration, pain, anxiety, or strenuous activity are the usual triggers. ^{Reference Crosson and Hanash10} True emergencies are uncommon; most cases are well-tolerated. Palpitations are also caused by paroxysmal atrial contractions and premature ventricular contractions, which, while frequently frightening, usually have positive results and spontaneously resolve in follow-up. ^{Reference Mohsin, Sangi and Sheikh11} Transient factors such as emotional stress, caffeine consumption, or acute illness can aggravate these benign arrhythmias. In order to avoid needless investigations and parental anxiety, it is critical to identify physiological triggers. Ectopic beats that originate outside of the typical conduction pathway are represented by premature atrial contractions and premature ventricular contractions. They can be found in perfectly healthy children or be the consequence of easily treatable conditions such as an electrolyte imbalance or drug side effects. Usually, premature ventricular contractions and premature atrial contractions are without symptoms; however, in some cases, they may cause palpitations or a brief sensation of lightheadedness. When there is no structural heart disease, the outlook is excellent and spontaneously occurring cases in children are many. ^{Reference Mohsin, Sangi and Sheikh11}

Supraventricular arrhythmias

Among the most common pathologic arrhythmias in paediatric emergency settings are supraventricular arrhythmias, such as atrioventricular reentrant tachycardia (from concealed accessory pathway or manifest ventricular preexcitation/Wolff–Parkinson–White syndrome) and atrial tachycardia. Between 1 in 1,000 and 1 in 250 children are thought to be affected. ^{Reference Balsam, Lodziński and Tymińska7,Reference Taylor, Thomas and Lawrence12} Because of its quick conduction through accessory pathways, atrioventricular reentrant tachycardia can be more dangerous than other supraventricular tachycardias because it can cause syncope or, in rare cases, ventricular fibrillation. ^{Reference Taylor, Thomas and Lawrence12} Acute stabilisation, medication therapy, and increasingly catheter ablation are all part of the management. Due to its high success rates and low risk of complications, catheter ablation has become a reasonable option for children who are deemed appropriate for the procedure. ^{Reference Hafez, Abu-Elkheir and Shokier13,Reference Smith and Clark14} Early detection of ablation-suitable patients can lower long-term morbidity and enhance quality of life.

Ventricular arrhythmias

Children with or without underlying structural heart disease may experience ventricular arrhythmias, such as idiopathic ventricular tachycardia. Prevalence may reach 17% in certain cohorts, such as those with left ventricular noncompaction. ^{Reference Brescia, Rossano and Pignatelli15} Idiopathic ventricular tachycardia in otherwise healthy children usually has a benign course and responds well to medical or interventional therapy. However, children with documented ventricular tachycardia require additional diagnostic evaluation and risk stratification by a paediatric cardiologist, as ventricular tachycardia is much more likely to be life-threatening in the setting of structural heart disease or a channelopathy, and may require close monitoring after first presentation. ^{Reference Mohsin, Sangi and Sheikh11} Since children with underlying cardiomyopathy may have higher morbidity and need close monitoring, the identification of structural abnormalities through echocardiography or MRI is essential to stratify risk and direct treatment. ^{Reference Brescia, Rossano and Pignatelli15}

Channelopathies

Abrupt syncope/loss of consciousness or an aborted sudden cardiac death event can be the first manifestation of a cardiac channelopathy such as Brugada syndrome, long QT syndrome, and catecholaminergic polymorphic ventricular tachycardia. Consequently, a typical presentation of long QT syndrome is the occurrence of torsades de pointes, syncope, or sudden cardiac death. In children with the family history of sudden cardiac death or unexplained syncope, it is vital that early detection is done by means of electrocardiogram screening and genetic testing. ^{Reference Clausen, Theophilos, Jackno and Babl8} The management of patients includes the use of medications, lifestyle modifications and when indicated implantation of a cardioverter-defibrillator.

Structural and inflammatory causes

Structural and inflammatory issues of the heart, such as myocarditis and different types of cardiomyopathies, may manifest as palpitation symptoms or documented rhythm abnormalities. Myocarditis, which is commonly caused by viral infections, can abruptly lead to rhythm changes and may at times necessitate hospital admission for close monitoring and supportive therapy. ^{Reference Brescia, Rossano and Pignatelli15} Certain cardiomyopathies, e.g., dilated, hypertrophic, and left ventricular noncompaction, can severely affect a child’s health and typically require the collaborative management of multiple healthcare professionals. ^{Reference Brescia, Rossano and Pignatelli15} Children with CHDs, those who have recently undergone cardiac surgery, and those with genetic syndromes or a family history of early sudden cardiac death are at increased risk of serious complications. Early identification, thorough evaluation, and close monitoring are the key steps in reducing this risk.

Red-flag features (“never-miss” list)

Syncope is a transient loss of consciousness and postural tone with spontaneous recovery. It is a common paediatric presentation and most cases are benign. A small proportion are due to life threatening conditions. ^{Reference Stewart, van Dijk, Balaji and Sutton16} Cardiac syncope is associated with high morbidity and substantial mortality. Any syncope due to a confirmed cardiac cause is classified as severe. Arrhythmias are the most common cardiac cause of syncope. ^{Reference Brignole, Moya and de Lange17} Arrhythmic syncope in children is more likely to occur in genetic conditions associated with cardiac disease. Certain triggers may suggest a specific inherited disease; startle such as by loud sound or cold water on the face (long QT syndrome), sudden onset syncope in fever (Brugada syndrome), and syncope during exercise (or similar catecholamine states; catecholaminergic polymorphic VT or arrhythmogenic right ventricular cardiomyopathy). Also, very rapid ventricular tachycardia, as seen in many channelopathies, may lead to syncope when sustained for more than 3–5 s.

Exertional palpitations: Sudden cardiac death remains a leading cause of death in young athletes. Exercise-related sudden cardiac death is commonly caused by hereditary conditions: channelopathies and cardiomyopathies. In particular, long QT syndrome, catecholaminergic polymorphic ventricular tachycardia, hypertrophic cardiomyopathy, and arrhythmogenic cardiomyopathy have an increased risk of triggered ventricular arrhythmias with exertion/catecholamines. ^{Reference Katyal, Li, Franciosi and Sanatani18}

Structural heart disease: A retrospective review of 5,307 paediatric exercise stress tests performed between 2013 and 2015 showed that, although self-terminating arrhythmias were common (46%), clinically significant arrhythmias were rare (0.6%) in a high-volume paediatric cardiology criterion. The absence of any high-risk criterion was associated with a negative predictive value of 99.7% (95% CI: 99.5–99.8%) for arrhythmias requiring test termination and 99.96% (95% CI: 99.85–99.99%) for arrhythmias requiring intervention beyond test termination. ^{Reference Barry, Gauvreau and Rhodes19}

Family history of sudden death: In a study of 419 paediatric relatives of 256 decedents, 27% of children were diagnosed with a cardiac disease or had findings of uncertain significance. An inherited cardiac disease was identified in 39 patients (9.3%), while non-heritable cardiac disease was diagnosed with an additional 5.5%. Findings of uncertain significance were present in 52 patients (12.4%), including abnormal electrophysiological findings (41 of 52) or imaging abnormalities (11 of 52). Among patients diagnosed with inherited cardiac disease, the nearest affected relative was almost always a first-degree relative (95%). The strongest predictors of a diagnosis were an abnormal electrocardiogram and a first-degree relationship to the nearest affected relative, with odds ratios of 24.2 and 18.8, respectively. ^{Reference Webster, Olson and Schoppen20}

Abnormal electrocardiogram: Electrocardiogram findings associated with arrhythmic risk include narrow or wide QRS complex tachycardia. In most cases, supraventricular tachycardia produces a narrow QRS complex; however, a wide QRS tachycardia can be the result of a baseline bundle branch block or can be transient due to rate-related aberrant conduction in supraventricular tachycardia. In atrioventricular reentrant tachycardia, P waves may not be visible when they overlap with the QRS complex. In atrioventricular reentrant tachycardia, ventricular preexcitation—manifesting as a delta wave, short PR interval, and wide QRS complex (Wolff–Parkinson–White syndrome pattern)—is typically appreciated in sinus rhythm, not during tachycardia. Importantly, a patient can have atrioventricular reentrant tachycardia from an accessory pathway that conducts only in the retrograde direction (concealed pathway) and thus may not exhibit ventricular preexcitation on a resting electrocardiogram.

Risk tiers and clinical meaning

In a review focused on studies between 2019 and 2024, included patients aged 2–18 years with different types of arrhythmias, a symptom-based guide designed to help non-specialist physicians in the management of paediatric arrhythmias (Table 1). ^{Reference Cepeda-Nieto, Roblero-Aguilar, Martínez-López and Balderrábano-Saucedo21}

Table 1.

Risk stratification tool. The table summarises risk stratification of palpitations in paediatric patients, along with the proper disposition for each category ^{Reference Cepeda-Nieto, Roblero-Aguilar, Martínez-López and Balderrábano-Saucedo21}

Table 1. Long description

A table categorizing arrhythmias in pediatric patients by risk level and recommended management strategies. The table has three rows and three columns. The columns are labeled ‘Tier classification’, ‘Clinical description’, and ‘Recommended disposition’. The rows are labeled ‘High risk’, ‘Intermediate risk’, and ‘Low risk’. Row 1: High risk, Arrhythmia associated with any of the followings: Syncope, Family history of sudden cardiac death, Exertional palpitation, Abnormal electrocardiogram, Structural heart diseases, Timely referral to a senior clinician is important. Since this group at serious risk of devastating complications, including sudden cardiac death. Row 2: Intermediate risk, Episodes of paroxysmal arrhythmia, supraventricular tachycardia is the most common arrhythmia in children, mainly as a result of re-entry mechanisms, Initial management consists of non-pharmacological treatment, and adenosine as the first-line pharmacological intervention. If haemodynamically unstable, electrical cardioversion is required. Subtypes of supraventricular tachycardia may require catheter ablation or antiarrhythmic therapy. Row 3: Low risk, Asymptomatic arrhythmia (Most common are sinus arrhythmia, sinus bradycardia, wandering pacemaker, and infrequent premature atrial and ventricular contractions), No treatment is required. However, there are special considerations for each. Also, certain conditions require watchful monitoring, such as pre-excitation syndromes and long QT syndrome (LQTS), due to the risk of serious complications.

The first group is asymptomatic arrhythmias, which can be considered a low-risk group. The most common asymptomatic arrhythmias are sinus arrhythmia, sinus bradycardia, wandering pacemaker, and infrequent premature atrial and ventricular contractions. Many asymptomatic cases are benign and require no treatment; however, there are special considerations for each. Also, certain conditions, such as pre-excitation syndromes and long QT syndrome, require watchful monitoring due to the risk of serious complications.

The second group is patients with episodes of paroxysmal tachycardia, which can be considered as an intermediate-risk. Supraventricular tachycardia is commonly encountered in children. Initial management consists of non-pharmacological, and adenosine as the first-line pharmacological intervention. If haemodynamically unstable, electrical cardioversion is required. Subtypes of supraventricular tachycardia may require catheter ablation or antiarrhythmic therapy. Timely referral involves identifying patients at high risk of serious complications, including sudden cardiac death, while managing benign arrhythmias conservatively. ^{Reference Cepeda-Nieto, Roblero-Aguilar, Martínez-López and Balderrábano-Saucedo21}

The high-risk group includes any arrhythmia associated with red-flag features such as syncope, exertional symptoms, a family history of sudden cardiac death, known structural heart disease, or a significantly abnormal electrocardiogram. These patients are at serious risk of devastating complications and require immediate, thorough evaluation.

Common pitfalls in risk assessment

Diagnosing arrhythmias in children can be challenging. Precise histories can be difficult to elicit from many patients, particularly children in addition the physical examination can be normal during the initial assessment. Also, normal rhythm variants may be seen in healthy paediatric patients, including sinus arrhythmia, wandering atrial pacemaker, ectopic atrial rhythm, and intermittent nodal rhythm. ^{Reference Goto, Witkowska, Slusarczyk, Grotek, Dziubinski and Clark22} A study included 1,884 healthy newborns, infants, children, and adolescents showed that the values of 15 key electrocardiogram parameters change characteristically during growth and development. The study also demonstrated that sex impacts electrocardiogram parameters, accordingly, participants aged 6–9 years, 9–13 years, and 13–18 years were divided into male and female groups. Additionally, some electrocardiogram parameters may change with race, ethnicity, and socioeconomic and nutritional status. ^{Reference Lue, Wu and Wang23} A significant pitfall is over-relying on a single, asymptomatic electrocardiogram tracing while downplaying a concerning history. Another is dismissing a family history of “fainting spells” or “seizures” without considering an underlying channelopathy.

Mandatory testing

In addition to a thorough history and physical exam, there are several investigations that are essential to leading clinicians towards finding the root cause of palpitations in the paediatric population presenting to the emergency department. A 12-lead electrocardiogram is mandatory and considered to be the gold standard in all children with palpitations, as proposed by paediatric cardiology experts. Electrocardiograms serve as an important initial screening tool, capable of identifying patterns suggestive of dangerous arrhythmias or structural heart disease that may predispose childrense to sudden cardiac death; ^{Reference Sebudandi, Brockmeier, Atmatzidou, Khalil and Wendt24} however, as emphasised in section When a “normal” electrocardiogram is not reassuring, a single normal electrocardiogram does not definitively exclude all high-risk conditions when compelling clinical red-flag features are present. Effective interpretation of electrocardiograms in the paediatric emergency department requires foundational knowledge of high yield pathologies. A short PR interval with a delta wave should prompt suspicion for Wolff–Parkinson–White syndrome. A prolonged correct QT interval should be concerning for congenital long QT syndromes or acquired including electrolyte disturbances, medications, myocarditis, and head injuries. ST segment elevations or depressions may be pathological in myocarditis, while convexity of the ST segment indicates pericarditis. Hyperkalemia may lead to peaked T waves, though hypokalaemia displays flattened T waves. ^{Reference Lambrechts and Fourie25} Electrocardiograms can help steer further testing if indicated or support a timely and safe discharge.

Orthostatic vitals, including blood pressure and heart rate assessment, are simple measurements that should not be overlooked when working up palpitations in a child. Once the patient has been supine for at least 5–10 minutes to allow for fluid equilibration, blood pressure and heart rate should be measured. Repeat both of these measurements after standing for 1, 3, 5, 8, and 10 minutes. Positive orthostatic hypotension is defined as a decrease in systolic blood pressure of ≥20 mmHg or diastolic blood pressure of ≥10 mmHg within 3 minutes of standing. Orthostatic tachycardia consistent with postural orthostatic tachycardia syndrome in adolescents is defined as a heart rate elevation of ≥40 bpm within 10 minutes of standing from the supine position, in the absence of orthostatic hypotension. A criterion of ≥10 bpm at the 3-minute mark was referenced in the original text; however, in keeping with established clinical practice and current guidelines, the ≥40 bpm/10-minute threshold is recommended for diagnosing orthostatic intolerance in adolescents. ^{Reference Raj, Fedorowski and Sheldon26} Orthostatic vitals combined with electrocardiogram findings help provide guidance and reassurance to the patient, parent, and clinician towards a specific diagnosis.

Research studies have suggested a correlation between increased heart rates and hypoglycaemia in children. ^{Reference Calcaterra, Bosoni and Sacchi27} Because of this, assessing blood glucose levels is necessary to unmask secondary causes of tachycardia, which may manifest as palpitations in children. A point of care blood glucose is a quick and noninvasive screening tool; therefore, emergency care clinicians should not hesitate to obtain it before moving further down the diagnostic testing chain.

Selective testing

If the diagnosis for palpitations remains unclear following mandatory investigations mentioned above, workup may be continued with exploring the use of selective tests. These studies (e.g. laboratory testing and imaging) should be intentional and driven by the complete clinical picture, rather than routine or reflex. For example, a complete blood count may be ordered if there is speculation of anaemia or infection, and electrolytes may be analysed if their disturbance appears to be the underlying cause of the palpitations. ^{Reference Govender, Nashed, Rangiah, Okeke and Maphasha28} Troponin, a cardiac marker, has been commonly used in the paediatric emergency department to detect myocarditis or pericarditis. However, this marker should be avoided in children unless there is strong clinical suspicion for cardiac aetiology of palpitations. Although high sensitivity for myocardial injury, studies specifically in children have demonstrated troponin elevation to also occur in pathologies of noncardiac origin, such as sepsis or asthma. Even then, research has shown cardiac troponin to be at normal levels in patients already diagnosed with myocarditis. In accordance with experts, blood work for troponin in children with palpitations should be limited to those with concurrent alarming symptoms (e.g. chest pain), an abnormal electrocardiogram, or abnormal chest radiography. Similarly, the use of chest radiography adds limited benefit to children with isolated palpitation symptoms. Chest radiography may uncover suspected diseases like cardiomegaly and pneumopericardium; however, this may be unnecessary given that such cases can also be discovered with a thorough history and physical exam. ^{Reference Huang and Liu29} This is consistent with evidence from standardised clinical pathways in the paediatric emergency department, which support selective use of chest radiography based on clinical indication rather than routine ordering. ^{Reference Mohan, Nandi, Stephens, M’Farrej, Vogel and Bonafide30}

Cardiac monitoring and advanced testing in children have diagnostic significance, since children often have greater difficulty expressing their symptoms. Outlined by the American College of Cardiology, the use of transthoracic echocardiogram is warranted in children with palpitations along with a family history of early cardiac arrest, pacemaker or defibrillator placement, or cardiomyopathy. Guidelines also suggest that a transthoracic echocardiogram may be appropriate in those with an atypical electrocardiogram or known channelopathy. And although rare, transthoracic echocardiogram may be used in cases with a normal electrocardiogram but with strong indication of structural heart disease. ^{Reference Puchalski, Lui and Miller-Hance31}

Cardiac monitoring devices, such as Holter monitors, are investigations of value since palpitations may be transient and not present at the time of initial consultation in the emergency department. Ambulatory Holter or event monitoring should also be considered when the clinical history is atypical or episodic, even without classic red-flag symptoms and when the resting electrocardiogram is unremarkable or non-diagnostic. This circumstance differs from an unclear aetiology after a completed standard workup: an atypical history indicates that the diagnostic evaluation remains open and requires symptom–rhythm correlation. ^{Reference Goto, Witkowska, Slusarczyk, Grotek, Dziubinski and Clark22,Reference Bieganowska, Miszczak-Knecht and Brzezińska32,Reference Leng, Aldalati and Homme33} Holter monitors have been shown to detect arrhythmias as well as normal sinus rhythm during a symptomatic episode. Having both positive and negative results during episodes of palpitations is especially important in the paediatric population. Patients with negative symptomatic episodes are more likely to be discharged from paediatric cardiology care. For the child and family, this implies less invasive testing, financial strain, and mental stress. ^{Reference Goto, Witkowska, Slusarczyk, Grotek, Dziubinski and Clark22} Those with recorded arrhythmias on a Holter monitor, abnormal electrocardiogram, or coexisting high-risk symptoms (e.g. syncope) require further analysis with telemetry. Studies have shown that long-term telemetry monitoring considerably increases arrhythmia detection compared to a short-term Holter monitor in paediatric patients. Long-term telemetry of this calibre should be reserved for children who have first undergone mandatory testing and whose evaluation remains non-diagnostic or raises persistent concern. ^{Reference Bieganowska, Miszczak-Knecht and Brzezińska32}

Cost-effectiveness discussion

Electrocardiogram, orthostatic vitals, and point of care glucose serve as dual benefit investigations in many countries as they hold significant diagnostic value while also providing a low cost. These tests are easily accessible, less invasive, and conducted quickly in most acute care facilities and hence they may be considered the first line investigations when evaluating symptomatic children. Studies have shown that including an electrocardiogram in initial evaluation, especially in symptomatic patients, substantially increases the likelihood of detection of serious cardiac disease whilst providing cost advantages compared to pathways without electrocardiograms. ^{Reference Dhutia, Malhotra and Finocchiaro34} In addition to their direct diagnostic value, such baseline investigations assist in standardising clinical practices, early stratification of risk, as well as facilitate transparent communication with families on possible causes and future course of treatment. The use of standardised baseline testing also provides objective data which may be combined with the findings from the patient’s history and physical examination to narrow down clinical judgement pertaining to both diagnosis and treatment.

After cost-effective mandatory testing, diagnostic testing must be hypothesis-driven to reduce false positive results and mitigate the financial burden of healthcare investigations, without sacrificing efficacy in diagnostic testing, patient safety, and family reassurance. An analytical and progressive strategy to using additional studies is useful in balancing between the vigilance of over-testing, minimisation of redundant tests, incidental results, and the length of stay in the hospital associated with unnecessary costs in patient care.

Wearable electrocardiograms in paediatrics

Wearable electrocardiogram devices, including smartwatches, offer noninvasive, ambulatory monitoring suitable for detecting intermittent arrhythmias missed during brief emergency department evaluations. While studies on devices like the Apple Watch Series 6 show feasibility in paediatric populations, significant validation gaps remain, particularly across diverse age groups from neonates to adolescents. ^{Reference Littell, Roelle and Dalal39} Younger patients present unique challenges due to smaller size, higher heart rates, and motion artefacts, highlighting the need for paediatric-specific algorithms. Post-emergency department use of wearables could enable prolonged monitoring for intermediate-risk patients, but research is needed to define optimal protocols and address barriers to clinical integration, such as data management and false alarms. ^{Reference Zahedivash, Chubb, Giacone, Boramanand and Dubin41} Future randomised controlled trials should compare wearable-enabled discharge strategies against standard admission to evaluate safety, diagnostic yield, and cost-effectiveness.

Artificial intelligence-electrocardiogram advancements

AI-electrocardiogram algorithms show promise in identifying subtle high-risk features better than human interpretation. Expert-level deep neural networks have demonstrated high accuracy in paediatric electrocardiogram diagnosis in research settings. ^{Reference Mayourian, La Cava, de Ferranti and Mah42} However, their translation to the chaotic emergency department environment is a major hurdle. Emergency department-specific validation is lacking, and models must be tested against the noisy tracings and confounding comorbidities common in acute care. While artificial intelligence could potentially reduce interpretation variability, significant barriers to adoption exist, including the need for explainable artificial intelligence models to build clinician trust, seamless integration into electronic health records, and rigorous prospective testing to ensure they do not increase false positives or miss low-prevalence conditions like long QT syndrome. ^{Reference Pantelidis, Ruipérez-Campillo, Vogt and Antonopoulos43,Reference Follansbee, Landstrom and Aziz44}

Emergency department arrhythmia registries

Prospective registries are the cornerstone for defining true arrhythmia incidence, validating red-flag criteria (such as exertional syncope and family history), and connect emergency department dispositions to outcomes such as sudden cardiac death or recurrent events. Existing quality improvement efforts lowered paediatric syncope testing by 50% without safety signals achieved by current quality improvement initiatives. ^{Reference Winder, Marietta, Kerr, Puchalski and Zhang40} When combined with inpatient and ambulatory cohorts, multicentre emergency department registries could serve as a benchmark for national practices and reveal areas that could be improved.

Standardised phenotyping for inherited arrhythmias, including genetic correlations such as those in long QT or catecholaminergic polymorphic ventricular tachycardia, is one of the main deliverables. In order to create comprehensive risk models, registries should incorporate wearables and artificial intelligence outputs, track patients over time (for example, one to five years), and record social determinants. Funding from bodies like the Pediatric Heart Network could facilitate this, which would produce predictive scores similar to adult CHADS2-VASc for customised follow-up. ^{Reference Winder, Marietta, Kerr, Puchalski and Zhang40,Reference Mariani, Pierucci, Fanisio and Laviola45} Such infrastructure would empower meta-analyses, refining guidelines from bodies like the American Academy of Pediatrics and informing public health campaigns on arrhythmia awareness.

Standardised emergency department pathways

Risk-based algorithms can help reduce unnecessary testing, such as echocardiograms, Holters, and event monitors, while also protecting high-risk cases. Minimal (observation), intermediate (wearables), or comprehensive (admission) pathways could result from algorithms based on patient history, electrocardiogram results, and artificial intelligence scores. This is similar to syncope quality initiative successes. ^{Reference Winder, Marietta, Kerr, Puchalski and Zhang40} Testing through stepped-wedge cluster trials in emergency rooms would confirm that safety metrics, such as missed diagnoses, are unaffected.

Adding channelopathy, red flags, and speckle-tracking insights for premature ventricular contractions-induced cardiomyopathy improves the accuracy of resource allocation. Future protocols must address implementation challenges, including getting clinicians on board through simulation training and tools integrated into electronic health records. Patient-centred designs, developed in collaboration with families, could improve compliance and fairness. ^{Reference Winder, Marietta, Kerr, Puchalski and Zhang40,Reference Follansbee, Landstrom and Aziz44}

Cost-effectiveness evaluations

Formal health economic assessments are essential but currently lacking for minimal-testing paradigms in paediatric palpitations. While such approaches promise savings by avoiding admissions and tests, the upfront costs of technologies such as wearables and artificial intelligence must be considered. Robust Markov models using registry-derived data are needed to evaluate the long-term cost-effectiveness and quality-adjusted life years compared to standard care. ^{Reference Winder, Marietta, Kerr, Puchalski and Zhang40} Paediatric-specific valuations, which account for the long-term impact of arrhythmias, remain an underexplored but critical area for future research to inform payers and policymakers. ^{Reference Winder, Marietta, Kerr, Puchalski and Zhang40}