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Palpitations are among the most common symptoms that prompt patients to consult general practitioners, cardiologists, or emergency healthcare services.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 patients. The aim of this article is to propose expert advice for diagnostic evaluation in order to guide optimal management of patients with palpitations.     Palpitations are a symptom defined as awareness of the heartbeat and are described by patients as a disagreeable sensation of pulsation or movement in the chest and/or adjacent areas.7 Implicit in that awareness is a sense of unpleasantness which may be associated with discomfort, alarm, and less commonly pain. As this awareness causes the individual to mentally focus on their heartbeat, the nature of the heartbeat, both in terms of its perceived ‘forcefulness' and its rate, is assimilated into the term. Therefore, the term is used to describe a patient's subjective perception of abnormal cardiac activity in a way that may be associated with a symptomatic cardiac arrhythmia. However, because palpitations are a symptom with a broad range of causes and underlying diseases, it does not have a rigorous and definable clinical correlate.