© 2015 Elsevier Inc. Background: Palpitations are a common emergency department (ED) complaint, yet relatively little research exists on this topic from an emergency care perspective. Objectives: We sought to describe the perceptions and clinical decision-making processes of emergency physicians (EP) surrounding patients with palpitations. Methods: We conducted 21 semistructured interviews with a convenience sample of EPs. We recruited participants from academic and community practice settings from four regions of the United States. The transcribed interviews were analyzed using a combination of structural coding and grounded theory approaches with ATLAS.ti, a qualitative data analysis software program (version 7; Atlas.ti Scientific Software Development GmbH, Berlin, Germany). Results: EPs perceive palpitations to be a common but generally benign chief complaint. EPs' clinical approach to palpitations, with regards to testing, treatment, and ED management, can be classified as relating to one or more of the following themes: 1) risk stratification, 2) diagnostic categorization, 3) algorithmic management, and 4) case-specific gestalt. With regard to disposition decisions, four main themes emerged: 1) presence of a serious diagnosis, 2) perceived need for further cardiac testing/monitoring, 3) presence of key associated symptoms, 4) request of other physician or patient desire. The interrater reliability exercise yielded a Fleiss' kappa measure of 0.69, indicating substantial agreement between coders. Conclusion: EPs perceive palpitations to be a common but generally benign chief complaint. EPs rely on one or more of four main clinical approaches to manage these patients. These findings could help guide future efforts at developing risk-stratification tools and clinical algorithms for patients with palpitations.