Background Patients with chronic obstructive pulmonary disease (COPD) are at high risk for developing arrhythmias due to hypoxemia, right heart failure, and the use of beta-agonist inhalers. Symptoms related to arrhythmias can often be masked or confounded by symptoms related to COPD exacerbation and remain undiagnosed. With this study, we identify the incidence of actionable arrhythmias in patients with no prior cardiology follow-up and moderate-severe COPD with continuous monitoring. Methods An automatic referral for electrophysiology (EP) consult was generated in patients with moderate-severe COPD if they endorsed one of the following: palpitations, dizziness, abnormal ECG, or near syncope. Eligible patients underwent ILR implantation after evaluation with an EP specialist and were followed via remote monitoring for 12 months. A control group of patients without COPD matched for age, sex, and implant indication were randomly selected in a 3:1 ratio. Actionable arrhythmias, defined as arrhythmias that correlated with symptoms triggered by the patient, necessitating EP intervention, were recorded for both groups. Results In this prospective cohort study, 21 patients with COPD were enrolled and compared to 63 controls. COPD patients experienced a significantly higher rate of actionable arrhythmias compared to the controls (48% vs 11%, p<0.001). EP interventions in response to actionable arrhythmias included eight patients initiated on anticoagulation, three catheter ablations, one implantable cardiac defibrillator, and one permanent pacemaker implanted. In multivariate analysis, COPD was an independent predictor of actionable arrhythmias (aOR 4.3, 95% CI 1.2-15.2, p=0.02) when adjusting for chronic kidney disease and all-cause readmissions. Conclusion: Continuous monitoring was highly effective in diagnosing significant arrhythmic events in patients with moderate-severe COPD. Awareness should be raised about the high arrhythmic risk in this population and the role of continuous monitoring should be evaluated in larger studies.