Palpitations

Summary

Palpitations (heartbeats you can feel yourself) are one of the most common reasons for visiting a cardiologist. You may feel them in the chest, throat or neck, as a heart that “pounds”, “flutters” or “misses a beat”.

The key point: a palpitation is a symptom, not a diagnosis. In most cases the cause is harmless (stress, coffee, lack of sleep), but sometimes a rhythm disorder such as atrial fibrillation lies behind it and needs treatment.

What they feel like

• a beat that “is missing” or comes early (extrasystole) — the most common
• fast, regular beats that start and stop suddenly
• fast and completely irregular beats
• a pounding heart with a normal rhythm (e.g. after coffee or during anxiety)

How you describe them — regular or not, how long they last, what sets them off — is one of the most valuable pieces of information for the doctor.

Common, harmless causes

• stress, anxiety, panic attacks
• caffeine, energy drinks, smoking, alcohol
• lack of sleep and fatigue
• dehydration and fever
• intense physical exercise
• hormonal changes: the menstrual cycle, pregnancy, menopause
• some medicines, e.g. nasal decongestants and asthma drugs
• low blood sugar

When the cause is in the heart or elsewhere in the body

From the heart: arrhythmias (atrial fibrillation, supraventricular tachycardia, frequent extrasystoles, rarely ventricular tachycardia), valve disease, cardiomyopathies and heart failure.

From other conditions:

• anemia (especially from iron deficiency)
• hyperthyroidism (an overactive thyroid)
• electrolyte disorders (potassium, magnesium)
• sleep apnea and lung disease

Palpitations with shortness of breath

When palpitations come together with dyspnea (difficulty breathing), the doctor first thinks of:

• atrial fibrillation or other fast arrhythmias, which make the heart pump less efficiently
• heart failure — often with edema (swelling) of the ankles, fatigue and difficulty breathing when lying flat
• anemia and hyperthyroidism
• anxiety and fast breathing (hyperventilation), which also causes tingling in the fingers and around the lips
• lung diseases (asthma, COPD)
• rarely, but seriously: a pulmonary embolism — sudden dyspnea, often with pain on breathing or swelling of one leg

New or worsening dyspnea together with palpitations should not be explained away as “nerves” without being assessed.

How they are assessed

The doctor asks about the heartbeats, what triggers them, medicines, coffee, alcohol and family history. Then, depending on the case:

• ECG — records the rhythm at that moment; it is normal when the palpitations are not happening
• Blood tests — blood count, ferritin, TSH, electrolytes, glucose
• Echocardiography — looks for valve or heart muscle disease
• 24–48-hour Holter ECG — catches the rhythm while an episode happens; when episodes are rare, longer monitoring may be needed

Keep a diary: the time, the duration, what you were doing and what you felt. Tell the doctor if episodes happen while you wear the Holter.

What you can do yourself

• avoid or reduce caffeine, energy drinks, smoking and alcohol
• sleep enough and reduce stress; slow breathing helps when anxiety makes it worse
• drink enough fluids
• ask the pharmacist or doctor about medicines that may cause them

For some fast arrhythmias, the doctor may teach you vagal maneuvers. Do not try them without guidance, especially if you have known heart disease.

When to see a cardiologist

• palpitations that recur or become more frequent
• they last more than a few minutes
• you have known heart disease or a family history of sudden death at a young age
• you have hypertension, diabetes or overweight
• they come with fatigue, dyspnea or dizziness

Many people are reassured to hear that their rhythm is healthy. Sometimes the assessment finds an arrhythmia that can be treated, preventing complications such as stroke.