Palpitations are the awareness of heartbeats. The sensation may feel like pounding, fluttering, racing, or skipping beats. Other symptoms—for example, chest discomfort or shortness of breath—may be present depending on the cause of the palpitations.

Palpitations are common. Some people find them unpleasant and alarming, but they rarely indicate a life-threatening heart disorder. Many people without heart disease also have palpitations.

Causes

Ordinarily, people do not notice the beating of their heart. However, many people can feel their heart beating when something causes it to beat more forcefully or rapidly than usual. Such rapid, forceful beats are a normal response by the heart (sinus tachycardia). Causes include the following:

• Exercise
• Strong emotions (such as anxiety, fear, pain)
• Low blood count (anemia)
• Low blood pressure
• Fever
• Dehydration

In other cases, palpitations result from a disturbance of heart rhythm (arrhythmia).

Types of arrhythmias : Arrhythmias range from harmless to life threatening.

The most common arrhythmias include

• Atrial premature beats
• Ventricular premature beats

Both of these arrhythmias usually occur in people without a heart disorder and are harmless. The premature beat itself is not felt. What is felt is the following normal heartbeat, which occurs after a slight delay and is slightly stronger than usual. Although people feel as if their heart skipped a beat, it actually did not.

Other arrhythmias that cause palpitations include

• Paroxysmal supraventricular tachycardia (PSVT)
• Atrioventricular nodal reentrant tachycardia
• Atrial fibrillation or flutter
• Ventricular tachycardia

These arrhythmias involve the heart beating much faster than normal. Arrhythmias in which the heart beats too slowly rarely cause palpitations although some people do feel the slow rate.

Causes of arrhythmias: Some arrhythmias (for example, atrial premature beats, ventricular premature beats, or PSVT) often occur in people who have no serious underlying disorders. Others are often caused by a serious heart disorder or a disorder elsewhere in the body.

Serious heart disorders include angina, heart attack, congenital heart diseases, disorders of heart valves, and conduction system disturbances (for example, Wolf-Parkinson-White syndrome).

Disorders not related to the heart that may cause arrhythmias include

• Overactive thyroid gland (hyperthyroidism)
• Low level of oxygen in the blood (hypoxia)
• Low level of potassium in the blood (hypokalemia)
• Low level of magnesium in the blood (hypomagnesemia)
• Certain drugs, including alcohol, caffeine, digoxinSome Trade Names
  LANOXIN
  , nicotineSome Trade Names
  NICORETTE NICOTROL
  , and some stimulant drugs (such as albuterolSome Trade Names
  PROVENTIL-HFA VENTOLIN HFA
  , amphetamines, cocaine, epinephrine, ephedrine, and theophyllineSome Trade Names
  THEOLAIR
  )

Complications: Arrhythmias that cause the heart to beat too fast can cause complications (particularly in older people). If the heart goes too fast, it may not be able to pump blood adequately, and people may feel faint or pass out, or develop heart failure. Heart failure occurs mainly in people who have previously had heart failure or a heart attack, although it can occur in other people if the heart rate is very fast or if the heart beats too fast for a long time. A rapid heart rate also increases the oxygen needs of the heart muscle. People who have narrowing of the arteries to the heart muscle (coronary artery disease) can develop chest pain due to angina or a heart attack (which may be fatal).

Some arrhythmias, particularly ventricular tachycardia, are unstable and can lead directly to cardiac arrest.

Evaluation

Although not all palpitations are caused by a heart disorder, the consequences of some heart disorders are so serious that people with palpitations should usually be evaluated by a doctor. The following information can help people decide when to see a doctor and help them know what to expect during the evaluation.

Warning signs: In people with palpitations, certain symptoms and characteristics are cause for concern. They include

• Light-headedness or fainting
• Chest pain or pressure
• Shortness of breath
• Pulse rate over 120 per minute
• Having heart disease or a family history of sudden death

When to see a doctor: People who have palpitations and any warning signs should go to an emergency department right away, as should those who have continuous, ongoing palpitations. Those who have fainting, chest pain, or shortness of breath should call emergency services.

People without warning signs who have occasional palpitations or had an episode that stopped should call their doctor. The doctor will determine how quickly they need to be seen based on their age, underlying conditions, and other symptoms. Typically a delay of a day or two is not harmful.

What the doctor does: Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination helps determine the possible cause.

Doctors ask

• How often palpitations occur
• How long palpitations last
• What factors (for example, emotional distress, activity, or intake of caffeine or other drugs) trigger or worsen palpitations
• What drugs, including caffeine, the person is taking

Sometimes doctors ask the person to tap out the rate and cadence of palpitations because the pattern of beats can help them determine the cause.

The physical examination begins with the doctor checking the vital signs (pulse, temperature, and blood pressure). The pulse rate and whether the pulse is regular or irregular help suggest causes. An elevated temperature suggests fever is the cause. A low blood pressure does not suggest a cause but indicates extreme urgency.

Doctors listen to the heart for abnormal sounds that might indicate a valve disorder or heart inflammation. They listen to the lungs for sounds that indicate heart failure. They look at and feel the front of the neck to see if the thyroid gland is enlarged or inflamed.

Palpitations that occur with other symptoms, such as shortness of breath, chest pain, weakness, fatigue, or fainting, are more likely to result from an abnormal heart rhythm or a serious disorder.

PrintOpen table in new window
Some Features and Causes of Palpitations Feature* Possible Cause Perception of an occasional skipped heartbeat Atrial premature beats or ventricular premature beats Sudden episodes of rapid heartbeats that abruptly slow to the normal rate Often in people who have had previous episodes of rapid heartbeats PSVT or Wolff-Parkinson-White syndrome Less often ventricular tachycardia or congenital long QT syndrome A constant sensation of rapid, irregular heartbeats Atrial fibrillation Fainting during palpitations Ventricular tachycardia, congenital long QT syndrome, inherited hypertrophic cardiomyopathy, or Brugada syndrome Palpitations during exercise or an emotional situation In healthy people: Sinus tachycardia (the heart's normal response to stress) In people with coronary artery disease: Sometimes arrhythmia caused by a decrease in blood flow triggered by exercise In people with a family history of fainting or sudden death Brugada syndrome, congenital long QT syndrome, or inherited dilated or hypertrophic cardiomyopathy In people who are bleeding, have a fever, are in pain, or have lost fluids (as may result from vomiting or diarrhea) Sinus tachycardia Intolerance of heat, weight loss, bulging eyeballs, and tenderness and/or swelling in the front of the neck Sinus tachycardia or atrial fibrillation due to hyperthyroidism *Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. PSVT = paroxysmal supraventricular tachycardia.

Testing: Even though most causes of palpitations are not serious, testing typically is done.

• Electrocardiography (ECG), sometimes with ambulatory monitoring
• Laboratory testing
• Sometimes imaging studies, stress testing, or both
• Sometimes electrophysiologic testing

ECG is done. If the ECG is done while the person is having palpitations or an abnormal pulse rate, the diagnosis is usually clear. However, only a few of the possible causes produce an abnormal ECG when people are not having palpitations. Thus, people who have intermittent palpitations may need to wear an ECG monitor for a day or two (Holter monitoring) or for a longer period (event recorder) to detect brief or irregularly occurring abnormal rhythms.

Laboratory testing is needed. Doctors do a complete blood count and measure serum electrolytes, including potassium, magnesium, and calcium. Doctors may measure other substances in the blood (cardiac markers) if the person has other symptoms that suggest a possible coronary syndrome. Doctors measure levels of thyroid hormone in the blood if they suspect an overactive thyroid and measure levels of other hormones in people who may have pheochromocytoma.

Imaging is often needed. In people with ECG findings that suggest heart disease, doctors do echocardiography and sometimes magnetic resonance imaging (MRI) of the heart. People with symptoms on exertion require stress testing sometimes with stress echocardiography or nuclear scanning.

Electrophysiologic testing (see Diagnosis of Heart and Blood Vessel Disorders: Electrophysiologic Testing) is done when people's symptoms are severe and doctors suspect a dangerous heart rhythm problem that was not found with other tests. In this test, doctors pass small electrodes through a vein into the heart. The electrodes record the heart's electrical activity in more detail than an ECG does.

Treatment

Drugs and substances such as caffeine that are known to worsen a person's palpitations are stopped. If dangerous or debilitating arrhythmias are caused by a necessary therapeutic drug, doctors try a different drug.

Doctors usually simply provide reassurance for people with atrial premature beats or ventricular premature beats that are not caused by a heart disorder. If such harmless palpitations are very bothersome, doctors sometimes give a beta-blocker (a type of antiarrhythmic drug). Other identified rhythm disturbances and underlying disorders are investigated and treated (see Abnormal Heart Rhythms). Doctors often first give rhythm-controlling drugs (such as digoxinSome Trade Names
LANOXIN
, flecainideSome Trade Names
TAMBOCOR
, verapamilSome Trade Names
CALAN ISOPTIN SR
, diltiazemSome Trade Names
CARDIZEM DILACOR XR
, or amiodaroneSome Trade Names
CORDARONE
). However, many of these drugs can themselves cause rhythm disturbances as well as other side effects. If drugs are not effective or if people have certain dangerous rhythm disturbances, doctors may use more invasive treatments such as direct current cardioversion, radioablation, or implantation of a combination pacemaker and defibrillator. The choice of procedure depends on the specific condition causing the disturbance.

Essentials for Older People

Older people are at particular risk of side effects due to antiarrhythmic drugs. Older people are likely to have several health problems and take several drugs, and these drug combinations may put them at risk of side effects. In older people, the kidneys are less effective at filtering drugs from the blood, which contributes to the risk of side effects. Some older people may even need a pacemaker before they can take antiarrhythmic drugs.

Key Points

• Palpitations are common, and they have many causes that range from harmless to life-threatening.
• People who have other symptoms such as light-headedness, chest pain or pressure, or shortness of breath may have a serious problem and should see a doctor quickly.
• ECG and certain blood tests are done.
• Treatment depends on the cause.

Last full review/revision October 2012 by Lyall A. J. Higginson, MD