Palpitations: symptoms and diagnosis
What are palpitations?
Palpitations are unpleasant sensations of excessively strong, rapid and/or irregular heartbeats. In many people who experience palpitations, no heart disease or abnormal heart rhythms (arrhythmias) can be found and the cause of the palpitations is unknown. Palpitations are mostly harmless, but there may be a serious cause and so they must be investigated.
Symptoms of palpitations
Palpitations are heartbeats that suddenly become more noticeable. You may feel a fluttering feeling in your heart, or that it is beating strongly (pounding), or beating out of sync.
You may feel like your heart missed a beat, or made an extra one. These are known as ectopic heartbeats.
The feelings may be in your neck or your ear.
The feelings don’t usually last very long. Palpitations can occur in everyone at some time during exercise, stress, pain or fright, but a normal heartbeat should return quickly.
When should I seek immediate medical attention?
You should seek emergency medical attention if your heart palpitations are accompanied by:
- chest pain
- shortness of breath.
Palpitations are unpleasant sensations of excessively strong, rapid and/or irregular heartbeats. In many people who experience palpitations, no heart disease or abnormal heart rhythms (arrhythmias) can be found and the cause of the palpitations is unknown.
In others, palpitations may be caused by arrhythmias of different types (heartbeats that are too slow, too rapid, irregular, or too early) or by other heart conditions such as leaking valves. Sometimes the underlying cause is unrelated to the heart — anaemia or an overactive thyroid gland, for instance, can cause palpitations. Palpitations can occur in everyone at some time during exercise, stress, pain or fright, but a normal heartbeat should return quickly.
What type of doctor should I see for palpitations?
Your General Practitioner (GP) is a good place to start if you are having palpitations. Palpitations are a common problem that GPs deal with all the time. They are one of the most common symptoms that people go to their GP for. If the GP thinks your palpitations warrant further investigation, they will refer you to a Cardiologist.
Diagnosis of palpitations
When you visit your doctor about palpitations, the doctor may ask you to tap out the beat of the palpitations. They should ask you how often you have felt the palpitations and how long they last for.
They will be interested whether you have noticed anything that is a trigger for the palpitations, such as exercise, emotion or a change in your posture. They will want to know whether the palpitations make you feel out of breath or faint, or whether you have chest pain at the same time.
Tests for palpitations
The doctor may evaluate your palpitations through blood tests, an electrocardiogram (ECG), echocardiogram, a Holter monitor (a portable ECG machine that can monitor heartbeat for 24 hours), exercise stress tests, or a test of the coronary arteries.
If you are asked to wear a 24-hour monitor, you will be asked to keep a time record of any symptoms so they can be correlated in time to the ECG results.
Exercise stress testing may be suggested where you have palpitations that are induced by exercise.
Rarely, electrophysiological studies are needed to determine the cause of an abnormal heart rhythm by applying small electric currents directly to the heart and recording its response.
Blood tests can measure the levels of thyroid hormones, potassium, magnesium and medications that may be causing the palpitations. Your doctor may also ask about food sensitivities and allergies.
What causes palpitations?
Palpitations can be triggered in some people by heavy smoking, excessive caffeine (from tea, coffee, cola drinks or energy drinks), food sensitivities or allergies, and some types of medications or reactions to medications.
Fever may also cause an increased or abnormal heart rate while it is present.
Excessive levels of thyroid hormone or hormone changes in pregnancy may cause a faster heart rate and may cause palpitations briefly.
During menopause, women may experience palpitations.
Palpitations may also be a symptom of several different types of arrhythmias, heart disease, such as problems with the heart valves, or heart attack.
Sometimes the heart may have inappropriate beats (called ectopic beats or premature extrasystoles) which may give the sensation of palpitations but are not considered serious unless occurring frequently. These ectopics happen when an extra or early heartbeat is followed by a pause, which makes you feel like you have missed a beat. Two common types are premature atrial contractions (PAC) and premature ventricular contractions (PVC). Ectopic beats are usually harmless and don’t signify that you have a heart condition.
Atrial fibrillation (AF), where the heart beats rapidly and irregularly, is another common cause of palpitations.
Certain medications that are used for asthma, angina pain, respiratory and lung conditions, and depression may have palpitations as a side effect.
Excessive alcohol intake is known to cause palpitations in some people.
Overexertion or strenuous exercise can cause palpitations.
Some illicit drugs (‘recreational drugs’) including cocaine, ecstasy and amphetamines, can cause palpitations.
There are a number of other causes of palpitations but these are not as common. Inadequate supplies of oxygen in the blood, as seen in anaemia, can be a cause. Palpitations can be one of the symptoms of a rare adrenal gland tumour called phaeochromocytoma.
Palpitations that are not related to specific arrhythmias or heart disease may not require specific treatment and your doctor may simply advise you to reduce emotional and physical stress and avoid any triggers.
If your palpitations are caused by an underlying heart condition, you may need specific treatment.
Your doctor or cardiologist may prescribe medications such as beta blockers or calcium channel blockers, to regulate abnormal heartbeats. For some causes of palpitations they may be able to advise the use of a technique (Valsalva technique or manouevre) to make the palpitations stop.
Tachycardia is a faster-than-usual heart rhythm – sometimes defined as over 100 beats per minute. This is normal under conditions such as exercise, or after a fright. Sinus tachycardia is tachycardia that is caused by your heart’s own pacemaker (the sinus node) without any identifiable cause. It may come on gradually and last for minutes or hours.
Your doctor may recommend medication, such as beta blockers, to slow down your heart rate.
Supraventricular tachycardia usually displays as sudden-onset, rapid, regular palpitations. They are called supraventricular because they arise in the area above the ventricles of the heart. Atrial fibrillation is a type of supraventricular tachycardia.
The palpitations can be triggered by bending over, sudden movements, stress, caffeine and alcohol. It’s common to feel anxiety and if these episodes affect your quality of life, your doctor may suggest you have catheter ablation, which can cure the problem in 95 per cent of people. There may also be the option of taking medication, such as beta blockers or calcium channel blockers.
If your palpitations are caused by atrial fibrillation, your doctor or cardiologist may recommend you take anticoagulants and medicines to slow your heart rate down. Or they may suggest you have catheter ablation.
Catheter ablation is a treatment used to destroy a small part of your heart tissue that is giving rise to the abnormal heart rhythms. It is often used to treat atrial fibrillation. Catheter ablation uses radiofrequency waves to scar the tiny area of heart tissue that is responsible for the abnormal electrical signals that give rise to the abnormal heartbeats. (The scar tissue does not carry any electrical signal.)
The procedure is carried out while you are sedated. Catheters are threaded through the femoral artery in your groin up to your heart. Then the catheter tip produces a pulse of energy, which scars the offending area of heart tissue.
Ventricular tachycardia occurs in the ventricles (lower chambers) of the heart. Treatment of ventricular tachycardia is aimed at treating the underlying problem that causes the symptom. This may involve catheter ablation or rarely, an implantable cardioverter defibrillator (ICD).
An ICD is a device that is implanted under the skin, similar to a pacemaker. It continuously tracks your heart rate and rhythm. If undesirable changes happen, the ICD sends impulses or a shock to the heart to nudge it back to normal rhythm. The impulses may feel like a flutter or palpitations. A shock will be felt more like a sudden jolt.
Ventricular fibrillation is a rapid, chaotic heart rhythm, where the ventricles quiver rather than pump. It can result in dizziness or blackouts. It needs urgent emergency medical attention.
Hypertrophic cardiomyopathy is an inherited condition which results in thickening of the muscular wall of the heart. This makes it harder for the heart to pump, and palpitations may be a symptom of this condition.
Treatment of hypertrophic cardiomyopathy may involve medicines, or even a pacemaker to control your heart rate.
Heart failure is a common condition in which the heart is damaged and can’t effectively pump blood around the body. Palpitations may be a symptom of heart failure. Heart failure is often treated with medicines and a low-salt diet to relieve the symptoms.
Heart valve problems
If heart valve problems are the cause of your palpitations, your cardiologist may suggest surgery to repair or replace your faulty heart valve.
While you won’t be able to influence underlying medical causes of heart palpitations yourself, you may be able to reduce any triggers you have for your palpitations, including:
- reduce physical stress and emotional stress where possible
- stop smoking
- reduce your intake of caffeine and alcohol
- get adequate sleep
- review your medications with your doctor or pharmacist, including over-the-counter medications such as cold and flu preparations, eye drops, and herbs and supplements.
There are some conditions and medicines that increase the risk of having palpitations, including:
- having an overactive thyroid (hyperthyroidism)
- having an anxiety disorder
- having heart disease
- having anaemia
- having a fever
- being stressed
- being pregnant
- having low blood pressure
- taking some asthma medicines
- taking some cold and flu medicines that contain pseudoephedrine
- taking some medicines for irregular heart rhythms (anti-arrhythmics)
- taking appetite suppressants
- taking some anti-histamines.
Last Reviewed: 07/09/2020
1. McLellan AJA, Kalman JM. Approach to palpitations. AJGP 2019; 48(4). https://www1.racgp.org.au/ajgp/2019/april/approach-to-palpitations
2. Ling L-H, Kistler P. The patient with palpitations. Cardiac, systemic or psychosomatic. Medicine Today 2015; 16; (10): 43-47. https://medicinetoday.com.au/sites/default/files/cpd/MT2015-10-043-LING.pdf
3. Medi C, Kalman JM, Freedman SB. Supraventricular tachycardia. Med J Aust 2009; 190 (5): 255-60. https://www.mja.com.au/journal/2009/190/5/supraventricular-tachycardia
4. eTG complete. Cardiovascular. Initial assessment and management of an acute tachyarrhythmia. Published March 2018. © Therapeutic Guidelines Ltd (eTG August 2020 edition). https://tgldcdp.tg.org.au/viewTopic?topicfile=arrhythmias-acute-management#toc_d1e47
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