🩺 Heart palpitations

## Overview Heart palpitations (ICD-10: R00.2) are the subjective awareness of one's own heartbeat, often described as a fluttering, pounding, racing, or skipping sensation in the chest, throat, or neck. They represent one of the most common reasons for cardiology referrals and emergency department visits, accounting for approximately 16% of outpatient general-medicine complaints [1]. Epidemiologic data suggest that up to 34% of the general adult population will experience palpitations at some point during their lifetime [2]. While the majority of cases are benign — arising from stress, caffeine, or minor rhythm disturbances — roughly 40–43% of palpitations are ultimately attributable to a cardiac arrhythmia, some of which carry meaningful morbidity [1][3]. Because distinguishing harmless from dangerous palpitations is difficult without clinical evaluation, this symptom drives significant health-related internet searching and patient anxiety. This article provides a comprehensive, evidence-based overview of heart palpitations for general adult readers. It is not a substitute for professional medical evaluation; if you are experiencing palpitations alongside chest pain, shortness of breath, or fainting, seek immediate medical attention. --- ## Common Causes Palpitations arise when changes in heart rate, rhythm, or contractile force become perceptible. The causes can be grouped into cardiac, systemic, and psychogenic categories, roughly ranked here by frequency in primary-care settings [1][3][4]. ### 1. Premature Beats (Most Common Cardiac Cause) - **Premature atrial contractions (PACs)** and **premature ventricular contractions (PVCs)** are early, extra beats followed by a compensatory pause. The subsequent normal beat is often felt as a "thump" because the heart fills with more blood during the pause. - PACs and PVCs are nearly universal; Holter-monitor studies detect them in over 90% of healthy adults [4]. They generally become clinically significant only when frequent (>10,000/day) or symptomatic. ### 2. Anxiety and Stress - Sympathetic nervous system activation raises heart rate and contractility via catecholamine release. Panic disorder, generalised anxiety disorder, and situational stress account for roughly 30–35% of palpitation presentations in primary care [3]. - Hyperventilation during anxiety can cause electrolyte shifts (respiratory alkalosis, reduced ionised calcium) that may further provoke ectopy. ### 3. Stimulants and Dietary Triggers - **Caffeine** (coffee, energy drinks, pre-workout supplements) sensitises cardiac adrenergic receptors. Evidence on caffeine as a direct arrhythmia trigger is mixed; a 2023 review noted that moderate intake (≤400 mg/day) does not significantly increase arrhythmia risk in most individuals, but individual susceptibility varies [5]. - **Alcohol** — even moderate use — can trigger atrial fibrillation ("holiday heart syndrome"). A randomised trial published in the *New England Journal of Medicine* (2020) demonstrated that alcohol abstinence significantly reduced recurrence of atrial fibrillation in regular drinkers [6]. - **Nicotine**, **amphetamines**, **cocaine**, and **pseudoephedrine** are well-established triggers. ### 4. Supraventricular Tachycardias (SVTs) - Atrioventricular nodal re-entrant tachycardia (AVNRT) and atrioventricular re-entrant tachycardia (AVRT, including Wolff-Parkinson-White syndrome) are the most common paroxysmal SVTs. They present as sudden-onset, regular, rapid heartbeats (150–250 bpm) that may terminate abruptly. - Prevalence is approximately 2.25 per 1,000 persons [7]. ### 5. Atrial Fibrillation / Atrial Flutter - Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide, with lifetime risk approaching 25% after age 40. Palpitations in AF are typically described as an irregularly irregular sensation. - Pathophysiology involves disorganised re-entrant wavelets in the atrial myocardium, often triggered by ectopic foci at the pulmonary vein ostia. ### 6. Thyroid Disorders - Hyperthyroidism increases beta-adrenergic receptor sensitivity and cardiac output. Even subclinical hyperthyroidism can provoke palpitations, sinus tachycardia, or AF. ### 7. Anaemia - Reduced oxygen-carrying capacity triggers compensatory increases in heart rate and stroke volume, producing a hyperdynamic circulation that may be felt as palpitations. ### 8. Structural Heart Disease and Ventricular Arrhythmias (Less Common but Serious) - Ventricular tachycardia (VT) and ventricular fibrillation (VF) may present initially as palpitations, often in patients with underlying ischaemic heart disease, cardiomyopathy, or channelopathies (Long QT, Brugada syndrome). - These account for a small percentage of palpitation presentations but carry the highest mortality risk. ### 9. Medications - Beta-agonist inhalers (salbutamol), thyroid-hormone replacement (if over-dosed), certain antidepressants (TCAs, SNRIs), and fluoroquinolone antibiotics can all provoke palpitations. ### 10. Hormonal and Metabolic - Perimenopausal oestrogen fluctuations, pregnancy-related haemodynamic changes, phaeochromocytoma (rare), and electrolyte imbalances (hypokalaemia, hypomagnesaemia) are additional triggers. --- ## RED FLAGS Seek **immediate emergency care (call 911/112)** if palpitations occur with any of the following: - **Chest pain or pressure** — may indicate myocardial ischaemia or infarction - **Syncope (fainting) or near-syncope** — suggests haemodynamically significant arrhythmia - **Severe shortness of breath at rest** — possible heart failure or pulmonary embolism - **Heart rate sustained above 150 bpm at rest** and not responding to vagal manoeuvres - **Known history of structural heart disease, cardiomyopathy, or prior cardiac arrest** - **Family history of sudden cardiac death under age 40** (raises suspicion for inherited channelopathies) - **New neurological symptoms** (slurred speech, weakness, vision changes) during palpitations — may indicate stroke from cardioembolism in AF - **Palpitations occurring during or immediately after vigorous exercise** with associated dizziness - **Wide-complex tachycardia on any available monitoring device** --- ## Self-Care at Home For benign palpitations (diagnosed or strongly suspected), the following evidence-based strategies may help reduce episodes: ### Vagal Manoeuvres Vagal manoeuvres increase parasympathetic tone and may terminate SVT episodes: - **Valsalva manoeuvre (modified):** Blow forcefully into a 10 mL syringe for 15 seconds in a semi-recumbent position, then lie flat and have someone passively raise your legs to 45° for 15 seconds. A 2015 randomised trial found the modified Valsalva restored sinus rhythm in 43% of SVT cases vs. 17% with the standard technique [8]. - **Cold-water face immersion:** Submerge the face in cold water for 15–30 seconds (triggers the diving reflex). - **Carotid sinus massage:** Should only be performed under medical supervision due to stroke risk. ### Lifestyle Modifications - **Reduce or eliminate caffeine and alcohol** — trial a 2–4 week washout to assess impact. - **Improve sleep quality** — sleep deprivation increases sympathetic tone and ectopy burden. - **Regular moderate exercise** — aerobic conditioning generally reduces resting heart rate and PVC frequency; avoid extreme endurance training, which may paradoxically promote AF. - **Manage stress** — cognitive-behavioural therapy, mindfulness-based stress reduction, and deep-breathing exercises have shown benefit in reducing palpitation frequency in anxiety-related cases. ### Electrolyte Optimisation - Ensure adequate intake of **magnesium** (320–420 mg/day from food) and **potassium** (2,600–3,400 mg/day). Magnesium-rich foods include dark leafy greens, nuts, seeds, and whole grains. - Dehydration can concentrate electrolytes unpredictably; maintain consistent hydration. ### Tracking and Awareness - Keep a palpitation diary noting timing, duration, triggers (food, drink, activity, stress), and associated symptoms. This information is valuable for clinical evaluation. - Consumer-grade smartwatches with ECG capability (e.g., Apple Watch, Samsung Galaxy Watch) can capture a single-lead ECG during an episode, which may aid diagnosis. --- ## OTC Medications That May Help No OTC medication is specifically approved for treating cardiac arrhythmias. However, certain over-the-counter agents may address underlying contributors. **Always consult a pharmacist or clinician before starting any new medication.** | Class | Example | Typical Adult Dose | Notes | |---|---|---|---| | **Magnesium supplement** | Magnesium glycinate, magnesium citrate | 200–400 mg elemental Mg/day | May reduce PVC burden in Mg-deficient individuals. Glycinate form generally better tolerated (less GI upset). Avoid in severe renal impairment. | | **Potassium supplement** | Potassium chloride (KCl) | 20–40 mEq/day if mildly low | Only use if documented deficiency. Excessive potassium is dangerous — hyperkalaemia can cause fatal arrhythmias. Consult clinician first. | | **Antihistamine (for anxiety-related palpitations)** | Diphenhydramine (Benadryl) | 25–50 mg at bedtime | Mild sedative effect may help anxiety-driven palpitations. **Caution:** anticholinergic effects can paradoxically cause tachycardia; avoid in elderly, glaucoma, urinary retention. Not a long-term solution. | | **Melatonin (for sleep-related triggers)** | Melatonin | 0.5–3 mg 30 min before bed | May improve sleep quality, indirectly reducing palpitations linked to sleep deprivation. Generally well tolerated. | | **Herbal — Valerian root** | Valerian extract | 300–600 mg before bed | Limited evidence suggests mild anxiolytic effect. May interact with sedatives. Not FDA-regulated for quality/purity. | > **Important:** Avoid OTC decongestants containing **pseudoephedrine** or **phenylephrine** if you experience palpitations, as these sympathomimetic agents can worsen symptoms. Similarly, high-dose **caffeine pills** and **ephedra-containing supplements** should be strictly avoided. --- ## Prescription Options Prescription treatment depends on the specific arrhythmia diagnosed. These medications should only be taken under the supervision of a qualified physician, typically a cardiologist or electrophysiologist. | Class | Examples | Indication | Key Notes | |---|---|---|---| | **Beta-blockers** | Metoprolol succinate 25–200 mg daily; Bisoprolol 2.5–10 mg daily; Propranolol 10–40 mg TID | First-line for SVT, rate control in AF, PVC suppression, anxiety-related sinus tachycardia | Reduce heart rate and myocardial oxygen demand by blocking β1-adrenergic receptors. Avoid in severe asthma, decompensated heart failure, bradycardia. | | **Non-dihydropyridine calcium channel blockers** | Verapamil 80–120 mg TID; Diltiazem 120–360 mg daily (extended-release) | Rate control in AF/flutter, termination of AVNRT | Block L-type calcium channels in the AV node. Avoid with beta-blockers (risk of severe bradycardia), systolic heart failure. | | **Class IC antiarrhythmics** | Flecainide 50–150 mg BID; Propafenone 150–300 mg TID | Rhythm control in AF ("pill-in-the-pocket" strategy), SVT prophylaxis | Highly effective but contraindicated in structural heart disease (increased mortality, per the CAST trial). Requires stress test before initiation. | | **Class III antiarrhythmics** | Amiodarone 200 mg daily (maintenance); Sotalol 80–160 mg BID; Dofetilide 125–500 mcg BID | Refractory AF, VT, complex arrhythmias | Amiodarone is highly effective but carries risks of thyroid, pulmonary, hepatic, and ocular toxicity. Sotalol and dofetilide require in-hospital initiation with QTc monitoring. | | **Antiarrhythmic — Adenosine** | Adenosine 6 mg IV rapid push (then 12 mg if needed) | Acute termination of SVT in emergency settings | Ultra-short acting (half-life <10 seconds). Administered only in monitored clinical settings. | | **Anxiolytics / SSRIs** | Sertraline 25–200 mg daily; Escitalopram 5–20 mg daily | When palpitations are predominantly anxiety-driven | SSRIs are first-line for panic disorder and GAD. Onset of full effect: 4–6 weeks. Prescribe with behavioural therapy for best outcomes. | | **Anticoagulants (for AF)** | Apixaban 5 mg BID; Rivaroxaban 20 mg daily; Warfarin (INR 2–3) | Stroke prevention in AF (CHA₂DS₂-VASc score ≥ 2 in men, ≥ 3 in women) | DOACs generally preferred over warfarin for convenience and safety profile. | ### Non-Pharmacological Procedural Options - **Catheter ablation** — curative for many SVTs (success rate >95% for AVNRT), increasingly used for AF and PVCs. Recommended when medications fail or as first-line patient preference [7]. - **Cardioversion** — electrical or pharmacological restoration of sinus rhythm in AF/flutter. - **Implantable cardioverter-defibrillator (ICD)** — indicated for patients at high risk of sudden cardiac death from VT/VF. --- ## Lab Tests Typically Ordered When a patient presents with palpitations, clinicians typically order the following investigations to identify or exclude underlying causes: | Test | Rationale | |---|---| | **12-lead electrocardiogram (ECG)** | First-line investigation. May reveal arrhythmia, pre-excitation (WPW), prolonged QT interval, Brugada pattern, or signs of structural disease. | | **Complete blood count (CBC)** | Screens for [anaemia](/tests/complete-blood-count), which can cause compensatory tachycardia and palpitations. | | **Thyroid function tests (TSH, free T4)** | Rules out [hyperthyroidism](/tests/thyroid-function-tests) — a common and treatable cause. | | **Basic metabolic panel (BMP)** | Assesses [electrolytes](/tests/basic-metabolic-panel) — potassium, magnesium, calcium — imbalances of which predispose to arrhythmias. | | **Serum magnesium** | Often not included in standard BMP; low magnesium is an underdiagnosed cause of ectopy and arrhythmia susceptibility. | | **Holter monitor (24–48 hr) or event recorder (2–4 weeks)** | Ambulatory ECG monitoring to capture intermittent arrhythmias that a resting ECG may miss. Event recorders and implantable loop recorders are used for infrequent episodes. | | **Echocardiogram** | Assesses cardiac structure and function — valvular disease, left ventricular ejection fraction, hypertrophic cardiomyopathy. Ordered when structural disease is suspected. | | **Troponin** | Ordered in the emergency setting if myocardial ischaemia is suspected alongside palpitations. | | **BNP or NT-proBNP** | If [heart failure](/tests/bnp-test) is a concern (dyspnoea, oedema in addition to palpitations). | | **Urine drug screen** | When stimulant use (cocaine, amphetamines) is suspected. | | **Haemoglobin A1c / fasting glucose** | Diabetes and metabolic syndrome are risk factors for AF. | --- ## Special Populations ### Children and Adolescents - Palpitations in children are most commonly due to sinus tachycardia (fever, anxiety, dehydration) or SVT (AVRT is more common than AVNRT in younger children, in contrast to adults) [7]. - **Wolff-Parkinson-White (WPW) syndrome** has peak presentation in infancy and adolescence and may cause life-threatening pre-excited AF. - Paediatric medication dosing differs substantially from adult dosing. **Do not administer adult doses to children.** All anti-arrhythmic therapy in paediatrics should be managed by a paediatric cardiologist. - Exercise-induced palpitations with syncope in a young person should raise suspicion for catecholaminergic polymorphic ventricular tachycardia (CPVT), hypertrophic cardiomyopathy (HCM), or long QT syndrome — all potentially fatal conditions that require specialist evaluation. ### Pregnancy - Palpitations are extremely common in pregnancy, reported by up to 60% of pregnant women, due to a 30–50% increase in blood volume, physiological tachycardia, and hormonal shifts. - Most pregnancy-related palpitations are benign (sinus tachycardia, increased PVCs/PACs). - **Medication safety:** - **Beta-blockers:** Metoprolol and labetalol are generally considered acceptable in pregnancy (former FDA Category C). Atenolol is avoided due to association with fetal growth restriction. - **Flecainide:** Used for fetal SVT treatment; generally considered relatively safe but requires specialist oversight. - **Amiodarone:** Contraindicated in pregnancy — risk of neonatal thyroid dysfunction, neurodevelopmental effects. - **Anticoagulants:** Warfarin is teratogenic in the first trimester; low-molecular-weight heparin is preferred. DOACs are not recommended in pregnancy due to insufficient safety data. - Management should be coordinated between obstetrics and cardiology (a maternal-fetal medicine specialist or a specialist in cardio-obstetrics). ### Elderly (≥65 years) - AF prevalence rises steeply with age (approximately 10% in those over 80). New-onset palpitations in elderly patients warrant thorough evaluation including echocardiography. - Drug metabolism is often slower; start beta-blockers and calcium channel blockers at the lowest dose and titrate cautiously. - Polypharmacy is common — review for QT-prolonging drug interactions (e.g., certain antibiotics, antipsychotics, antidepressants combined with anti-arrhythmics). - Falls are a significant risk; medications causing bradycardia or hypotension require careful monitoring. - Anticoagulation for AF should be assessed using the CHA₂DS₂-VASc and HAS-BLED scores; age alone is generally not a reason to withhold anticoagulation. ### Athletes - Endurance athletes have a 2–10-fold increased risk of AF compared to sedentary individuals, likely related to vagal tone enhancement and atrial remodelling from chronic volume overload. - Resting bradycardia (heart rates of 35–50 bpm) is common and usually physiological in well-trained athletes — it does not typically require treatment. - PVCs may increase during training periods and generally diminish with detraining. - **Pre-participation screening** with ECG is recommended in many European countries (Italian model) to detect conditions like WPW, HCM, arrhythmogenic right ventricular cardiomyopathy (ARVC), and long QT syndrome. - Athletes with diagnosed arrhythmias should be managed per the AHA/ACC eligibility guidelines for competitive athletes [7]. --- ## When to Escalate Use the following framework to decide the appropriate level of care: ### Call 911 / Go to the Emergency Room Immediately - Palpitations with **chest pain, severe breathlessness, syncope, or altered consciousness** - Sustained heart rate **>150 bpm at rest** that does not respond to vagal manoeuvres within 10–15 minutes - Known **structural heart disease** or **prior cardiac arrest** with new-onset palpitations - Palpitations associated with **acute neurological symptoms** (possible stroke) - Signs of **haemodynamic instability**: pallor, cold sweats, severe dizziness, inability to stand ### Same-Day or Next-Day GP / Primary Care Visit - First episode of palpitations lasting **>30 minutes** without red-flag symptoms - Palpitations occurring **multiple times per week** and affecting daily activities - Palpitations associated with **new-onset shortness of breath on exertion** - Palpitations in the context of **recent medication change** or new supplement use - Any palpitation episode in a patient with **known thyroid disease, diabetes, or valvular heart disease** ### Urgent Care (Within Hours) - Recurrent palpitations with **near-syncope** (feeling like you will faint but not losing consciousness) - Heart rate **120–150 bpm at rest** without obvious trigger, persisting >15 minutes - Palpitations with **significant anxiety** that you cannot manage at home ### Routine Cardiology Referral (Weeks) - Frequent PVCs or PACs that are bothersome but without red flags - Recurrent SVT episodes that self-terminate but are becoming more frequent - Abnormal findings on ECG or Holter requiring specialist interpretation - Discussion of catheter ablation as a treatment option > **General rule:** When in doubt, err on the side of seeking medical attention sooner. Palpitations are usually benign, but the exceptions can be life-threatening. A clinician can often provide reassurance after a focused history, examination, and ECG — which may be all that is needed. --- ## References [1] Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. Am J Med. 1996;100(2):138-148. PMID:8629647. [2] Raviele A, Giada F, Bergfeldt L, et al. Management of patients with palpitations: a position paper from the European Heart Rhythm Association. Europace. 2011;13(7):920-934. PMID:21697315. [3] Zimetbaum P, Josephson ME. Evaluation of patients with palpitations. N Engl J Med. 1998;338(19):1369-1373. PMID:9571258. [4] Abbott AV. Diagnostic approach to palpitations. Am Fam Physician. 2005;71(4):743-750. PMID:15742913. [5] Voskoboinik A, Kalman JM, Kistler PM. Caffeine and arrhythmias: time to grind the data. JACC Clin Electrophysiol. 2018;4(4):425-432. PMID:30067480. [6] Voskoboinik A, Kalman JM, De Silva A, et al. Alcohol abstinence in drinkers with atrial fibrillation. N Engl J Med. 2020;382(1):20-28. PMID:31893513. [7] Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia. Circulation. 2016;133(14):e506-e574. PMID:26399663. [8] Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015;386(10005):1747-1753. PMID:26314489. [9] National Institute for Health and Care Excellence (NICE). Palpitations: Clinical Knowledge Summary. Last revised 2023. Available at: https://cks.nice.org.uk/topics/palpitations/. --- *Reviewed for PillsCard.com. This article is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment of cardiac symptoms.*