Palpitations: Are Your Heartbeats Normal or Dangerous?

Types of Palpitations

References

Sources cited on this page. PubMed links open the original abstract.

1. Wexler RK, Pleister A, Raman SV. Palpitations: evaluation in the primary care setting. Am Fam Physician. 2017;96(12):784–789. PMID 29431384

When palpitations need an urgent ECG – red flags to act on immediately

Most palpitations are benign ectopic beats – extra heartbeats that feel like a "thud", "flip", or "missed beat" – which require no immediate treatment. However, certain features should prompt same-day or emergency assessment:

• Palpitations with syncope or near-syncope: Loss of consciousness during palpitations is a red flag for a potentially life-threatening arrhythmia such as ventricular tachycardia or complete heart block.
• Palpitations with chest pain: Suggests ischaemia or structural heart disease triggering the arrhythmia.
• Regular, rapid palpitations lasting more than 30 minutes: Sustained supraventricular tachycardia (SVT) or atrial flutter requires cardioversion or IV medication to restore rhythm.
• Palpitations in a patient with known structural heart disease: Pre-existing cardiomyopathy or prior heart attack dramatically raises the risk that palpitations reflect ventricular arrhythmias.
• Irregular palpitations with breathlessness: Suggests new-onset atrial fibrillation – which carries stroke risk and requires prompt anticoagulation assessment.

The diagnostic challenge – correlating symptoms with rhythm

The most difficult aspect of investigating palpitations is that they are usually episodic. A 12-lead ECG in clinic may be entirely normal if the patient is in sinus rhythm at the time of recording. The key diagnostic tool is a 24-hour Holter monitor (or 48-hour to 7-day extended recording) that captures the heart rhythm continuously during normal daily activity. If palpitations occur daily, a 24-hour monitor has a good yield. If they are infrequent, an event recorder worn for 2–4 weeks (activated by the patient when symptoms begin) is more sensitive. For very rare episodes, an implantable loop recorder (ILR) can monitor for up to 3 years.

Functional palpitations and anxiety

A substantial proportion of patients with palpitations have no arrhythmia on prolonged monitoring. In this group, palpitations are often a heightened perception of normal sinus rhythm – either during anxiety, panic attacks, or in the context of heightened cardiac awareness after a stressful event. Hyper-awareness of the heartbeat (sometimes called somatosensory amplification) can be maintained by the anxiety the palpitations themselves generate, creating a feedback loop. Identifying a normal rhythm during symptomatic episodes is reassuring and can itself break this loop; cognitive behavioural therapy (CBT) has evidence in functional palpitations when cardiac causes have been excluded.

What palpitations feel like, and why the description matters

Describing the rhythm is genuinely diagnostic, because different arrhythmias feel different. A single thump or a sensation that the heart has skipped and then restarted usually reflects an ectopic beat, which is common and generally harmless. A fast, regular racing that starts and stops abruptly, like a switch, suggests a supraventricular tachycardia. A fast, completely irregular rhythm raises the possibility of atrial fibrillation. A pounding that builds and fades over minutes, often with sweating and a sense of dread, more often reflects anxiety or an adrenaline surge than a primary rhythm problem.

Tapping the rhythm out on a table for your doctor is more informative than it sounds, and so is recording an episode. Most modern phones and smartwatches can capture a single-lead trace, and while these should not be used to self-diagnose, a recording made during symptoms is often the piece of evidence that resolves the question.

Common triggers worth removing before testing

• Caffeine, including energy drinks and pre-workout supplements, which frequently contain far more than coffee.
• Alcohol, particularly binge drinking, which has a well-recognised association with atrial fibrillation.
• Nicotine from any source, and stimulant decongestants such as pseudoephedrine.
• Poor sleep and dehydration, both of which lower the threshold for ectopic beats.
• Thyroid over-replacement, a common and easily missed cause in people taking levothyroxine.

Features that need prompt assessment

Palpitations accompanied by fainting or near-fainting, chest pain, or breathlessness at rest should be assessed urgently, as should any episode in someone with known heart disease, a weak heart muscle, or a family history of sudden cardiac death under 50. Palpitations that begin during exertion, rather than after it, deserve particular attention. Isolated skipped beats in an otherwise well person with a structurally normal heart are usually benign, but that reassurance depends on the assessment having been done.