Heart Health

Palpitations

August 24, 2009

Palpitations

At least once a week I get a consult for palpitations.  Since this is such a common problem I thought it might serve as a good subject to write about.

If we define palpitations as the abnormal sensation of one’s own heart beat then I would propose that everyone has palpitations at some point in their lives.  The most common descriptions I hear are the sensations of irregular or skipped beats, pounding in the chest, flip-flopping of the heart, or just the simple “awareness” of a regular heart beat.  It can affect patients of all ages, though I think it’s more often present in younger people.  For some reason older patients can have remarkably irregular heart rhythms and feel little or no symptoms.

By far the most common cause of episodic palpitations is the presence of premature atrial (PACs) or ventricular contractions (PVCs).  Virtually everyone has these occasionally.  It is relatively uncommon to see a patient who can wear a 24-hour continuous ambulatory heart monitor (Holter monitor) and not exhibit at least a couple PACs or PVCs in a day.  These are almost always benign.  Only rarely is the presence of premature beats a marker for a more serious underlying structural or functional problem that could put the patient’s health at risk.  Previously unidentified problems such as atrial septal defect or cardiomyopathy could produce palpitations as their initial symptoms.  These can be easily screened with an echocardiogram.

An electrocardiogram (ECG) is useful but will be normal in most people.  In a small subset of patients we’ll pick up sustained arrhythmias such as atrial fibrillation or flutter.  The substrate for a few very rare life-threatening arrhythmias can also show up on resting ECG.

The Holter 24-hour monitor is often the next evaluation.  The patient wears a monitor for a day and every single heart beat for that period is recorded and analyzed.  The 24-hour monitor has several limitations, though.  My experience is that most patients with frequent and severe palpitations will enjoy the quietest 24 hours they’ve had in weeks.
In physics this phenomenon is called the “observer” or “Hawthorne effect,” but I prefer to call it the “bring-your-broken-car-to-the-shop-and-watch-it-work-like-brand-new-when-the-mechanic-starts-it effect”, for obvious reasons.

If the Holter monitor doesn’t provide enough information—and if the patient hasn’t yet had their fill of stickers on the chest—we also have other monitors that can be worn for up to a month.

Since palpitations due to PACs and PVCs are universally benign (as long as the resting ECG and echocardiogram are normal) the question arises: do we need to treat them?  The answer depends on the patient.  For significantly symptomatic patients I start with a low dose of a beta-adrenergic blocking drug (beta-blocker).  This class of medication essentially decreases the effect of adrenaline on the heart and can blunt the symptoms that accompany the abnormal heart beats.  If the palpitations are nothing more than a nuisance, then perhaps the knowledge that they don’t portend anything ominous is all the patient needs.  Most patients in my clinic prefer to not take a medication every day (with associated possible side effects) in order to treat something that poses no risk.

For a very few, the palpitations can be truly miserable and disrupt their quality of life.  In most cases we can provide some measure of relief with beta-blockers or other, more aggressive, medications.  The good news is that most young symptomatic patients will eventually “outgrow” this problem and the palpitations will fade away as the years progress.  Also, the presence of frequent PACs or PVCs is not a contraindication to exercise, since most patients will have fewer premature beats as their heart rate increases.

In summary, I evaluate the patient with palpitations with an ECG and an echocardiogram to screen for rare underlying problems. I ask for a 24-hour monitor on only the most symptomatic patients who have frequent episodes.  Thankfully, most palpitations in young, otherwise healthy individuals arise for benign reasons and require no treatment except the knowledge that this isn’t a dangerous problem.

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26 Comments
  1. Megan

    Can anxiety cause heart palpitations, irregular heart beat or fluttering? I seem to experience them when I'm feeling pretty anxious or stressed. Thanks for this info.

  2. Dr. Van De Graaff

    Yes, Megan, anything that "revs" up your autonomic nervous system will lead to worse palpitations if you are already susceptible to suffering from them. Other triggers: sleep deprivation, illness, caffeine, alcohol, some decongestants and diet pills, even chocolate. It doesn't mean you necessarily have to avoid these things--just recognize that your palpitations may worsen when you indulge in a giant mocha latte or a night of revelry and bar-hopping (which I'm sure you don't do). So, to avoid palpitations, all you have to do is completely eliminate all stress and anxiety from your life. I'm sure that'll be no problem. Thanks for the comments.

  3. Jane

    Dear Dr. VDG, Thank you so much for sharing your reassuring and wise response. I will follow up with my doctor regarding the echocardiogram, while also holding hope and peace in my "heart" as I am more aware that this experience is likely only, as you say, a "nuisance." Thank you again for your time and consideration. Blessings to you in your ministry of medicine! Jane

  4. Jane

    Dear Dr. Van De Graaff, I am a new first time mom to a 5 month old. Although my little guy is now thankfully sleeping through the night, I have been getting very little sleep as one would expect for over 4.5 months due to being mommy and also evening work responsibilities. I have been experiencing heart palpatations every day ranging from 20-25 episodes /day, the most frequent I have ever experienced in my life. During the third trimester of the pregnancy, I was experiencing spells where I would almost black out and feel lighter types of palpitations, nothing quite like this. The cardiologist did both a 24 hour halter and the EEG and found nothing of consequence. I am hesitant to go back to the physician again b/c everything was fine and that was only 6-7 months ago. I am thinking it is likely just sleep deprivation contributing to this, but was curious if you would suggest to get it check out. I am a 31 year old Caucasian female with no history of heart issues in my family. Thank you for your thoughts!

  5. Eric Van De Graaff

    Jane, Congrats on your new baby and especially that he is sleeping through the night. Your heart is probably extremely healthy and you are simply suffering from the PACs and PVCs I described above. I find that the echocardiogram is the most useful test to distinguish between the patients with "nuisance" palpitations and "problematic" palpitations. If the structure of the heart is normal it is extremely unlikely that the palpitations are anything of consequence and don't need treatment. It sounds from your note like your doctor did not do an echocardiogram. You may wish to revisit the issue with your doctor and ask in particular about the echo. Sleep deprivation and stress can exacerbate palpitations, as can caffeine, decongestants and diet drugs. Sounds like your sleep is improving and with it let's hope your palpitations clear up. Good luck with everything (enjoy your little guy!). Dr. VDG

  6. Jaye

    Dear Dr. Van De Graaff, Thank you for your great insight. I am a 32 year old white female. I have been at a healthy weight my whole life except for the past couple years. I have polysistic ovarian syndrom, high trigs (which im being treated for) and i'm suffering from daily heart palpitations. I went in for a stress test and my dr said everything looked good. My family dr said it was probably stress related and put me on Zoloft. I've been on it for a year now and still have daily palps. I am also on Chantix to stop smoking. Sometimes i experience dizziness with the palps. I'm not sure what my next step should be. Any suggestions? This is scary. thank you, Jaye

  7. Dr. VDG

    Jaye, It sounds like you are actively trying to improve your health on several levels (stopping smoking, getting a check-up with your doctor). It is reassuring to hear that you had a normal stress test. One thing you didn't mention in your note is your exercise pattern. If you've read other blog entries I've written you'll know that I am a vocal proponent of activity and exercise and I hope you are incorporating it into your quest for better health. You palpitations are not uncommon but do require further evaluation (especially if you are experiencing dizziness with them). I'd suggest a Holter (24 hr) or event (2-4 weeks) monitor and an echocardiogram. These are studies your primary doctor can order without the need for cardiology referral. Odds are pretty good that your palpitations are benign and require no treatment. Thanks for the comments and questions and good luck with your decision to quit smoking! Dr. VDG

  8. Eric Van De Graaff

    Casie, A normal echocardiogram and EKG are enough to tell you what the problem isn't (essentially rules out dangerous arrhythmias and structural heart disease) but they don't tell you what it is. PACs and PVCs are the most likely culprits and would be benign in your case. To figure it out specifically you'd have to wear a monitor while your are actively having symptoms, something your doctor could easily arrange. Whether you choose to be treated is a different matter. As I pointed out in the blog post, no harm would come to you if you decide to just live with the symptoms and sometimes the medications used can have side effects that are worse than the palpitations. So, to answer your question: yes, the echocardiogram is enough to prove this is not a dangerous problem. Good luck and thanks for the comments. Dr. VDG

  9. Chris

    Hello I'm a healthy 30 year old male not over weight i do smoke and drink occasionaly ( quit both for 4 months and still had same prob) No caffine at all I've been having palps for the past 10 years. My first episode i was jogging at age 20 and decided to sprint the last of a 3 mile jog, it was very hot and humid that day when my heart felt like it went into high gear but was in neutral it kinda flip flopped around for 30 seconds.This scared me to push physically hard anymore. As time went on i started having single palps 3 times weekly on average. Then 2 years ago at age 28 i also started getting palps during and after anything that was physically demanding especially if i hadn't done anything physical in a while. I do my best to ignore them but sometimes my anxieties will get the best of me. I've had ekg,eco stress test and holter monitor twice and was told i have a healthy heart, but I've never had any episodes while being tested. My question is do you think it could be something not being detected. Without having a clear picture of what it is i feel i could be at risk of ventricular fib or sudden cardiac death. I would really love to start exercising but am a little worried. Any input or advise would be greatly appreciated thanks for reading.

  10. Casie

    I have a 3 year old and a 3 week old and I have been having heart palitations since my first son was about 1. I didn't even know what they were until my second pregnancy when they got VERY bad. I went to my primary care physician and he sent me for an echocardiogram, the results were normal. I am still having palpitations no where near as bad as when I was pregnant though. I sometimes only have a couple a day sometimes none other days it feels like a lot. My question is was the echocardiogram enough? Do I just go on now saying well my heart is healthy this is normal or should I be further tested?

  11. Christina Finn

    Hi, I am healthy 29 year old female. I am a pretty big runner and have run a marathon and a few half marathons. I had a ECG in September-and I have borderline a WPW wave-but my cardiologist said not to worry about it-and to call if I became symptomatic. I recently starting running more since I am training for a race.I ran close to 30 miles last week and probably will run the same this week. I know in the past when I have trained a lot-i have felt like I had some palpitations, and last night while lying down I had the same thing. My resting heart rate was 82-but it is generally around 60 and was earlier that day. It was pretty uncomfortable but it went away after an hour or so. Could this be caused by decreased potassium? I have been bordeline in the past.. Is this related to training or do you it could be WPW? Thanks!

  12. Dr. Van De Graaff

    Christina, Congratulations on all the running. It sounds like you are doing well. My guess is that your symptoms are nothing more than frequent PACs. I say because you mentioned that your heart rate stays normal despite the presence of palpitations. The potassium is probably not a problem since it has to get pretty low to trigger arrhythmias. With all the running you do, though, you may wish to supplement your diet with electrolyte solutions or potassium-rich foods. WPW is a syndrome that arises from an abnormal tract of conducting tissue between the atria and ventricles. It causes problems in two ways: 1. Atrial fibrillation with abnormally rapid ventricular conduction (with rates above 200 bpm and potential fainting or even cardiac arrest), or 2. supraventricular tachycardia, a regular fast rhythm (typically around 200 bpm or less) that produces lightheadedness, fainting, or profound palpitations. Neither of these manifestations fits with your description. The symptoms your doctor would be looking for are those associated with sustained, very rapid heart rates like those described above, and so I'd feel pretty comfortable that you've not yet had any real problems with WPW. You're probably fine (more than fine, in fact, with all your running) and your symptoms are just from benign PACs. If I were you I'd probably just put up with them and go back to your doctor only if they get worse. Good luck with your racing. Dr. VDG

  13. Sylvia Davalos

    My 3 year old nephew said he had a cough so my sister took him to his dr. After the exam she said she would like for him to get an echo. My nephew has not had an major health problems. He is an active 3 year old. Why would she want an echo done and what would she be looking for? Thanks

  14. Dr. Van De Graaff

    Sylvia, I'm no pediatric cardiologist, so take anything I say with a grain of salt. The closest thing I come to interacting with 3-year-olds is when I attend contentious hospital staff meetings (I'm hoping my physician colleagues are not big blog readers). Your nephew's doctor probably heard a murmur during her routine exam. A murmur is the sound made when blood flow through the heart is turbulent rather than smooth. In most children murmurs are benign, expected findings and relate to forceful contraction of blood through small valves. Sometimes a murmur can be a marker of a previously undiagnosed congenital heart abnormality, such as a septal defect or narrowing of a valve. Pediatricians are pretty good at sorting out which murmurs are benign and which need further evaluation. The echocardiogram for your nephew is probably nothing more than a routine precaution and will likely reveal no problems. Thanks for the question. Dr. VDG

  15. katt

    Hi, I recently had an ekg for palpitations and was terrified during the test. I could feel the palpitations happening at the time. The test came back abnormal so I went and had an echocardiogram. Test came back 100 percent normal. Do you think I should have a stress test because of that ekg or is the echo enough? Thank you

  16. Dr. Van De Graaff

    Katt, I wouldn't order a stress test unless you were having chest pain or shortness of breath with exertion. The whole concept behind stress testing is to screen for coronary blockage of 70% or greater and it's best used in people whose symptoms fit with coronary disease. Take a look at this post for more details regarding stress testing: http://www.blogalegent.com/Cardiology-Stress-Testing Coronary disease and palpitations are unrelated problems in most cases. Palpitations are usually the result of PACs or PVCs, or some type of arrhythmia that originates in the upper chambers of the heart (atrial fibrillation, atrial flutter, SVT). None of these problems are life-threatening and none are associated with coronary blockage. I think an echo is enough of an evaluation if your health is good otherwise. If your palpitations are bad enough that they impact your quality of life you should see a cardiologist for more aggressive therapy. Good luck and I hope you feel better. Try not to be "terrified"--you're going to do fine. Dr. VDG

  17. Debra Sweistris

    I have been having palpatations for approx. 3 years now, they have over the past year become worse. I have high thyroid antibodies also. I have had a EKG, ECHO, Heart Monitor they said my heart was smaller on the lower leftside which meant that I was most likely dehydrated. I now drink over 1 gallon of water a day and have now for the last 6 months. I have palps off and on and the degree changes regularly. I sometimes have chest pain and then think I have pain in my jaw and back. (Not sure if I am having the pain because of the palps) if all the tests are ok can I still have heart issues or would this be because of my high thyroid antibodies. I have had blood tests done every 4 months so 3 blood tests and each one the antibodies have increased. I just want to make sure I am not going to have a heart attack.

  18. Laurie Theunissen

    Hi l have experienced occasional palpatation for the passed 8 years over the past 2 weeks the palpitations are much more frequent, every day almost hourly. This is causing me to feel very anxious. l am 50 years old and possibly at the beginning of my menopause. Could the menopause be causing the palpitations?

  19. Eric Van De Graaff, MD

    Chris, Thanks for the question and I'm sorry I didn't see your comments before now. I hope you get this response. The one really reassuring aspect of your story is that your echocardiogram has been normal. This effectively rules out the really dangerous causes of palpitations in young, healthy people who are exercising (see http://blogalegent.com/Cardiology-Sudden-Cardiac-Death-in-Athletes). In your case, your palpitations, while bothersome, are truly benign and won't lead to any significant problems. You've done well to give up smoking and I commend you on your exercise habits--it's those changes that will really make a difference in your future longevity. There are medications that can be used to settle down your palpitations if they are such a nuisance that they interfere with your quality of life and I'd recommend you talk to a cardiologist if this is the case. Good luck with everything. Dr. VDG

  20. Eric Van De Graaff, MD

    Debra, The thyroid gland is an interesting machine. The hormone it realeases has the ability to really mess with the rest of your body if it is produced in too great (or too little) of quantity. Without seeing your numbers in detail it would be hard for me to draw too many conclusions about your specific case, but it's fair to say that your thyroid function can most certainly impact the severity of your palpitations. While your symptoms may be truly bothersome, your concerns of a possible heart attack are unfounded. There is no link between benign palpitations and an increased risk of heart attack, even if the palpitations are quite severe. Heart attacks arise from cholesterol plaque in the coronary arteries and this phenomenon is structurally and functionally unrelated to the causes of palpitations (for a more thorough discussion of this topic please see: http://blogalegent.com/Cardiology-Plumbing-Wiring-Drywall). Your intake of water may also not be necessary. A one-time finding of a small LV cavity on echocardiogram is relatively meaningless and shouldn't dictate your ongoing activity. You can give up the gallon-a-day before you get too waterlogged. If you continue to have chest pain you'll want to look into having a stress test done (if you haven't already). That is currently the best way to get an assessment of coronary status. All the best, and good luck with that thyroid. Dr. VDG

  21. Dhruba Banerjee

    I am a 17 year boy from India. I have got a WPW Syndrome diagonised earlier! Often I get fast palpitaions. I have also got a significant delta wave in my ECG. But doctor has prescribed me beta blockers and I am having breathing trouble. Please suggest something

  22. Eric Van De Graaff, MD

    Eric Van De Graaff, MD

    Dhruba, Thanks for your comments and I’m glad to hear that the electrons of my blog make it all the way to Asia. It sounds like you are already well educated on the subject of WPW and understand how it can be the cause of your palpitations. You may also know that beta-blocker medications can induce some breathing difficulty in people with even borderline asthma. As I see it, you have two choices: 1. Switch from a beta-blocker to another medication that can limit the occurrence of your palpitations. Another class of drugs that can offer benefit is the calcium channel blockers (diltiazem and verapamil), and I’m sure these are also available in India. Treating your WPW with medications alone is not optimal but it can improve palpitations. 2. Find some way to see a doctor (an electrophysiologist) who can perform an ablation of your bypass tract. This may be tough where you live (I’ve never been to India and know nothing about the availability of sub-specialized cardiac care), but it is the only way to provide you a definitive fix to the problem. Good luck, Dhruba, and please let us know how things go. Dr. VDG

  23. Dhruba Banerjee

    dear dr.VDG I will like to explain the whole thing to you..this thing started 3 yrs ago...at that time i consulted an electrophysiologist he presscribed me dilzem...since then it used to happen for 10 secs 15 secs not a prolonged episode.in the mean time another cardiologist prescribed me Metocard. but a few days back i was studying and out of the blue palpitations started off...but this time it did not stop even after consuming two dilzems..so i went straight off to the hospital..there they gave me beta blockers and i got admitted for 2 days halter under the same electrophysiologist...now he prescribed me two beta blockers per day...and secondly he also advised me to sit for a EPS+/- RFA...which is readily available in India! but the main problem for me is the breathing trouble as i am a per time singer!

  24. Dhruba Banerjee

    i forgot to tell u the halter report came normal...except that WPW delta wave!

  25. Michelle

    I have had palpitations off and on for many years. Usually I only have a few a day but sometimes I can have up to 10 palpitations a minute for days. And sometimes they are painful. I have had an echo and a stress echo with normal results but I have never had an ekg. Earlier this month I had palpitations last for a week and they were happening several times a minute that entire time. The first two days were painful during each palpitation and I had chest pressure in between. They are back to every now and then again. My doctor is not going to pursue further testing but I am concerned about a possible arrhythmia or fibrillation. If they start happening frequently again or become painful again, I am considering going to ER for an EKG. What is your opinion?

  26. sam bransden

    Hi, I have had palpitations at least once a day for the last three years, I am a 21 year old male, o am a hypochondriact and suffer anxiety, there normally just one big skipped beat which makes me feel dizzy for a second although sometimes I get the fluttering when I'm lying in my left side for ten minutes or so, ice had ecgs and an echo done all was fine, should i be worried

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