Palpitations

Palpitations are an awareness of the heartbeat. Most people are not normally aware of their heart beating, so noticing it can feel alarming — but in the great majority of cases palpitations turn out to be harmless. Patients describe them in many different ways: a thumping in the chest, a fluttering, a skipped or missed beat, a pause followed by a heavy thud, or a sustained racing of the heart.

Palpitations may occur on their own, or with accompanying symptoms such as breathlessness, light-headedness, chest pain or feeling generally unwell. The pattern of symptoms — and what brings them on — is often the most useful clue to the underlying cause.

What causes palpitations?

There are many possible causes, ranging from completely benign through to important rhythm problems that benefit from treatment.

Ectopic beats are extra heartbeats that arise from outside the heart’s normal rhythm. They are extremely common — almost everybody has some — and most of the time they are felt as a skipped beat, a pause, or a heavy thud after the pause. They are usually harmless, particularly when the heart is otherwise structurally normal.

Atrial fibrillation (AF) is the most common sustained heart rhythm problem. The top chambers of the heart beat in a chaotic, irregular pattern, and patients often describe an irregular, sometimes fast, fluttering pulse. AF can come and go (paroxysmal AF) or be persistent. It is important to identify because it increases the risk of stroke and may need treatment with anticoagulation, rate control, rhythm control or, in selected cases, ablation.

Supraventricular tachycardia (SVT) describes a sudden onset of a fast, regular heart rhythm — often around 150 to 220 beats per minute — that typically starts and stops abruptly. Episodes can last seconds, minutes or hours. SVT is usually not dangerous but can be very disruptive, and is often very treatable, sometimes with a curative ablation procedure.

Ventricular ectopy and ventricular tachycardia (VT) are rhythms that arise from the lower chambers of the heart. Occasional ventricular ectopics are common and usually benign, but sustained VT — particularly in patients with underlying heart disease — is more serious and needs prompt assessment.

Sinus tachycardia is simply a fast version of the normal heart rhythm. It is the appropriate response to exercise, stress, fever, dehydration, anaemia, an overactive thyroid, caffeine or alcohol — and is not in itself a heart problem.

Anxiety and panic can produce strong, fast heartbeats, often felt particularly at rest or when trying to fall asleep. The heart rhythm is usually normal and these episodes can be addressed alongside the cardiac assessment.

When should I be concerned?

Most palpitations are not a sign of anything dangerous, but the following features should prompt earlier assessment:

Palpitations associated with blackout, near-blackout, or significant light-headedness.
Palpitations with chest pain or significant breathlessness.
Palpitations that come on during exertion (rather than at rest).
A family history of sudden cardiac death at a young age.
Known underlying heart disease — for example previous heart attack, cardiomyopathy or significant valve disease.

If you are experiencing any of these red-flag features alongside palpitations, you should seek prompt medical attention rather than wait for an elective appointment.

How are palpitations assessed?

The first step is a careful history and examination, supported by an ECG. Because palpitations are often intermittent, the most useful question is how to capture the heart rhythm at the moment the symptoms occur.

Electrocardiogram (ECG) — a quick recording of the heart’s electrical activity. If you are in an abnormal rhythm at the time, this gives the diagnosis. Even an ECG taken between episodes can give important clues.
Ambulatory ECG monitoring — a small device worn for 24 hours, several days, or up to two weeks, recording continuously. This is the standard next step when symptoms occur frequently.
Event recorder / patch monitor — a longer-duration patch (often 7 to 14 days) that the patient activates when symptoms occur, increasingly used in place of the traditional 24-hour Holter.
Implantable loop recorder (ILR) — a small device, around the size of a USB stick, inserted just under the skin in the upper chest in a quick clinic procedure. It can record the rhythm continuously for up to several years and is used when symptoms are infrequent but potentially important (for example unexplained blackouts).
Transthoracic echocardiogram (TTE) — to look for any underlying structural problem.
Stress echocardiography — used in selected patients, particularly when symptoms occur with exertion.
Cardiac MRI — for selected patients, particularly when an underlying cardiomyopathy or scar tissue is suspected.
Exercise testing — for symptoms that come on with exertion.
Blood tests — to look for thyroid problems, anaemia and other contributors.

How are palpitations treated?

Treatment depends entirely on what is found. Many patients need no more than reassurance and a few sensible lifestyle adjustments — reducing caffeine and alcohol, improving sleep, and managing stress. Where a specific rhythm problem is identified:

Atrial fibrillation is treated with a combination of stroke prevention (anticoagulation in most patients), rate control, and in selected patients rhythm control with medication, cardioversion, or catheter ablation.
SVT can often be controlled with medication and is curable in most patients with a catheter ablation procedure.
Frequent symptomatic ectopy can be treated with reassurance, beta-blockers, or in selected cases ablation.
Ventricular arrhythmias are managed according to the underlying cause and may involve medication, ablation, or an implantable defibrillator.

Dr Dawkins works closely with electrophysiology colleagues at Cleveland Clinic London and the John Radcliffe for patients who need ablation or device therapy.