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What are Palpitations and Tachycardia?
Palpitations, also called cardiopalmus, are the uncomfortable awareness of one’s own heartbeat. When experiencing palpitations, a person may feel as though the heart is:
- Skipping a beat
- Beating too fast (tachycardia)
- Beating too forcefully or with unusual intensity
These sensations may be felt in the chest, throat, or neck and can occur during physical activity. They may also happen at rest, such as while sitting quietly or lying down.
What Can Trigger Palpitations?
The causes of palpitations are varied and wide-ranging. Common triggers include:
- Strong emotions, like anxiety, fear, or excitement
- Intense physical activity
- Medications, including diuretics, nasal decongestants, and asthma inhalers
- Stimulant substances like caffeine, alcohol, tobacco, and recreational drugs are important to consider
- Medical conditions, such as thyroid disorders, anemia, hypoglycemia, and low blood oxygen (hypoxia), can play a significant role
More everyday triggers include:
- Sleep deprivation
- Large, spicy, or particularly heavy meals
- Emotional factors: excitement, nervousness, stress, anxiety, panic attacks
- Hormonal fluctuations, such as those during menstruation or pregnancy, can have significant effects
- Dehydration
In susceptible individuals, these triggers can cause the heart to:
- Beat faster than normal (tachycardia)
- Beat with greater force than usual
- Produce extrasystoles (premature heartbeats)
In all of these cases, the heart continues to function effectively, and palpitations are typically not dangerous.
When Are Palpitations a Warning Sign?
In a subset of patients, palpitations may signal an arrhythmia (a problem with the rate or rhythm of the heartbeat). Arrhythmias can occasionally be a manifestation of serious cardiac conditions, such as myocardial infarction (heart attack), heart failure, valvular disease, or cardiomyopathy.
However, it is important to note that fewer than half of patients who experience palpitations have an underlying arrhythmia. The vast majority of episodes are benign.
If you begin experiencing palpitations, consult your doctor for an evaluation. This is important even if they seem mild or infrequent.
Causes
Palpitations can arise from a remarkably broad spectrum of causes. In many cases, a person may feel them even when the heart is beating normally or only slightly faster than usual. Most episodes are harmless and self-limiting, but some may reflect true cardiac pathology.
Causes Unrelated to Heart Disease
Strong emotions and psychological factors Anxiety, fear, stress, excitement, and panic attacks are among the most common non-cardiac triggers. During emotional arousal, the sympathetic nervous system releases adrenaline, also known as epinephrine. This hormone increases heart rate and contractile force, leading to sensations perceived as palpitations.
Intense physical activity Vigorous exercise naturally accelerates the heart rate. In some individuals, this is perceived as palpitations even when the heart is responding normally. Exercise can also trigger extrasystoles in otherwise healthy people.
Medical conditions (non-cardiac) Several systemic diseases can cause palpitations by increasing cardiac output or altering electrical conduction:
- Hyperthyroidism: excess thyroid hormone accelerates the heart rate
- Hypoglycemia, or low blood sugar, triggers adrenaline release
- Anemia: the heart compensates for reduced oxygen-carrying capacity by beating faster
- Low blood pressure (hypotension)
- Fever
- Dehydration reduces blood volume, which prompts a compensatory increase in heart rate
Hormonal changes Fluctuations in hormone levels during pregnancy, the menstrual cycle, and the perimenopausal period (the transition leading up to menopause) can trigger palpitations. These typically resolve when hormone levels normalize. In pregnant women, palpitations may also be linked to pregnancy-associated anemia.
Medications and stimulant substances A wide variety of drugs and substances can precipitate palpitations:
- Asthma inhalers (beta-2 agonists such as salbutamol) directly stimulate the heart
- Thyroid hormone medications, if taken in excess, can induce a hyperthyroid state and cause palpitations
- Antiarrhythmic drugs: paradoxically, drugs used to treat arrhythmias can sometimes trigger new arrhythmias (a pro-arrhythmic effect)
- Over-the-counter decongestants, which are found in many cold and flu remedies as well as some herbal supplements
- Caffeine is found in coffee, cola drinks, and energy beverages
- Nicotine, found in tobacco products and nicotine replacement therapies
- Alcohol, particularly during binge-drinking episodes known as “holiday heart syndrome”
- Recreational drugs, such as cocaine, amphetamines, and MDMA, are potent cardiac stimulants
Causes Related to Cardiac Conditions
In a significant minority of patients, palpitations indicate a true cardiac arrhythmia, which is an abnormality in the electrical system that governs the heartbeat.
During arrhythmia episodes, the heart may beat:
- Too slowly: bradycardia (fewer than 60 beats per minute)
- Too rapidly: tachycardia (more than 100 beats per minute at rest)
- Irregularly, as in atrial fibrillation
Arrhythmias result from dysfunction within the heart’s electrical conduction system. The likelihood that palpitations reflect an arrhythmia is higher when the patient:
- Has a history of heart attack or is at high cardiovascular risk
- Suffers from known cardiac conditions (heart failure, valvular disease, cardiomyopathy)
- Has electrolyte abnormalities: electrolytes such as potassium, magnesium, and sodium are critical for the electrical stability of the heart. For more information, see electrolytes. Both deficiency and excess can trigger dangerous arrhythmias.
Risk Factors
The following groups are at increased risk of experiencing palpitations:
- Individuals with anxiety disorders, panic disorder, or chronic stress
- Users of stimulant medications or substances (see above)
- Patients with systemic non-cardiac conditions such as hyperthyroidism or anemia
- Patients with underlying heart disease: prior heart attack, arrhythmia, heart failure, valvular disease, or cardiomyopathy
- Women during pregnancy, menstruation, or the perimenopausal period: due to hormonal changes that can lower the arrhythmia threshold
Symptoms
Patients typically describe the experience of palpitations using a characteristic set of expressions:
- The heart “skips” or “misses” a beat
- A sensation of the heart being felt in the throat
- The heart pounding, racing, or fluttering in the chest (tachycardia)
- A feeling of sudden, unexpected strong heartbeats
These sensations may be felt in the chest, throat, or neck and can arise during activity or while at rest.
When Should Palpitations Raise Concern?
In most cases, palpitations do not indicate a serious problem. However, they may be a warning sign of a more significant condition if accompanied by:
- Dizziness or lightheadedness and/or mental confusion
- Near-fainting (presyncope) or actual loss of consciousness (syncope)
- Shortness of breath or difficulty breathing
- Chest pain, pressure, or tightness or pain radiating to the jaw or arm
- Excessive sweating
Seek emergency care immediately if palpitations are accompanied by chest pain, fainting, severe shortness of breath, or sudden extreme dizziness. These may signal a life-threatening arrhythmia or acute cardiac event.
Even if your doctor has previously told you not to worry about your palpitations, contact them again if:
- Episodes become more frequent or more bothersome
- They begin to occur alongside any of the warning symptoms listed above
Diagnosis
The primary diagnostic goal is to distinguish benign palpitations, commonly linked to lifestyle factors, anxiety, or transient physiological changes, from those caused by potentially dangerous arrhythmias. The modern diagnostic pathway is multidisciplinary and may involve the general practitioner, cardiologist, and in complex cases, an electrophysiologist.
Medical History and Physical Examination
The diagnostic process begins with a detailed clinical interview. The physician will investigate:
- The onset pattern of palpitations: sudden or gradual?
- Duration of each episode
- Whether the perceived rhythm is regular or irregular
- Any associated alarm symptoms (chest pain, syncope, breathlessness)
- Triggers, medications, substance use, and personal/family cardiac history
On physical examination, the physician will auscultate the heart to detect murmurs or abnormal rhythms and will look for signs of non-cardiac conditions (e.g., thyroid enlargement, anemia).
Resting Electrocardiogram (ECG)
The electrocardiogram (ECG) is the cornerstone of the initial workup. Although the ECG lasts only seconds and may be completely normal if palpitations are not occurring at the time of the test, it can still provide critical information about:
- Pre-excitation syndromes (e.g., Wolff-Parkinson-White syndrome)
- Conduction abnormalities (bundle branch blocks)
- Signs of prior cardiac ischemia or structural heart disease
- QT interval prolongation: a risk factor for dangerous arrhythmias
Prolonged Monitoring and New Technologies
Because palpitations are often intermittent, long-term cardiac monitoring is essential to “capture” the abnormal rhythm at the exact moment it occurs:
- Holter ECG (24–48 hour monitoring): Continuously records electrical heart activity. Best suited for patients with daily or near-daily symptoms.
- Extended Holter (7–30 days): Used when symptoms are less frequent.
- Event recorders / Loop recorders: External or implantable subcutaneous devices that monitor the heart for weeks to months, activating automatically when the patient experiences symptoms or when the device detects an arrhythmia. Implantable loop recorders (ILRs) can record for up to 3 years.
- Wearable devices (smartwatches and clinical-grade skin patches): Clinically validated smartwatches and adhesive ECG patches are now integrated into diagnostic protocols. They allow patients to record a single-lead ECG at the exact moment of palpitations, providing valuable real-time data for the cardiologist.
Imaging and Laboratory Tests
To exclude structural or metabolic causes, the following are commonly ordered:
- Blood tests: Thyroid function (TSH, free T4), electrolyte panel (potassium, magnesium, calcium, sodium), complete blood count (to detect anemia), fasting glucose, and renal function.
- Echocardiography: Cardiac ultrasound to assess the morphology and function of the heart valves, ventricular size, and contractile performance.
- Exercise stress test: Essential when palpitations are triggered by physical activity, to detect exercise-induced arrhythmias or underlying coronary artery disease.
- Electrophysiological study (EPS): An invasive test reserved for patients with suspected serious arrhythmias, in which catheters are used to map the heart’s electrical system.
Treatment and Therapy
The management of palpitations aims primarily to improve quality of life and prevent complications from any underlying arrhythmia. When palpitations are benign and not linked to cardiac pathology, reassurance combined with lifestyle modification is often all that is needed.
Lifestyle-Based Approach
Correcting daily habits is the first-line therapy in a large proportion of cases:
- Limit or eliminate stimulants: Caffeine, nicotine, and alcohol increase the excitability of cardiac muscle and lower the threshold for arrhythmias.
- Manage stress actively: Relaxation techniques, mindfulness, yoga, and psychotherapeutic support have been shown to significantly reduce palpitation frequency in anxious individuals.
- Maintain adequate hydration: Dehydration reduces blood volume and can trigger compensatory tachycardia.
- Prioritize regular sleep: Sleep deprivation dysregulates the autonomic nervous system and lowers the arrhythmia threshold.
- Review medications: Inform your doctor of all drugs and supplements you take, as some may be contributing to palpitations and can be adjusted.
Pharmacological Therapy
When palpitations persist or are associated with rapid heart rhythms, the doctor may prescribe:
- Beta-blockers (e.g., metoprolol, bisoprolol, propranolol): The most widely used agents for palpitations. They work by blocking the effects of adrenaline on the heart, slowing the rate and reducing contraction force. Highly effective for anxiety-related palpitations and extrasystoles.
- Calcium channel blockers (e.g., verapamil, diltiazem): An alternative to beta-blockers for rate control, particularly in patients who cannot tolerate beta-blockers.
- Antiarrhythmic drugs (e.g., flecainide, propafenone, amiodarone): Reserved for specific, identified arrhythmias such as atrial fibrillation or supraventricular tachycardias. These agents require close medical supervision due to their potential for serious side effects, including pro-arrhythmic effects.
Vagal Maneuvers
For sudden episodes of regular, rapid tachycardia (paroxysmal tachycardias), the physician may teach the patient physical techniques that stimulate the vagus nerve. This nerve acts as the heart’s natural “brake”.
- Valsalva maneuver: Forcefully exhale against a closed mouth and pinched nose (as if trying to equalize ear pressure on an airplane). This increases intrathoracic pressure, activates the vagus nerve, and can abruptly terminate certain types of supraventricular tachycardia.
- Diving reflex: Briefly immersing the face in cold water triggers a powerful vagal response and slows the heart rate.
- Carotid sinus massage: Applied by a physician in a clinical setting; not for self-administration.
Important: Vagal maneuvers should be learned and performed under medical guidance. They are not appropriate for all types of arrhythmia.
Interventional Procedures and Innovations
For patients in whom palpitations are caused by an identified, drug-resistant arrhythmia, modern interventional options include:
- Catheter ablation (radiofrequency or cryoablation): A minimally invasive procedure in which a thin catheter is guided into the heart and used to destroy (by heat or freezing) the small areas of tissue responsible for the abnormal electrical signal. Catheter ablation is often curative for many types of supraventricular tachycardia, including atrial flutter, AV nodal re-entrant tachycardia (AVNRT), and accessory pathway-mediated tachycardias.
- Implantable devices: In rare cases of life-threatening arrhythmias, implantation of a pacemaker (for bradyarrhythmias) or an implantable cardioverter-defibrillator (ICD) (for ventricular arrhythmias at risk of sudden cardiac death) may be necessary.
When palpitations are secondary to another medical condition, such as anemia, hyperthyroidism, or electrolyte imbalance, treating the underlying cause typically resolves the cardiac symptoms entirely.
Prevention
Many episodes of palpitations can be prevented or significantly reduced by adopting the following strategies:
- Reduce anxiety and stress through relaxation techniques, adequate sleep, regular moderate exercise, and psychological support when needed
- Limit or eliminate stimulants: caffeine, nicotine, alcohol, and recreational drugs
- Stay well hydrated, especially during physical activity or hot weather
- Treat underlying conditions, such as anemia, thyroid disorders, or electrolyte imbalances, that may be driving arrhythmia susceptibility
- Review your medications with your doctor to ensure none of your current drugs are contributing to palpitations
- Follow up regularly: if you have a known cardiac condition, adhere to scheduled check-ups with your cardiologist
Frequently Asked Questions
What are palpitations?
Palpitations are an enhanced awareness of one’s own heartbeat, which may be experienced as:
- The heart skipping or missing a beat
- The heart stopping momentarily
- An acceleration of the heartbeat
- Unusually strong or forceful heartbeats
They can be unsettling, but in the vast majority of cases are not associated with a serious health problem.
When should I be worried?
After any episode of palpitations, it is always advisable to consult your doctor to rule out organic causes (such as heart disease or thyroid disorders). However, in the absence of cardiovascular risk factors, palpitations are most often caused by stress, anxiety, panic, physical exertion, or excess stimulants (caffeine, nicotine, recreational substances).
According to Mayo Clinic experts, occasional, brief palpitations in otherwise healthy individuals are typically harmless. However, in patients with a personal or family history of cardiac disease, it is important to seek further evaluation if episodes worsen or become more frequent.
Go to the emergency room immediately if palpitations are accompanied by:
- Chest discomfort or pain
- Fainting or near-fainting
- Difficulty breathing
- Severe dizziness or vertigo
How can I stop palpitations?
Treatment strategies vary by cause. When the cause is benign, it is generally sufficient to avoid triggers, for example by reducing stress, eliminating stimulant substances, and improving hydration and sleep. Relaxation techniques and breathing exercises can be effective during an acute episode.
In cases of significant anxiety, beta-blockers may be prescribed by your doctor to reduce the frequency and intensity of episodes. For identified arrhythmias, specific pharmacological or interventional treatments (see above) will be recommended.
Sources and Bibliography
- NIH National Heart, Lung, and Blood Institute: Arrhythmias
- Mayo Clinic: Heart Palpitations
- American Heart Association Arrhythmia
- Zimetbaum P, Josephson ME. “Evaluation of patients with palpitations”. New England Journal of Medicine. 1998;338(19):1369–1373.
- ESC Guidelines for the management of patients with supraventricular tachycardia. European Heart Journal. 2020;41(5):655–720.
- Raviele A, et al. “Management of patients with palpitations: a position paper from the European Heart Rhythm Association”. Europace. 2011;13(7):920–934.
