Palpitations are the sensation of your heart beating and are common. Most cases are harmless. They usually only last for a short time and can be accompanied by other symptoms such as breathlessness, dizziness, chest tightness and a feeling of anxiety. Palpitations that are severe or don't settle quickly may need urgent medical attention. The most common causes are mentioned below.
What are palpitations?
Palpitations are rapid, thumping or fluttering feelings that people experience in their chest. They may be on the left-hand side or middle of the chest. Normally we are not aware of our heart beating. The term 'palpitations' is used when we are aware of our heart beating. Some people say their heart feels like its racing; others say their chest hurts, thumps or flutters. Usually this sensation is caused by a heart rate that is faster than usual for your age, gender and level of fitness. Occasionally, the feeling is due to an irregular heart rate.
What is the heart?
The heart is a muscle that pumps blood round the body. It has two upper chambers - the right atrium (RA) and the left atrium (LA) - and two lower chambers - the right ventricle (RV) and the left ventricle (LV).
The pumping movements of the upper and lower chambers of the heart are coordinated to ensure constant circulation of the blood through our bodies. When we need more oxygen to reach our cells - eg, when exercising - the heart beats faster to pump more blood to the lungs and cells.
An electrical impulse is generated in the RA. It travels across to the LA and down to the RV and LV. This electrical impulse stimulates the chambers of the heart to contract, which propels blood out of the chamber.
What types of palpitations are there?
Palpitations can be caused by:
- An unusually rapid but regular heart rate; or
- Extra beats of the heart; or
- An abnormal heart rhythm; or
- A combination of the above.
The heart usually beats at around 70 beats per minute (bpm). The normal range for an adult can be anything from 40-100 bpm. Your normal resting rate depends on your age and level of fitness. Generally speaking, the fitter you are, the slower your pulse. Also, generally heart rate increases a little with age. Your normal heart rate may increase for several reasons. Some of these are described in the section below. These include:
Extra beats are usually harmless. They occur because all heart muscle cells can generate an electrical signal that can spread outside the normal pathway mentioned above. They feel like a missed beat or thump in the heart. They are usually felt when resting.
An abnormal heart rhythm can cause palpitations. Your pulse will feel irregular because the heart will be beating in an uncoordinated way. An abnormal heart rhythm can result from abnormal electrical activity in the atria or ventricles. Those originating from the ventricle are less common and can be more dangerous than atrial ones.
What problems can cause palpitations?
This list does not include all the possible causes of palpitations but lists some of the more common causes including:
A fast but regular heartbeat (sinus tachycardia)
There are many reasons why the heart rate can be faster than normal. Some of these are:
- Exercise. Your heart beats faster when you exercise; it then gradually slows to normal afterwards.
- Anxiety. This can be either normal worry, or excessive worry, such as in panic attacks or anxiety disorder.
- Caffeine. Drinking too much caffeine in coffee, tea, cola or drinks such as Red Bull® may cause your heart to beat faster, giving you palpitations.
- Certain medication. Some medication such as salbutamol, terbutaline, hyoscine, and hydralazine, amongst others, can cause your heart to beat faster. Some over-the-counter cough and cold medicines can also do this.
- Other stimulant drugs. Some recreational drugs such as ecstasy, cannabis, cocaine and amfetamines can cause a fast heart rate.
- An overactive thyroid gland.
- Smoking. The nicotine in cigarettes can cause a faster heart rate.
- Having a temperature (fever).
A serious underlying abnormality of the heart is a rare cause of sinus tachycardia. Serious heart problems are more likely to causes prolonged runs of palpitations and often other problems such as breathlessness.
Treatment will depend on the underlying reason for the fast heart rate.
Extra beats and missed beats (extra systoles or ectopic beats)
These extra beats occur when heart cells fire off an electrical impulse outside of the normal, coordinated impulses which make the heart contract. After an extra beat, the heart rests or a little longer than usual and this feels like a missed beat. The extra beats are harmless and tend to occur at rest and disappear during exercise. The diagnosis is made by seeing the extra beats on an electrocardiogram (ECG). No specific treatment is needed unless these are very frequent, or there is an underlying problem with your heart.
Atrial fibrillation (AF)
AF is the most common abnormal rhythm of the heart (arrhythmia). It causes an irregular, usually rapid, heartbeat. The upper chambers of the heart (atria) beat in an uncoordinated way. It becomes more common as you get older. It is also more common if you have high blood pressure (hypertension) or underlying heart disease. Excess alcohol and an overactive thyroid (hyperthyroidism) may also trigger AF. The diagnosis is made by the doctor feeling an irregular pulse and is confirmed on an ECG.
Treatment can include:
- Medicines to slow down the heart rate (eg, beta-blockers such as bisoprolol, diltiazem or digoxin).
- Medicines to restore normal rhythm (eg, amiodarone or flecainide).
- Medicines to thin the blood and prevent a stroke (eg, warfarin, rivaroxaban, apixaban, and dabigatran).
- Physical types of treatment such as:
- Electric shock treatment to restore normal heart rhythm (cardioversion).
- Destruction of the area of the heart causing the abnormal rhythm (catheter ablation).
- Pacemaker insertion (to override the heart's natural rhythm).
Supraventricular tachycardia (SVT)
SVT is another cause of palpitations. The heart starts racing extremely fast then stops or slows suddenly. SVTs happen when abnormal electrical impulses start in the atria and override the normal coordinated electrical system of the heart. There is often no underlying reason. Some people find their SVTs are triggered by exercise, getting upset, coffee or alcohol. They often happen for the first time in young people. Most cases are harmless and don't require treatment. If troublesome, treatment with beta-blocker medication (eg, bisoprolol) which slows the heart down or catheter ablation (see under 'Atrial fibrillation (AF)', above) can be effective. See separate leaflet called Supraventricular Tachycardia for more details.
These are much less common and potentially more dangerous than atrial arrhythmias such as AF and SVT. Diagnosis is made by an ECG and referral to a heart specialist (cardiologist) for expert advice will be necessary.
What investigations might be advised?
You are likely to be asked about your intake of the substances mentioned above and the circumstances in which the palpitations occur. Your doctor will take your pulse and blood pressure, listen to your heart and order further tests as appropriate.
You may be asked to have an electrocardiogram (ECG). This records the electrical activity of your heart to check whether the heart rate is regular, and of normal rate. It also looks for underlying or previous heart disease. The ECG can give clues about whether there is any underlying heart problem. However, it is most useful if you have the palpitations while you have the ECG. If you are not having the palpitations at the time, a normal ECG cannot rule out an abnormal heart rhythm.
If this is the case, other tests may be used. For example, you may have an ECG which monitors your heart as you carry on your normal life over 24 or 48 hours. This is called an ambulatory ECG. You will be asked to make a note of when you get the palpitations. The reading will then show what your heart was doing when you felt the palpitations. If the palpitations are not very frequent, they may not occur in that time frame. In this case, you may have to have other tests arranged by a heart specialist (cardiologist). These may involve various devices which record the palpitations when they happen.
If the palpitations last more than a few minutes, you may be advised to attend your surgery or Accident and Emergency while they are present. In this way an ECG may be able to pick up what is happening at the time.
All these tests are to make sure there is no abnormality in your heart causing the palpitations. In many cases, however, palpitations are NOT caused by any problem with your heart.
What is the treatment for palpitations?
Treatment will depend on the likely cause of your palpitations. If, for example, your palpitations are caused by drinking too much caffeine, you will be advised to cut down how much caffeine you drink. If your palpitations are caused by anxiety, your GP will discuss ways of managing this.
Some cases of palpitations are managed by a GP; other cases may be referred to a heart specialist (cardiologist). In either case, the treatment you will be given depends on the cause that has been found.
What should I do if I have palpitations?
Occasionally, palpitations can be serious. In the following situations, you should call an ambulance:
- If you have palpitations that do not go away quickly (within a few minutes).
- If you have any chest pain with palpitations.
- If you have severe breathlessness with palpitations.
- If you pass out, or feel as if you are going to pass out, or feel dizzy.
- If you have palpitations and have had heart problems in the past.
- If you have palpitations which began as you were exercising.
If the palpitations do not make you feel unwell, and settle on their own, you should see your GP. Keep a diary of when they happen and how long they last, as this information will help your GP.
If you have an episode of palpitations it can be useful to check your pulse. In particular it may be useful for your doctor to know how fast your pulse was during the episode. That is, how many beats per minute. Also, if your pulse felt regular or irregular. This information can help identify the cause of the palpitations. Your practice nurse can show you how to take your own pulse. Or you can follow the steps shown on the British Heart Foundation website, given below.
Dr Ann Robinson
Dr Mary Harding
Dr Hannah Gronow