Heart Palpitations

What Causes Them and How Should They Be Treated?

Nurse Adjusts the ECG Pads on a Male Hospital Patient's Chest
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Heart palpitations refers to an unusual awareness of the heartbeat. People who experience palpitations most often describe them as "skips" in the heartbeat, periodic heartbeats that feel too strong, or rapid and/or irregular heartbeats.

The symptom of palpitations is extremely common, and affects most people at some time in their lives. While many people who have palpitations are able to simply ignore them, others find them extremely disturbing or frightening, and often worry that they are about to die at any moment.


Fortunately, the fact is that the vast majority of palpitations are not caused by dangerous or life-threatening heart rhythm disturbances. Still, palpitations can occasionally indicate a potentially serious cardiac arrhythmia, so anyone who has palpations should report them to their doctor. And it is the duty of the doctor to take this symptom seriously.

When you tell your doctor you are having palpitations, he or she ought to take the appropriate steps to identify the underlying cause of your palpitations, and then to provide you with the best advice for treating that cause.

What Kinds of Arrhythmias Produce Palpitations?

Most people with palpitations have some type of cardiac arrhythmia. Virtually any arrhythmia can cause palpitations, but the most common causes are premature atrial complexes (PACs)premature ventricular complexes (PVCs), episodes of atrial fibrillation and episodes of supraventricular tachycardia (SVT).

However, in some cases palpitations can be caused by more dangerous arrhythmias, such as ventricular tachycardia. Life-threatening arrhythmias are usually seen in people who have some type of significant heart disease, so it is especially important to identify the cause of palpitations in people with heart disease, or who have significant risk factors for heart disease (such as a family history of heart disease, smoking, high cholesterol, being overweight, or a sedentary lifestyle).

Not all people who report palpitations have heart arrhythmias, however. The same sorts of symptoms can be caused by musculoskeletal problems or gastrointestinal disturbances, such as gas.

How Palpitations Should Be Evaluated

If you have palpitations, your doctor's first order of business is to find out whether the palpitations are caused by a heart rhythm disturbance, and to identify the particular arrhythmia that is producing the symptom.

This should be relatively straightforward to do, so it's surprising how often doctors seem to have trouble with it. The “trick” in making the diagnosis is simply to record an electrocardiogram (ECG) at the time the symptoms are occurring. That is, the palpitations have to be “captured” on an ECG. That’s it — it’s not exactly rocket science. Unfortunately, the process of making the appropriate diagnosis is often made much harder than it should be.

Don't Let These Mistakes Happen to You

Doctors commonly make two mistakes in their attempt to determine the cause of palpitations:

  • They often fail to record the arrhythmia that is causing the symptoms.
  • They often attribute the palpitations to an arrhythmia that is actually not causing them.

Mistake 1: The doctor will order an ECG (which records the heart rhythm for only 12 seconds) or an ambulatory monitoring study for an insufficient amount of time. When this happens it is often the case that neither the palpitations nor an arrhythmia will be seen during the monitoring period. In such cases doctors have been known to inappropriately conclude that the palpitations are not related to an arrhythmia. Worse, the doctor may tell their patient that the symptoms are "all in your head." Actually, the doctor’s workup was just inadequate.

To make a correct diagnosis, the palpitations and ECG recording must occur at the same time. If the palpitations occur only intermittently, and especially if they do not occur every single day, instead of doing an ECG or doing ambulatory monitoring only for a 24-hour or a 48-hour period (the most common lengths of time employed with these studies), much longer periods of recording should be used. Ambulatory monitoring systems are available that can record the heart rhythm for several weeks — or even months — at a time. The point is, to make a definitive diagnosis the recording needs to continue for however long it takes to "capture" an episode. 

Mistake 2: The doctor will see an arrhythmia during the monitoring period that is not associated with palpitations, and blame the palpitations on that arrhythmia. This is wrong. In order to determine that a particular arrhythmia is the cause of the palpitations, the arrhythmia and the palpitations must occur at the same time.

Since doctors all too frequently make these two mistakes, it is important for you to keep in mind this simple rule if you have palpitations: To make a correct diagnosis, an ECG must be recorded at the very time the palpitations are taking place. If your doctor thinks the workup is complete before this has been accomplished, then you must redirect his or her efforts through gentle reminders, guile, appeals to reason, righteous indignation or whatever it takes.

Treating Palpitations

Appropriately treating palpitations depends entirely on which arrhythmia is causing them. Different cardiac arrhythmias often require quite different treatment approaches.

Most palpitations are caused by arrhythmias that are completely “benign” — that is, not life threatening, or threatening to your health. In these cases, often the palpitations can be adequately “treated” with simple reassurance, since it is often the fear provoked by heart palpitations, rather than the palpitations themselves, that magnify the symptoms. 

If the arrhythmia causing the palpitations is potentially dangerous to life or to health, then the arrhythmia itself will need to be addressed. If you turn out to have one of these arrhythmias, you should learn all you can about it, and about the treatment options available. Read here about specific cardiac arrhythmias


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Mayou R, Sprigings D, Birkhead J, Price J. Characteristics of Patients Presenting to a Cardiac Clinic with Palpitation. QJM 2003; 96:115.

Zimetbaum, P, Josephson, ME. Evaluation of Patients with Palpitations. N Engl J Med 1998; 338:1369.

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