Understanding Heart Palpitations: Causes, Diagnosis, and Treatment

Heart palpitations are a common symptom and a valid reason for concern. Palpitations account for approximately 16% of primary care visits and are among the most common reasons people see a cardiologist. (10) 

Heart palpitations can stem from a multitude of factors, ranging from benign lifestyle choices to serious medical conditions. Understanding their origins, implications, and treatment options is required for effective management and peace of mind. 

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What Are Heart Palpitations?

Heart palpitations are a type of abnormal heart rhythm defined as a rapid or irregular heartbeat. They are often described as feeling like a skipped or extra heartbeat or a rapid fluttering, pounding, or flip-flopping sensation in the chest that lasts a few seconds or minutes. These sensations can also be felt in the neck and throat. (12) 

Causes of Heart Palpitations

A wide range of factors can cause palpitations, but the good news is that they are not dangerous in most cases. (1, 17) 

In a study of 190 patients presenting with palpitations, the underlying cause was cardiac in 43%, psychiatric in 31%, miscellaneous in 10%, and undetermined in 16% of cases. 

Here is a list of possible causes of palpitations to consider when making a differential diagnosis for palpitations: 

Physiological Causes

• Stress and anxiety disorders
• Physical exertion and intense exercise
• Hormonal changes, such as those occurring during pregnancy and menopause

Lifestyle Factors

• Use of drugs, alcohol, tobacco, and caffeine
• Use of medications, including asthma inhalers, decongestants, and thyroid drugs
• Poor sleep and extreme fatigue
• Eating spicy foods
• Dehydration 

Medical Conditions

• Cardiac arrhythmias: bradycardia, tachycardia, premature ventricular and atrial contractions, sick sinus syndrome, atrial fibrillation, supraventricular tachycardia 
• Valvular diseases, such as aortic stenosis 
• Congestive heart failure
• Cardiomyopathy
• Pericarditis
• Fever
• Hypoglycemia
• Anemia
• Hyperthyroidism
• Pheochromocytoma

When to Seek Medical Attention

Palpitations that occur frequently and resolve within a few seconds usually don't warrant the need for medical evaluation. 

Certain signs and symptoms can indicate that palpitations are caused by a more serious underlying heart condition. Talk with your doctor if you experience palpitations that: 

• Last longer than a few minutes and are increasing in frequency 
• Occur with chest pain, shortness of breath, dizziness, or fainting 

Palpitations are more likely to be related to a cardiac etiology if you have heart disease or significant risk factors for heart disease, which include: 

• High blood pressure
• High cholesterol
• Diabetes
• Obesity
• Increased age
• Family history of cardiovascular disease 

Diagnosis and Evaluation

In this section, we will discuss the steps and methodologies used to accurately identify the underlying cause of heart palpitations.

Step 1: Medical History & Physical Examination

The initial step in diagnosing and evaluating heart palpitations involves a comprehensive review of the patient's medical history and a thorough physical examination. This step is essential as it provides valuable insights into potential underlying causes and contributing factors of palpitations.

A detailed medical history allows healthcare providers to identify any pre-existing medical conditions, medication use, family history of heart disease, and lifestyle factors that may influence heart health. Doctors should ask their patients the following questions about their symptoms and health history: 

• Palpitation onset, frequency, duration, and triggers
• Associated symptoms, such as chest pain, shortness of breath, and dizziness
• Current list of medications and supplements
• Personal medical history 
• Family medical history
• Social history, including diet, exercise, and substance use

Most times, doctors will be unable to examine the patient while they are actively experiencing palpitations. The physical exam should be focused on looking for signs that indicate underlying medical conditions are present, which may include:

• Abnormal vital signs (blood pressure, respiratory rate, heart rate and rhythm, body temperature)
• Cardiac: heart enlargement, murmurs, extra heart sounds
• Thyroid: glandular enlargement, tenderness to palpation, sweating, abnormal reflexes
• Skin: pallor of conjunctiva, oral mucosa, and nail beds
• Psychiatric: elevated score on GAD-7 screening questionnaire

Step 2: Lab Tests & Biomarkers

Following the medical history and physical examination, various laboratory tests and biomarkers can be used to further evaluate heart palpitations and identify potential underlying causes.

Blood Tests 

Blood tests are performed to evaluate for suspected disorders that can cause palpitations, including anemia, electrolyte imbalances, heart failure, infection, pregnancy, and thyroid disease. 

The following list includes examples of specific tests that can help in the initial diagnostic evaluation:

• CBC w/ Diff by Access Med Labs
• Comprehensive Metabolic Panel by Access Med Labs
• N-Terminal Pro-Brain Natriuretic Peptide (NT-proBNP) by BostonHeart Diagnostics
• Complete Thyroid Panel w/ Antibodies by Precision Point
• hCG, Total by Access Med Labs

Evaluating Heart Rhythm

It is important to rule out abnormal electrical heart rhythms that may be causing the palpitations. An electrocardiogram (ECG or EKG) is the most common test for diagnosing arrhythmias. This noninvasive test records the electrical activity of the heart. One drawback of the EKG is its potential to overlook irregular heart rhythms in patients with intermittent symptoms, as the test captures a snapshot of heart activity at a specific moment rather than continuously monitoring fluctuations over time.

For patients with intermittent palpitations, at-home heart monitoring may be recommended. This can be done with either a Holter monitor, which records heart activity continuously, or an event monitor, which takes short recordings of the heart while the patient is experiencing symptoms. 

Echocardiogram 

Findings from the physical exam or EKG may indicate the need for an echocardiogram. This imaging test uses sound waves to create a detailed picture of the heart's structure and function. It helps assess for structural abnormalities, such as valve disorders or cardiomyopathy, which may predispose individuals to palpitations.

Stress Tests

Stress tests are indicated for patients who experience palpitations during physical exertion. Stress tests evaluate cardiac activity while the patient exercises, usually on a treadmill or stationary bike. 

Treatment and Management

Unless heart palpitations are caused by a heart condition or other underlying medical condition, they rarely require treatment. Instead, strategies can be recommended to avoid triggers known to cause palpitations and stop palpitations when they occur. 

Lifestyle Modifications

For many individuals, simple lifestyle changes can significantly reduce the occurrence of heart palpitations. These changes include reducing the intake of caffeine and alcohol, quitting smoking, and avoiding recreational drugs (13).

Managing stress through techniques such as yoga, meditation, regular physical activity, and adaptogenic supplements can also be beneficial for patients with palpitations secondary to anxiety disorders. 

The Valsalva maneuver is a breathing technique that increases pressure in the chest and affects the heart's rhythm by stimulating the vagus nerve, which helps slow down heart rate. Research shows this maneuver is an effective first-line intervention for episodes of supraventricular tachycardia. Other similar tricks, such as carotid sinus massage or applying ice water to the face, can also stop the heart from racing. 

Medical Treatments

When lifestyle modifications are insufficient, or there is an underlying medical condition responsible for causing palpitations, medications may be prescribed to manage them.

Antiarrhythmic medications are used to control heart rate and rhythm. There are four main classes of antiarrhythmics:

• Class I: sodium channel blockers
• Class II: beta-blockers
• Class III: potassium channel blockers
• Class IV: calcium channel blockers

Some arrhythmias, such as atrial fibrillation, may also require blood-thinning medications to prevent severe complications like blood clots and stroke. 

In patients with underlying conditions such as hyperthyroidism or electrolyte imbalances, medications or supplements targeting these specific issues can help alleviate palpitations.

If medications are ineffective or if the palpitations are due to a significant underlying heart condition, more invasive treatments may be required. For example, catheter ablation is a procedure used to treat certain types of arrhythmias by destroying the areas of the heart that are causing the abnormal rhythm. 

Monitoring & Follow-Up

The prognosis for individuals experiencing heart palpitations largely depends on the underlying cause. Most palpitations are benign and do not pose a significant risk for increased cardiac morbidity or mortality. Simple lifestyle modifications and reassurance are often sufficient for these patients to manage symptoms effectively. 

However, when palpitations are linked to underlying cardiac conditions such as arrhythmias, heart disease, or structural abnormalities, a more cautious approach is necessary. These cases may require more frequent monitoring and a higher force of intervention with medications, medical procedures, or implantable devices to manage the condition and prevent health complications.

Patients should closely follow their healthcare provider's recommendations, which may include periodic evaluations, medication adjustments, and lifestyle changes to mitigate risk factors. Patients should monitor their symptoms and promptly report any changes in the quality, frequency, or severity of palpitations to their healthcare team. Ongoing communication with healthcare providers ensures timely adjustments to the treatment plan and helps maintain optimal heart health. 

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Key Takeaways

• Palpitations are among one of the most common symptoms that prompt patients to seek medical care. 
• While most palpitations are benign, they can be a symptom of severe underlying heart disease, so it is always recommended that patients get evaluated by a doctor. Palpitations are considered more serious if they are accompanied by dizziness, fainting, and chest pain.
• The treatment of palpitations will depend on their underlying cause. All patients with palpitations can benefit from making positive lifestyle changes, focusing on a healthy diet, regular exercise, and avoiding stimulants to support cardiovascular health.