What is Palpitation?
Palpitations are a common reason why people seek medical help, often visiting local emergency departments, their primary care doctor, or a heart specialist. In one survey, it was found that 16% of people complained of palpitations when they visited their primary care doctor.
Here’s what you need to know: When we say ‘palpitations,’ we’re talking about the feeling of a fast or irregular heartbeat. Some describe palpitations as feeling like they’ve missed a beat, a fluttering feeling in the chest, a sensation of pounding in the chest or neck, or the chest flip-flopping.
Palpitations can be somewhat vague as they might be both a symptom of something else or a diagnosis in themselves. Most of the time, they’re harmless, but they could also be a sign of a life-threatening condition. So, if you’re experiencing palpitations, it’s crucial to get checked out by a healthcare professional.
What Causes Palpitation?
Our understanding about how the brain processes feeling of the heartbeat isn’t fully developed. It’s thought that different structures both inside and outside the heart are involved. Palpitations, or the feeling of a fast-beating, fluttering, or pounding heart, are very common, especially in those with heart disease. Various causes are behind these palpitations and sometimes, we can’t determine the cause.
One study on the culprits behind palpitations found that 43% were heart-related, 31% were related to mental health, and about 10% were classified as miscellaneous (caused by medication, overactive thyroid, caffeine, cocaine, anemia, amphetamines, or mastocytosis, a rare disease that involves the mast cells).
Heart-related causes of palpitations can be life-threatening and include a variety of conditions. These conditions can involve the lower chambers of the heart (ventricles) such as premature heartbeats, fast heartbeat, or chaotic heartbeat. They can also involve the upper chambers of the heart (atria) like fibrillation, a condition that involves a very irregular heartbeat, or flutter, which is a type of abnormal heartbeat. Other causes can be related to high output states such as anemia, the formation of an abnormal connection between arteries and veins, Paget’s disease, or pregnancy. Structural abnormalities such as being born with a heart defect, enlarged heart, aneurysm of the main artery that carries blood from the heart, or acute heart failure can also lead to palpitations. Other causes include conditions like postural orthostatic tachycardia syndrome (a condition in which your heart rate increases upon standing), Brugada syndrome (an inherited heart rhythm disorder), and sinus tachycardia (fast heartbeat originating from the natural pacemaker of the heart).
At times of high adrenaline level, such as during exercise or stress, palpitations can occur. This is most often caused by a sustained fast heartbeat originating from the atria or ventricles, particularly after finishing exercise as adrenaline levels drop and the nervous system that controls rest and digestion activities kicks in. Palpitations can also happen during emotionally startling moments, particularly in patients with long QT syndrome, a heart rhythm condition that can cause fast, chaotic heartbeats.
Different mental health conditions, such as depression, general anxiety disorder, panic attacks, and somatization (a condition in which a person experiences physical symptoms in response to psychological distress) can result in palpitations. However, it’s interesting to note that in one study, up to 67% of patients diagnosed with a mental health condition had an underlying arrhythmia, or irregular heart rhythm.
Several metabolic conditions, or conditions that affect how your body converts or uses energy, can also cause palpitations. These include overactive thyroid, low blood sugar, low calcium levels, high or low potassium levels, high or low magnesium levels, and pheochromocytoma, a rare tumor of the adrenal gland which can cause high blood pressure.
Various medications can lead to palpitations as well. These include drugs that mimic sympathetic nervous system (involved in body’s “fight or flight” response), drugs that block the action of a neurotransmitter called acetylcholine, drugs that widen blood vessels, and withdrawal from drugs called beta blockers. Common causes also include excessive caffeine or marijuana. Recreational drugs like cocaine, amphetamines, and 3-4 methylenedioxmethamphetamine (also known as Ecstasy or MDMA) can also trigger palpitations.
Risk Factors and Frequency for Palpitation
Many people, especially those with heart conditions, often experience palpitations. There are four main types of palpitations: extrasystolic, tachycardic, linked with anxiety, and intense. The type most often seen is the one related to anxiety.
Signs and Symptoms of Palpitation
When a person experiences heart palpitations, it’s crucial for their healthcare provider to gather a detailed medical history and conduct a thorough physical examination. Part of the medical history includes finding out when the palpitations first started, what they feel like, any circumstances that seem to trigger them, and how quickly they come on and depart. Also important are the duration of the symptoms and any actions or factors that may relieve them, such as rest or doing a Valsalva maneuver (a breathing technique). Other symptoms like chest pain, feeling lightheaded, or fainting, should also be reported. The patient might be asked about their medication use (including any over-the-counter drugs), personal habits like exercise, caffeine intake, alcohol, and illicit drug use, as well as their past medical history and family history.
Palpitations since childhood are most likely linked to a type of rapid heartbeat called supraventricular tachycardia. However, those that start later in life could be due to heart disease. The type of heartbeat rhythm can be a clue to the cause of the palpitations as well: a fast, regular beat could suggest ventricular tachycardia or paroxysmal supraventricular tachycardia, while a fast, irregular beat might point to atrial fibrillation or atrial flutter. Palpitations that are quickly relieved by the Valsalva maneuver might also imply supraventricular tachycardia. If palpitations are accompanied by chest pain, this may suggest the heart isn’t getting enough blood. Lastly, if a person feels lightheaded or faints when they have palpitations, it can indicate serious heart rhythm problems like ventricular tachycardia or other arrhythmias.
Unfortunately, patients often aren’t having palpitations during their medical examination, which makes diagnosis more challenging. A complete physical examination will include checking vital signs, listening to the heart and lungs and examining the extremities. Sometimes, patients can tap out the rhythm of their previous palpitations to help the doctor understand what they felt.
Positive orthostatic vital signs, which involve changes in blood pressure and heart rate with different body positions, may suggest dehydration or an electrolyte problem. Heart sounds such as a midsystolic click and murmur may suggest a heart valve problem called mitral valve prolapse. A loud murmur throughout the heartbeat cycle can point to a condition known as hypertrophic obstructive cardiomyopathy. Certain characteristics in the heart’s sounds or rhythm can suggest an atrial septal defect, a birth defect of the heart. If there’s an irregular rhythm, that would indicate atrial fibrillation or atrial flutter. Also, signs of an enlarged heart or swelling in the legs may suggest heart failure or other heart problems.
Testing for Palpitation
If you experience abnormal heart rhythms, known as palpitations, your doctor will perform a 12-lead electrocardiogram or EKG. This test helps to understand what might be causing your palpitations. For instance, a short PR interval and a specific wave, known as a delta wave, might indicate a condition called Wolff-Parkinson-White syndrome. If the test detects significant changes in your left ventricle, a main pumping chamber of the heart, and deep Q waves in specific leads of the EKG, it might be due to hypertrophic obstructive cardiomyopathy, a type of heart muscle disease. The presence of Q waves can hint at a previous heart attack, while a prolonged QT interval could suggest long QT syndrome, a heart rhythm condition that can cause fast, chaotic heartbeats.
At the same time, your doctor will also order routine blood tests to rule out other issues. Blood counts can help check for low hemoglobin, a condition called anemia, or signs of infection. It’s also important to check your kidney function and electrolyte levels as they play a major role in maintaining a healthy heart rhythm. In addition, thyroid function tests can tell if your thyroid is hyperactive, which could also cause palpitations.
In many cases, palpitations are not due to a serious health condition. However, your doctor will still want to identify any potential risks for abnormal heart rhythms. This might include further tests to check for anemia, overactive thyroid, and electrolyte imbalances. An echocardiogram, an ultrasound of your heart, may be ordered if there’s a concern about potential structural heart problems.
Extra tests may be recommended for certain patients. Those who need more testing include patients whose EKG suggests an abnormal heartbeat, those at high risk for an abnormal heartbeat, and those who want a clearer understanding of their symptoms. High-risk patients typically have some form of heart disease or abnormal heart muscle condition that can trigger severe irregular heartbeats.
In high-risk patients, a more forthright approach is recommended. This can include continuous heart monitoring or electrophysiologic studies, in which a detailed analysis of the heart’s electrical activity is made to pinpoint the location and cause of the arrhythmia. There are three types of monitors, including the Holter monitor, continuous-loop event recorder, and an implantable loop recorder. The Holter monitor and continuous-loop event recorder are worn by the patient, while the implantable loop recorder is placed under the skin. These devices are particularly useful in patients who faint without a known cause. They can continuously monitor for heart rhythm problems over extended periods of time, offering cost-effective solutions to capture irregular heart rhythms as they occur.
Treatment Options for Palpitation
The treatment for palpitations, or noticeable rapid heartbeats, depends on what’s causing the problem. For certain types of fast heart rhythms (known as supraventricular and ventricular tachycardias), a treatment called radiofrequency ablation can usually cure these. This is a procedure that uses heat to destroy the problematic heart tissue that is causing the fast rhythms.
The trickier cases involve palpitations that are due to supraventricular or premature ventricular contractions (PVCs) that occur with a normal heartbeat rhythm. These conditions are generally considered harmless, and treatment often consists of reassuring the patient that these irregular heartbeats are not life-threatening.
However, if a person is experiencing symptoms from the PVCs, or they’re extremely frequent (more than 10,000 PVCs in 24 hours based on heartbeat monitoring, or if they make up more than 10% of all heartbeats), they will need treatment. Too many PVCs can lead to heart issues like PVC-induced cardiomyopathy (a disease of the heart muscle) and worsening left ventricular (main pumping chamber of the heart) function in about a third of patients.
The first treatment approach for symptomatic or frequent PVCs typically involves taking heart medicines known as Beta-blockers or calcium channel blockers. If the patient’s symptoms don’t improve with medication, or if they develop left ventricular dysfunction, they may need a procedure called catheter ablation of the PVCs. This is similar to the radiofrequency ablation mentioned before and can cure PVC-induced cardiomyopathy in most patients.
Patients who arrive at the emergency department without symptoms, and their heart exams and lab tests are all normal, can usually go home safely. They should follow up with their family doctor or heart specialist. Patients who have palpitations along with symptoms such as fainting, uncontrolled irregular heartbeats, significant body weakness, or chest pain should be admitted to the hospital for further evaluation. PVCs are common and usually not harmful.
What else can Palpitation be?
The following are various types of heart rhythm problems, also known as arrhythmias:
- Atrial fibrillation/flutter
- Slow heart rate due to advanced heart block or sinus node problems (Bradycardia)
- Heartbeats that alternate between fast and slow (Bradycardia-tachycardia syndrome)
- Multiple sites in the heart initiating beats at once (Multifocal atrial tachycardia)
- Early heartbeats starting from the upper or lower chambers of the heart (Premature supraventricular or ventricular contractions)
- Fast heart rate starting from the natural pacemaker of the heart (Sinus tachycardia) or irregular rhythm (Sinus arrhythmia)
- Fast heart rate starting from the upper chambers of the heart (Supraventricular tachycardia)
- Fast heart rate starting from the lower chambers of the heart (Ventricular tachycardia)
- A disorder in which there is an extra pathway in the heart, leading to fast heart rates (Wolff-Parkinson-white syndrome)
