Heart palpitations

What heart palpitations feel like

A palpitation is an awareness of your own heartbeat, and people describe that awareness in very different ways. Some notice a rapid pounding in the chest. Others feel a fluttering sensation, or the impression that the heart has skipped a beat. Occasionally people describe a sudden thump followed by a pause.

In practice these sensations often occur at rest, particularly in the evening when the body is quieter and you are more aware of internal sensations. That timing unsettles a lot of people, and on its own it is not a sign that anything is wrong.

The key point is that palpitations are a symptom, not a diagnosis. The underlying cause can vary widely, so the pattern of your symptoms matters far more than the sensation itself.

• A rapid pounding in the chest
• A fluttering sensation in the chest
• The impression that the heart has skipped or missed a beat
• A sudden thump in the chest followed by a pause
• A heartbeat that feels irregular or uneven
• Nothing noticeable at all, with an unusual rhythm only showing up on a heart tracing or a smartwatch

The common causes that have nothing to do with your heart

Most heart palpitations are not caused by serious heart disease. One of the most common questions Dr Jogiya hears in clinic is whether palpitations are something to worry about, and his honest answer is that context matters. How they feel, how long they last and when they occur all help to work out whether they are benign or need investigating.

Common triggers include the following.

These factors can increase adrenaline levels or affect the heart's electrical activity, which leads to temporary changes in rhythm. Stress and anxiety can produce a very real racing heartbeat, and that sensation deserves to be taken seriously even when the cause is not a heart problem.

There are also medical causes that sit outside the heart itself. Electrolyte imbalances, thyroid disorders and certain medications can all affect the heart's electrical activity, which is one reason a set of blood tests is often part of an assessment.

A common mistake is to assume that any noticeable heartbeat must indicate a serious problem. In reality, many palpitations are simply the body's response to lifestyle factors.

• Stress or anxiety
• Caffeine
• Poor sleep
• Dehydration
• Alcohol

When palpitations may be heart related

There are situations where palpitations are linked to an underlying heart condition. The main group is rhythm disorders, also known as arrhythmias, where the electrical signals that control the heartbeat become irregular.

Several of the conditions Dr Jogiya treats list palpitations among their symptoms.

When palpitations are caused by these conditions they may feel more persistent, occur during activity, or come with other symptoms such as breathlessness, dizziness or fainting.

It is worth being clear about the ventricular rhythms in that list, because they are the ones people worry about most. Ventricular ectopics on their own are not dangerous. Ventricular arrhythmias as a group are very rare, but they can be life threatening if they are not treated appropriately, and that is the reason persistent or worsening symptoms are always looked at properly rather than dismissed.

Less commonly, the rhythm disturbance sits on top of a problem with the heart muscle itself. Cardiomyopathy and ventricular hypertrophy both list palpitations among their symptoms, which is part of why a proper assessment looks at the structure of the heart as well as its rhythm.

• Atrial fibrillation, where the upper chambers of the heart quiver rather than beat, so the heartbeat becomes irregular and is often faster than normal. It is important to diagnose because it raises the risk of stroke
• Atrial flutter, where the upper chambers beat rapidly but in a regular, organised pattern
• Supraventricular tachycardia, a fast rhythm starting above the ventricles, which includes atrial tachycardia and Wolff Parkinson White syndrome. Short bouts can be common and can usually be treated very easily
• Ventricular ectopics, extra beats produced in the lower chambers. The extra beats themselves are not dangerous, and most people who feel them describe a skipped beat
• Ventricular tachycardia, a fast rhythm from the lower chambers. Ventricular arrhythmias are very rare, but it occurs in patients of all ages and it does need to be assessed and monitored properly
• Sick sinus syndrome and tachy brady syndrome, where the heart's own natural pacemaker is unreliable and the rate can swing between slow and fast
• Heart block and bundle branch block, which are faults in the heart's electrical wiring rather than a blockage in an artery. Milder degrees often go completely unnoticed, while complete heart block causes symptoms in almost everyone and is always treated as urgent

The warning signs that change the picture

Certain features make palpitations more likely to need further assessment. Dr Jogiya pays closer attention when palpitations do any of the following.

One pattern he sees regularly is that people either worry excessively about benign palpitations or dismiss symptoms that actually need investigation. Episodes that settle on their own get ignored, and recurring episodes should always be evaluated. An episode that feels different from anything you have experienced before is worth mentioning even if it passed quickly.

Mild symptoms are not the same as no problem. Some people describe only occasional fluttering, yet monitoring reveals a rhythm abnormality that needs attention. That is precisely why the pattern is recorded rather than guessed at.

New or unusual palpitations, particularly ones that come with breathlessness or dizziness, deserve to be investigated rather than attributed to stress or hormones. Dr Jogiya makes that point specifically about women. Anxiety, hormones and the menopause are all real and can genuinely cause physical symptoms, but they can also be used, sometimes unconsciously, as convenient explanations for symptoms that deserve a more thorough assessment. Research has shown women are around 50 per cent more likely to be initially misdiagnosed after a heart attack, so if something feels different from anything you have felt before, that is worth acting on rather than explaining away.

Anything listed in the emergency box at the top of this page is a different matter altogether. That is a 999 call rather than a reason to book an appointment.

• They occur alongside dizziness or fainting, and fainting during exercise or fainting with no warning at all is always taken seriously
• They are associated with chest discomfort
• They happen during physical exertion
• They last for prolonged periods
• They are frequent or getting worse
• They occur in someone already known to have heart disease
• The episodes feel different from anything you have experienced before

How Dr Jogiya investigates palpitations

When assessing palpitations, the most important step is to capture what the heart is doing during an episode. The evaluation usually begins with a detailed history of your symptoms, because that pattern tells Dr Jogiya a great deal before any test is arranged.

Several tests may then be recommended.

Where the heart muscle itself needs a closer look, a cardiac MRI may be added, which is Dr Jogiya's own research field.

One of the practical challenges is that palpitations may not occur during a short clinic visit, and this is where longer monitoring becomes particularly valuable. Wearable technology has changed that picture. From working with patients across his NHS and private clinics, Dr Jogiya finds that roughly seven in ten people who present with intermittent palpitations now arrive with some form of wearable data already in hand. It does not replace a medical grade investigation, but it gives him a head start on when the episodes happen, how long they last and what the heart rate looks like during them. If you use a smartwatch or tracker with heart rate or ECG features, bring the app on your phone to your appointment.

It is worth being honest about the limits of that data. A smartwatch ECG is a single lead trace, which is enough to flag atrial fibrillation reasonably well but not enough to diagnose more complex rhythm problems or to assess the structure of the heart. False alarms happen, so a single unusual reading is not a diagnosis and is not a reason to panic. It is not a reason to dismiss the symptom either. If your device flags an irregular rhythm, save the trace, note when it happened and how you felt, and arrange to see your GP or a cardiologist.

• A 12 lead ECG, a simple test that looks at the electrical conduction of the heart from twelve different vectors
• An ECG monitor, also called a Holter monitor, worn for anywhere from 24 hours to 14 days so an intermittent rhythm can be caught
• An echocardiogram, a specialised ultrasound scan of the structure and function of the heart including the valves and chambers
• Blood tests, which can pick up causes outside the heart such as anaemia or a thyroid problem
• An exercise tolerance test, which combines exercise with an ECG, where symptoms come on with exertion

What helps, and when to arrange an assessment

For many people, simple lifestyle adjustments reduce how often palpitations happen.

Consistency is key here. Small changes in daily habits often have a noticeable impact over time.

If palpitations turn out to be linked to an underlying rhythm disorder, treatment may involve medication or specialised procedures. Depending on the rhythm, that can mean a DC cardioversion to reset it, an ablation to isolate the part of the conduction system creating it, or a pacemaker where the problem is with the heart's electrical wiring.

It is always reasonable to seek advice if you are unsure about your symptoms. Dr Jogiya would recommend an assessment if palpitations are frequent or worsening, if they come with other symptoms such as dizziness or breathlessness, if there is a history of heart disease, or if the episodes feel different from anything you have experienced before.

Early evaluation provides reassurance when the cause is benign, and it allows timely treatment when it is not. This page is general information rather than individual medical advice, so please speak to your GP or contact the practice about your own symptoms, and treat anything in the emergency box above as a 999 call.

• Reducing caffeine and alcohol intake
• Staying well hydrated
• Improving sleep quality
• Managing stress effectively
• Maintaining regular physical activity