Written by Dimitrios Vrachatis, Specialist Cardiologist, PhD, National and Kapodistrian University of Athens.
What are palpitations or fluttering in the chest?
Palpitations, fluttering in the heart, chest or neck, a hollow feeling in the chest, or a sensation that the heart stops and starts describe awareness of the heartbeat.
Normally we do not notice it. Palpitations mean an unpleasant, intrusive awareness of the heartbeat or a pause, continuously or intermittently.
They can reflect disease, but can also occur with completely normal heart function.
The intensity varies greatly between people. Some experience benign events as frightening, while others barely notice or have no symptoms from dangerous arrhythmias.
What should I do when I feel palpitations?
They can occur at rest, during exercise, on waking, before sleep, around fainting or near-fainting or chest pain, while sitting or standing. First, do not panic. Practical steps include:
- Make your position safe. Sit down, hold onto something or ask for help, reducing injury risk if you faint.
- Take a few deep breaths and notice what is happening. The sensation will most likely settle within seconds.
- Feel your pulse with two fingers at the wrist, palm upwards. Note whether it is regular or irregular and count beats over 60 seconds.
- If your smartwatch records events, note the time. Some watches can record an ECG after a specific action, such as touching the crown. These records can be particularly useful to the cardiologist.
- If available, use a blood pressure monitor or pulse oximeter and record the result. Some oximeters also display a waveform that gives an indication of rhythm regularity.
Note what you were doing, duration, associated dizziness, pain or other symptoms, whether onset and ending were sudden or gradual, and frequency. This helps guide investigation.
When should palpitations concern me?
Most reflect benign conditions with no immediate or future danger. Even some arrhythmias are less significant when the heart is otherwise normal.
Nevertheless, timely diagnosis can relieve symptoms and prevent harm.
People with multiple risk factors, such as hypertension or diabetes, known heart failure, previous stroke or cardiac surgery should contact their cardiologist promptly because a significant cause is more likely.
Otherwise healthy people should seek immediate advice if:
- Symptoms do not settle quickly
- Cold sweats, dizziness, chest, abdominal or head pain occur
- There is nausea or an urge to vomit
- They feel generally unwell
- Fainting or loss of consciousness occurs
- Resting heart rate exceeds 120 beats per minute
- The pulse is irregular
Brief or episodic symptoms without concerning features can be assessed routinely. If you were recently assessed and discussed the same symptom, reassessment is not needed every time it occurs.
What happens at a cardiology consultation?
Palpitations are a common reason for consultation. Investigation usually proceeds routinely until a cause is found, though this is not always possible. Sudden, severe symptoms may require urgent assessment.
If symptoms are still present on arrival, an ECG may be performed even before the history is taken. These events are often transient, and recording electrical activity during the symptom is especially valuable, including when the rhythm is normal and several conditions can be excluded.
The cardiologist then reviews personal and family history. Further assessment usually includes an echocardiogram and blood tests, including blood count, electrolytes and thyroid hormones, to identify causes and assess overall cardiac health.
Prolonged 24-hour Holter monitoring, an implantable loop recorder or an exercise test may be needed. More significant cases occasionally require an electrophysiology study.
What can cause palpitations?
Many causes can produce this sometimes very troubling symptom. There may be no arrhythmia at all.
Most cases reflect benign events, such as isolated atrial extra beats, or non-cardiac factors such as anxiety. Caffeine, alcohol and even chocolate can cause or worsen symptoms in some people. The following lists are not exhaustive.
Cardiovascular Causes
- Atrial fibrillation
- Supraventricular or atrial arrhythmias
- Atrial extra beats
- Ventricular extra beats
- Valve disease
- Myocardial infarction or acute coronary syndrome
- Dissecting aneurysm
- Pacemaker malfunction
- Heart failure
- Sick sinus syndrome
- Pulmonary embolism
- Low blood oxygen
- Low blood pressure
Non-cardiac Causes
- Anaemia
- Fever
- Pregnancy
- Menopause
- Anxiety or stress
- Panic attacks
- Thyroid disease
- Hypoglycaemia
- Electrolyte disturbances
- Dietary triggers: coffee, tea, alcohol, energy drinks, spicy food or a heavy meal
- Medicine side effects, such as nasal decongestants or asthma inhalers
- Illicit drugs, such as cocaine or amphetamines
Complications
Feeling your heartbeat is not itself harmful. The symptom causes no physical complications, though psychological distress can develop into panic and a self-perpetuating cycle.
If an arrhythmia is present, the risks depend on its type. They may include:
- Marked weakness or dizziness
- Fainting
- Tachycardia-induced cardiomyopathy or heart failure from a prolonged arrhythmia
- Stroke with atrial fibrillation
- Cardiac arrest with dangerous ventricular arrhythmias
How are palpitations treated?
Treatment depends on the underlying cause. Often no disease is found and no specific treatment is needed.
For many benign causes, regular moderate exercise, such as brisk walking or swimming, reduces or resolves symptoms. Avoid smoking, insufficient rest and stimulants, including coffee, tea, cola, cocoa, chocolate and energy drinks.
If anxiety or stress is responsible, managing it, possibly with professional support, can help.
When an arrhythmia is diagnosed, the cardiologist may recommend medication, urgent cardioversion or ablation, and treatment of any underlying cardiac or non-cardiac cause, such as heart failure or thyroid disease.