Palpitations are symptoms of everything from short or long-term stress to a variety of arrhythmias (irregular heartbeats). They may feel alarming, but do not always reflect a serious heart condition.  Joseph Marine, M.D., vice-director of the Division of Cardiology at Johns Hopkins, starts his evaluation by asking his patients what they hear.

What are palpitations?

Palpitations are characterized as a general or heightened awareness of your own heartbeat – whether it’s too fast, too slow, or otherwise irregular. You might feel like your heart is thumping, racing, or fluttering. And you could feel this sensation in your chest or your neck.

“I ask them to tap out what their heartbeat feels like. Then I get a sense of whether we’re dealing with isolated skipped beats or a more sustained arrhythmia,” says Marine. “Patients frequently will feel their skipped beats more at night, when they’re lying in bed and nothing is distracting them from it.”

Diagnosing palpitations

Palpitations can occur for a variety of reasons unrelated to heart disease. These include:

• Overexertion
• Stress
• Caffeine, alcohol, tobacco, or diet pills
• Overactive thyroid
• Hormone changes associated with menstruation, pregnancy, or menopause
• Low blood pressure
• Heart disease or abnormal heart valves
• The body’s response to medications such as thyroid pills, cold medicines, and asthma drugs

Palpitations can also result from a range of heart arrhythmias. These are classified by location, and type of heartbeat. A few common types:

• Supraventricular tachycardia – A rapid heart rate originating above the ventricles (lower heart chambers). It can cause the heart to beat very quickly or erratically. Symptoms might include an overly fast pulse and dizziness.
• Atrial fibrillation – The most common type of arrhythmia, an atrial fibrillation can result in a rapid and erratic heartbeat, which may interfere with blood flow to the ventricles and possibly lead to serious clotting conditions or stroke. Symptoms might not exist at all, or involve chest pain, palpitations, or shortness of breath.
• Ventricular tachycardia – A rapid heartbeat originating in the ventricles (lower heart chambers). When associated with structural heart disease, this arrhythmia may cause loss of consciousness and, in some cases, cardiac arrest or sudden death.

Separating serious palpitations from harmless ones

It’s important to differentiate palpitations caused by stress or minor arrhythmias from those that may point to an underlying heart disease. Inconveniently, palpitations don’t always occur during the time you’re with your doctor.

Marine recommends coordinating an electrocardiogram (ECG) with the irregular heart beat symptoms the patient is having by using a Holter or event monitor.

A Holter monitor is a portable machine you would carry in your pocket or small pouch around your neck or waist for 24 to 48 hours. Electrodes connect your chest to the monitor wires to record your heart rhythms.

An event monitor records heart rhythms for a longer span of time (about a month). The patient activates the monitor whenever he or she experiences an irregular heartbeat.

Treating palpitations

Depending on the severity of the symptoms and underlying cause of the palpitation, your doctor will typically recommend one of three treatment options:

• Preventive care (for non-severe palpitations) – Try eliminating smoking, excess caffeine, and alcohol from your daily regimen; practice general deep breathing and yoga; get plenty of sleep and exercise; regularly schedule “you” time.
• Medications – Your physician might prescribe antiarrhythmic drugs such as beta blockers and calcium channel blockers, both of which have a safe track record. Occasionally these drugs don’t work effectively and stronger antiarrhythmic drugs that directly act on the sodium and potassium channels of the heart might be necessary.
• Catheter ablation – Small wires are threaded through the leg veins into the heart to trigger an arrhythmia, identify the cause, and cauterize the problem area. This treatment is highly effective when the physician can identify an arrhythmia in a specific region of the heart (such as supraventricular tachycardia).

Other outpatient procedures include cardioversion (electric shock sent to the chest wall to synchronize the heartbeat to a normal rhythm), and an implantable defibrillator (a special type of pacemaker that automatically detects and terminates ventricular arrhythmias associated with heart disease).

Sometimes comfort and reassurance are the best medicine

“While palpitations can sometimes signal a more serious condition, they’re often just a sensation of a normal heartbeat,” says Marine. “Confirming that nothing is seriously wrong is sometimes all a person needs. Relaxation techniques and reassurance from a physician – I find that both are very helpful when the cause of palpitations is benign.”