Irregular Heartbeat

Should You Call 911 or Schedule a Cardiology Appointment?

Call 911 now

Emergency evaluation is appropriate when palpitations occur with:

• Chest pain or pressure
• Severe difficulty breathing
• Fainting or loss of consciousness
• Collapse or unresponsiveness
• New facial drooping
• New weakness or numbness on one side
• New difficulty speaking or understanding speech
• Severe confusion
• A sudden, major change in symptoms in someone with known heart disease

Do not use an online form for possible heart-attack or stroke symptoms.

Request a non-emergency cardiology appointment

An outpatient evaluation may be appropriate when:

• Palpitations are new or different from your usual heartbeat
• Episodes occur repeatedly
• Symptoms last for several minutes or longer
• Your heart suddenly begins racing while you are resting
• Episodes wake you from sleep
• Palpitations occur during walking or exercise
• You frequently feel skipped or extra beats
• Your pulse repeatedly feels irregular
• You experience non-emergency dizziness, fatigue, or breathlessness
• A smartwatch or home device repeatedly reports a possible irregular rhythm
• A primary-care clinician or emergency department recommended cardiology follow-up
• You have known heart disease or a previous abnormal EKG
• You have a family history of serious arrhythmia or unexplained sudden death
• Your symptoms are interfering with your normal activities

Palpitations accompanied by significant new symptoms should receive timely medical attention. Call 911 when emergency warning signs are present.

Our Coverage

What Are Heart Palpitations?

Heart palpitations are an increased or unusual awareness of your heartbeat. They may be felt in the chest, neck, or throat.

Patients may describe the sensation as:

• Racing
• Pounding
• Fluttering
• Thumping
• Flip-flopping
• Quivering
• Skipping a beat
• Pausing and then beating forcefully
• Beating too fast
• Beating irregularly
• Beating harder than usual

An episode may last a few seconds, several minutes, or longer. Palpitations can happen during physical activity, emotional stress, rest, or sleep.

The sensation alone does not reveal the cause. A person may feel palpitations while the heart is beating normally but more forcefully, or while an abnormal rhythm is occurring. Some people with arrhythmias do not feel any symptoms at all.

Are Palpitations And Arrhythmias The Same Thing?

No.

A palpitation is what you feel. It is a symptom.

An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart may beat:

• Too quickly
• Too slowly
• Irregularly
• With premature or extra contractions
• With pauses
• Through an abnormal electrical pathway

Palpitations can occur without a clinically significant arrhythmia. An arrhythmia can also occur without noticeable palpitations.

An EKG or heart monitor may be needed to determine what the heart is doing during the sensation.

What Can Cause Heart Palpitations?

Heart palpitations have many possible causes. It is important not to assume that every episode is caused by anxiety, caffeine, dehydration, or atrial fibrillation without an appropriate evaluation.

Stress, activity, and everyday triggers

Possible triggers include:

• Emotional stress or anxiety
• Panic symptoms
• Physical exercise
• Lack of sleep
• Fever or illness
• Dehydration
• Excessive caffeine
• Energy drinks or stimulant-containing products
• Alcohol
• Nicotine
• Recreational stimulant drugs
• Significant changes in physical activity

One trigger may affect one patient but not another. Keeping a symptom record can help identify whether your episodes follow a consistent pattern.

Medications and supplements

Some palpitations may be associated with:

• Nasal decongestants
• Certain asthma medications
• Some attention-deficit medications
• Weight-loss stimulants
• Thyroid medication when the dose is too high
• Certain prescription heart or blood-pressure medicines
• Supplements or pre-workout products containing stimulants
• Cocaine, methamphetamine, or other illegal stimulants

Do not stop a prescribed medication without speaking to the clinician who manages it. Bring a complete list of prescriptions, over-the-counter medicines, vitamins, supplements, and energy products to your appointment.

Medical conditions

Possible medical contributors include:

• Overactive thyroid
• Anemia
• Fever or infection
• Abnormal potassium, magnesium, or other electrolyte levels
• Low blood sugar
• Kidney disease
• Lung disease
• Obstructive sleep apnea
• Pregnancy-related changes
• Other conditions that cause the heart to work harder

Heart-related conditions

Palpitations may also be associated with:

• Premature atrial contractions
• Premature ventricular contractions
• Sinus tachycardia
• Supraventricular tachycardia
• Atrial fibrillation
• Atrial flutter
• Slow rhythms or conduction disorders
• Heart-valve disease
• Cardiomyopathy
• Coronary artery disease
• Heart failure
• Less commonly, a potentially dangerous ventricular rhythm

The American Heart Association identifies stress, exercise, excessive caffeine, electrolyte disturbances, certain medications, stimulant drugs, premature beats, and arrhythmias among possible causes of palpitations. Thyroid abnormalities and anemia may also contribute.

Heart Rhythms That May Cause Palpitations

Premature atrial and ventricular contractions

Premature atrial contractions, or PACs, begin in the heart’s upper chambers. Premature ventricular contractions, or PVCs, begin in the lower chambers.

A premature contraction occurs earlier than expected. A short pause may follow, causing the next normal heartbeat to feel stronger. Patients may interpret this as a skipped beat, even though an early beat occurred.

Occasional premature contractions are common. More frequent premature beats, significant symptoms, an abnormal EKG, or underlying structural heart disease may require further evaluation.

Sinus tachycardia

Sinus tachycardia is a faster heartbeat that begins in the heart’s natural pacemaker. It may be a normal response to:

• Exercise
• Stress
• Fever
• Dehydration
• Pain
• Anemia
• Thyroid disease
• Another condition that increases the body’s demand for blood flow

When sinus tachycardia is caused by another condition, treatment generally focuses on that underlying cause.

Supraventricular tachycardia

Supraventricular tachycardia, or SVT, is a rapid rhythm that begins above the heart’s lower chambers. Episodes may begin and end suddenly.

Possible symptoms include:

• Rapid pounding in the chest
• Pulsing in the neck
• Lightheadedness
• Shortness of breath
• Weakness
• Chest discomfort

An EKG recorded during an episode or an ambulatory heart monitor may be needed to identify the rhythm. Some patients may need medication or referral to a cardiac electrophysiologist to discuss catheter ablation.

Atrial fibrillation and atrial flutter

Atrial fibrillation, or AFib, is a common irregular rhythm that begins in the heart’s upper chambers. It may cause:

• A rapid and irregular heartbeat
• Fluttering or thumping
• Fatigue
• Shortness of breath
• Weakness
• Dizziness
• Reduced exercise tolerance

Some people with AFib have no symptoms and are diagnosed during an examination or heart test.

AFib is important because it can increase the risk of blood clots and stroke. Treatment may involve controlling the heart rate, restoring or maintaining rhythm, assessing stroke risk, and prescribing a blood thinner for selected patients. A clinician should confirm the rhythm and evaluate the benefits and risks before treatment begins.

Learn About Atrial Fibrillation and Atrial Flutter Care

Slow heart rhythms and conduction problems

A slow heartbeat does not always cause palpitations, but pauses or alternating slow and fast rhythms may create unusual heartbeat awareness, fatigue, dizziness, or fainting.

A lower heart rate can be normal in some physically active people. It can also be related to medication or a problem with the heart’s electrical conduction system. Symptoms and the clinical context determine whether testing or treatment is needed.

Ventricular arrhythmias

Certain rhythms beginning in the heart’s lower chambers can be serious. A rapid heartbeat associated with chest pain, fainting, severe weakness, breathing difficulty, or collapse requires emergency evaluation.

When Should You See a Cardiologist For Heart Palpitations?

A cardiologist can evaluate whether palpitations may be associated with an abnormal rhythm, structural heart disease, another cardiovascular condition, or a noncardiac trigger.

A cardiology consultation may be especially appropriate when:

• Episodes are recurring or becoming more frequent
• Symptoms are lasting longer than before
• Your heartbeat starts and stops suddenly
• Palpitations occur at rest or wake you from sleep
• Symptoms develop during exercise
• You experience dizziness or near-fainting
• Your pulse is repeatedly fast or irregular
• You have coronary disease, heart failure, valve disease, or cardiomyopathy
• You have high blood pressure, diabetes, kidney disease, or sleep apnea
• A previous EKG or heart monitor was abnormal
• You have a pacemaker or defibrillator that requires assessment
• You have a family history of inherited rhythm conditions or sudden cardiac death
• A wearable device repeatedly detects a possible arrhythmia
• The symptoms are affecting your daily activities or quality of life

Call 911 rather than waiting for an office appointment when emergency symptoms are present.

How are Heart Palpitations Evaluated?

A detailed symptom history

The cardiologist may ask:

• When did the episodes begin?
• How often do they occur?
• How long do they last?
• Do they begin and end suddenly or gradually?
• Does the heartbeat feel regular or irregular?
• Does it feel fast, forceful, fluttering, or interrupted by pauses?
• Does it happen at rest, during exercise, after eating, or at night?
• What were you doing before the episode?
• Do you experience dizziness, breathlessness, chest discomfort, weakness, or fainting?
• Do caffeine, alcohol, poor sleep, stress, illness, or medication changes appear related?
• Did a watch or home device record anything during the episode?

A description helps guide the evaluation, but an electrical recording is generally needed to identify an intermittent arrhythmia.

Medical, medication, and family-history review

Your consultation may include a review of:

• Previous heart conditions
• High blood pressure
• Thyroid disease
• Anemia
• Kidney disease
• Sleep apnea
• Diabetes
• Recent illness or fever
• Prescription medications
• Over-the-counter medicines
• Vitamins and supplements
• Caffeine, alcohol, nicotine, and stimulant exposure
• Family history of arrhythmia, cardiomyopathy, unexplained fainting, or sudden death

Physical examination

The visit may include:

• Blood-pressure measurement
• Heart-rate and pulse assessment
• Listening to the heart and lungs
• Evaluation for a heart murmur
• Assessment for swelling
• Examination for findings suggesting thyroid disease, heart failure, or another contributor

Electrocardiogram

An electrocardiogram, also called an EKG or ECG, records the heart’s electrical activity at that moment.

An EKG may identify:

• Atrial fibrillation
• Atrial flutter
• Premature beats
• A fast or slow rhythm
• Electrical conduction abnormalities
• Findings suggesting another cardiac condition

An EKG can be normal when an intermittent rhythm is not occurring during the test. Longer monitoring may then be appropriate. The NHLBI identifies the EKG as the most common test used to diagnose an arrhythmia.

Blood testing

Depending on your symptoms and medical history, laboratory testing may evaluate:

• Potassium and other electrolytes
• Thyroid function
• Blood count for anemia
• Kidney function
• Blood glucose
• Other findings suggested by the evaluation

Blood testing does not identify every arrhythmia, but it may find a condition that is causing or worsening palpitations.

Heart-Rhythm Monitoring For Intermittent Palpitations

A short office EKG records only a brief period. When symptoms occur intermittently, an ambulatory monitor may provide a better opportunity to record the heartbeat during an episode.

The appropriate monitor depends on how frequently symptoms occur, how long they last, and whether they are associated with concerning symptoms. Ambulatory ECG monitoring is commonly used for palpitations, dizziness, fainting, chest discomfort, and shortness of breath when an intermittent arrhythmia is suspected.

Holter monitor

A Holter monitor continuously records heart-rhythm information for a limited period.

It may be useful when symptoms occur:

• Every day
• Almost every day
• During predictable activities
• Frequently enough to be captured during short-term monitoring

Extended patch monitor

A wearable patch monitor may record continuously for several days or longer. It may improve the chance of capturing symptoms that do not occur every day.

Cardiac event monitor

An event monitor may be worn for a longer period. Depending on the device, the patient may activate a recording when symptoms begin, or the monitor may automatically detect selected rhythm abnormalities.

Mobile cardiac telemetry

Mobile cardiac telemetry continuously analyzes rhythm information and may transmit selected events for review. It may be considered when the symptom pattern and clinical risk call for this type of monitoring.

Implantable loop recorder

An implantable loop recorder is a small device placed beneath the skin. It can monitor the rhythm over a much longer period than an external device.

It may be considered for rare but concerning symptoms, particularly unexplained fainting or episodes that shorter monitoring has not captured.

Other Tests That May Be Recommended

Not every patient needs every test.

Echocardiogram

An echocardiogram uses ultrasound to evaluate:

• Heart-chamber size
• Heart-pumping function
• Heart valves
• Heart-muscle thickness
• Certain structural abnormalities

An echocardiogram does not directly record every intermittent rhythm episode. It may be useful when the clinical evaluation suggests an underlying structural heart condition.

Exercise stress testing

A stress test may be considered when palpitations:

• Occur during exercise
• Are associated with exertional chest discomfort
• Occur with reduced exercise tolerance
• Raise concern about exercise-related rhythm changes
• Occur in a patient who also needs assessment for coronary disease

Sleep-apnea assessment

Sleep-apnea screening or testing may be considered when palpitations or an arrhythmia occur with:

• Loud snoring
• Witnessed breathing pauses
• Daytime sleepiness
• Resistant high blood pressure
• Obesity
• Recurrent atrial fibrillation

Electrophysiology study

An electrophysiology study, or EP study, is an invasive test that uses specialized catheters to measure electrical activity inside the heart and identify where an arrhythmia begins.

It is not a routine first test for every patient with palpitations. It may be recommended when noninvasive testing identifies or strongly suggests an arrhythmia requiring specialized evaluation or treatment. EP studies are performed by physicians with specialized electrophysiology training.

Can A Smartwatch Diagnose An Irregular Heartbeat?

A smartwatch or portable consumer ECG may capture useful information, especially when symptoms occur unpredictably.

Bring the following to your appointment:

• Saved ECG recordings
• Screenshots
• Irregular-rhythm notifications
• Dates and times
• Recorded heart rates
• Notes about what you felt during the alert

Consumer devices can help detect possible atrial fibrillation, but they have limitations:

• They are not worn continuously
• They may miss infrequent episodes
• Motion or poor skin contact may affect recordings
• Some regular rapid rhythms are difficult for algorithms to classify
• False-positive notifications can occur
• They do not reliably identify every type of arrhythmia

A smartwatch notification is not a complete diagnosis. Do not begin or stop a heart medication, aspirin, or blood thinner solely because of a wearable-device alert. A clinician may need to review the tracing and obtain a medical-grade EKG or ambulatory monitor.

How Are Heart Palpitations Treated?

Treatment depends on:

• The rhythm recorded during symptoms
• How frequently episodes occur
• Associated symptoms
• Underlying heart structure and function
• Other medical conditions
• Medication tolerance
• The patient’s individual risks and preferences

Reassurance and observation

When testing shows infrequent premature beats or no clinically important arrhythmia, active treatment may not be needed.

The cardiologist may recommend:

• Monitoring symptoms
• Reviewing possible triggers
• Following up if the pattern changes
• Repeating testing only when clinically appropriate

Treating an underlying condition

Care may focus on:

• Correcting an electrolyte abnormality
• Treating thyroid disease
• Treating anemia
• Addressing dehydration
• Improving sleep
• Evaluating or treating sleep apnea
• Reviewing stimulant exposure
• Adjusting a contributing medication with the prescribing clinician
• Reducing excessive alcohol
• Stopping tobacco and recreational stimulants

Do not discontinue a prescribed medication without professional guidance.

Lifestyle changes

Depending on the diagnosis, recommendations may include:

• Maintaining a consistent sleep schedule
• Staying appropriately hydrated
• Identifying personal food or beverage triggers
• Reducing excessive caffeine or energy-drink use
• Limiting alcohol when it triggers episodes
• Avoiding nicotine and recreational stimulants
• Participating in appropriate physical activity
• Managing high blood pressure, cholesterol, diabetes, and weight
• Following a heart-healthy eating pattern

Lifestyle recommendations should be individualized rather than automatically imposing the same restrictions on every patient.

Medication

Depending on the diagnosed rhythm, medication may be used to:

• Slow an excessively fast heart rate
• Reduce symptomatic premature beats
• Help maintain a regular rhythm
• Treat an underlying heart condition
• Reduce stroke risk in selected patients with atrial fibrillation

Heart-rhythm medications can have significant interactions and side effects. Do not change a dose or stop treatment without instructions from your healthcare professional.

Electrical cardioversion

Electrical cardioversion may be used for selected patients with atrial fibrillation, atrial flutter, or another sustained rhythm for which cardioversion is appropriate.

It is not a treatment for every palpitation or occasional skipped beat. Preparation and blood-clot precautions depend on the diagnosed rhythm and how long it has been present.

Catheter ablation

Catheter ablation targets a small area or electrical pathway responsible for certain abnormal rhythms. It may be considered for selected patients with:

• Recurrent SVT
• Symptomatic atrial fibrillation
• Atrial flutter
• Certain ventricular arrhythmias
• Another rhythm for which ablation is appropriate

Ablation is generally performed by a cardiologist with specialized electrophysiology training. Advanced Cardiology may coordinate referral or shared care with an electrophysiologist when appropriate.

Pacemaker or implantable defibrillator

A pacemaker may be recommended for selected patients with clinically important slow rhythms or conduction disease.

An implantable cardioverter-defibrillator, or ICD, may be recommended for selected patients at risk of dangerous ventricular rhythms.

These devices are not routine treatments for occasional palpitations. The diagnosis, symptoms, heart function, and individual risk determine whether a device is appropriate.

What Can You Do Before Your Appointment?

Keep a brief symptom record that includes:

• Date and time
• How the heartbeat felt
• How long the episode lasted
• Whether it began and ended suddenly
• Your heart rate, when safely available
• Whether the rhythm felt regular or irregular
• What you were doing at the time
• Recent caffeine, alcohol, exercise, stress, illness, or poor sleep
• Associated dizziness, breathlessness, chest discomfort, weakness, or near-fainting
• Medication timing
• Smartwatch recordings or alerts

Do not repeatedly check your pulse to the point that it increases anxiety. Record enough information to help identify a pattern.

Do not:

• Double or skip heart medication
• Take another person’s medication
• Start aspirin or a blood thinner on your own
• Drive when you feel faint
• Exercise through severe symptoms
• Wait for an office response when emergency warning signs are present