Palpitations: what the patient feels, what to ask and the danger signs
- Topic
Feeling the heart race, pound or skip: the questions that separate harmless extra beats from a dangerous rhythm.
See it in 3D: Sinoatrial (SA) node · Atrioventricular (AV) node · Left atrium
What it is
Palpitations are an unpleasant awareness of one's own heartbeat: racing, pounding, fluttering or skipped beats. Most are due to harmless premature beats, anxiety or stimulants, but some reveal a serious arrhythmia, structural heart disease or a systemic cause such as hyperthyroidism or anemia. The history and an electrocardiogram recorded during symptoms give most of the answer.
Key facts
- Description: 'skipped beat' or a thump after a pause suggests premature beats; 'racing' suggests tachycardia; 'pounding' at normal rate can come from anxiety or a high stroke volume.
- Onset and offset: abrupt in reentrant tachycardias; gradual in sinus tachycardia (exercise, fever, anxiety, anemia, hyperthyroidism).
- Triggers: exertion, emotion, standing up, caffeine, alcohol, nicotine, cocaine and other stimulants, decongestants, diet pills.
- Ending: episodes stopped by breath holding or straining (vagal maneuvers) suggest a supraventricular reentrant tachycardia.
- Associated symptoms: fainting, chest pain, breathlessness, tremor, heat intolerance, weight loss, sweating and headache (paroxysmal hypertension).
- Background: known heart disease, previous infarction, valve disease, Chagas disease in the region, thyroid disease, family history of sudden death or inherited arrhythmia.
Step by step
- Check pulse rate and rhythm, blood pressure and consciousness; a very fast or very slow rate with low pressure is an emergency.
- Let the patient describe it, then ask them to tap the rhythm on the table.
- Ask how it starts and stops, how long it lasts, how often it comes, and what they were doing.
- Ask about fainting, chest pain, breathlessness and what happens on exertion.
- Review caffeine, alcohol, tobacco, drugs, supplements and all medicines, including over-the-counter ones.
- Ask about thyroid symptoms, bleeding or heavy periods, anxiety and panic, and family history of sudden death.
- Examine: pulse, heart sounds and murmurs, signs of heart failure, thyroid gland, tremor, pallor; record an electrocardiogram.
Causes of palpitations and their clues
| Cause | What the patient feels | Clues |
|---|---|---|
| Premature beats | A skipped beat, then a strong thump | Worse at rest or at night, with caffeine or stress; usually benign |
| Supraventricular tachycardia | Regular racing that starts and stops suddenly | Young patient, pounding in the neck, ended by vagal maneuvers |
| Atrial fibrillation | Irregular, often fast | Older age, hypertension, valve disease, alcohol; irregularly irregular pulse |
| Ventricular tachycardia | Fast rhythm with dizziness or fainting | Previous infarction, cardiomyopathy, Chagas disease |
| Pre-excitation | Episodes of regular or irregular racing | Short PR interval and delta wave on the resting tracing |
| Hyperthyroidism | Constant fast heartbeat | Weight loss, tremor, heat intolerance, goiter |
| Catecholamine-secreting tumor | Attacks of pounding | Headache, sweating and high blood pressure during attacks |
| Panic and anxiety | Pounding with fear and breathlessness | Tingling, sense of doom; a diagnosis after excluding arrhythmia |
Clinical notes
- Palpitations with syncope, especially during exercise, need urgent cardiac evaluation for ventricular arrhythmia or an inherited channel disorder.
- Resting heart rate above about 120 or below about 45 beats per minute with symptoms is a red flag.
- A new irregularly irregular rhythm suggests atrial fibrillation and brings up stroke risk.
- Palpitations in a patient from an endemic rural area with conduction disease on the tracing: consider Chagas cardiomyopathy.
- Labeling palpitations as anxiety is safe only after an electrocardiogram and basic tests are normal.
In the lab
- Twelve-lead electrocardiogram, ideally during an episode; look for pre-excitation, long QT, Brugada pattern, conduction disease and signs of old infarction.
- Ambulatory monitoring: Holter for daily symptoms, event recorder for less frequent ones.
- Complete blood count, electrolytes including potassium, magnesium and calcium, and thyroid-stimulating hormone.
- Echocardiography when structural heart disease or a new arrhythmia is found; troponin if ischemia or myocarditis is possible.
Test yourself
Think of the answer, then tap the question to see it.
Which history suggests a supraventricular reentrant tachycardia?
A regular, very fast rhythm that starts and stops abruptly, sometimes ended by breath holding or straining.
What does a 'skipped beat followed by a strong thump' usually represent?
A premature beat followed by a compensatory pause; the next beat feels stronger because the ventricle has filled more.
Which are the red flags in a patient with palpitations?
Syncope or near-syncope, chest pain or dyspnea, palpitations on exertion, known structural heart disease or a family history of sudden death.
Why is a normal resting electrocardiogram not enough to rule out an arrhythmia?
Most arrhythmias are intermittent, so the tracing must be captured during symptoms with an ambulatory monitor.
Connections
See it in 3D3
The structures of Durgical's 3D anatomy where it is found.
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Sources: Heart palpitations (MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine, 2025); Palpitations (MSD Manual Professional Edition, 2025).
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Representative model, for educational purposes only.