[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Cardiovascular system](https://durgical.com/en/clinical-exam/areas/cardiovascular/) › Palpitations: what the patient feels, what to ask and the danger signs

# 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.

Updated Nov 13, 2026

**See it in 3D:** [Sinoatrial (SA) node](https://durgical.com/en/anatomy/sinuatrial-node/) · [Atrioventricular (AV) node](https://durgical.com/en/anatomy/atrioventricular-node/) · [Left atrium](https://durgical.com/en/anatomy/left-atrium/)

## Key points

- Ask the patient to tap out the rhythm: regular and fast, irregular and fast, or a single skipped beat followed by a strong beat.
- Sudden start and sudden stop of a regular fast rhythm suggests supraventricular tachycardia; an irregularly irregular rhythm suggests atrial fibrillation.
- Danger signs: syncope or near-syncope, chest pain, dyspnea, known structural heart disease, palpitations on exertion, family history of sudden death at a young age.
- An electrocardiogram recorded during symptoms is the most useful test; a normal tracing between episodes does not rule out an arrhythmia.
- Always check for hyperthyroidism, anemia, electrolyte disorders, stimulants and medicines.

## 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](https://durgical.com/en/conditions/premature-atrial-and-ventricular-contractions/) | A skipped beat, then a strong thump | Worse at rest or at night, with caffeine or stress; usually benign |
| [Supraventricular tachycardia](https://durgical.com/en/conditions/supraventricular-tachycardia/) | Regular racing that starts and stops suddenly | Young patient, pounding in the neck, ended by vagal maneuvers |
| [Atrial fibrillation](https://durgical.com/en/conditions/atrial-fibrillation/) | Irregular, often fast | Older age, hypertension, valve disease, alcohol; irregularly irregular pulse |
| [Ventricular tachycardia](https://durgical.com/en/conditions/ventricular-tachycardia/) | Fast rhythm with dizziness or fainting | Previous infarction, cardiomyopathy, Chagas disease |
| [Pre-excitation](https://durgical.com/en/conditions/wolff-parkinson-white-syndrome/) | Episodes of regular or irregular racing | Short PR interval and delta wave on the resting tracing |
| [Hyperthyroidism](https://durgical.com/en/conditions/graves-disease/) | Constant fast heartbeat | Weight loss, tremor, heat intolerance, goiter |
| [Catecholamine-secreting tumor](https://durgical.com/en/conditions/phaeochromocytoma/) | Attacks of pounding | Headache, sweating and high blood pressure during attacks |
| [Panic and anxiety](https://durgical.com/en/conditions/panic-disorder/) | 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.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/palpitations-what-the-patient-feels-what-to-ask-and-the-danger-signs/)

## Connections

## See it in 3D 3

The structures of Durgical's 3D anatomy where it is found.

- [Sinoatrial (SA) node](https://durgical.com/en/anatomy/sinuatrial-node/)
- [Atrioventricular (AV) node](https://durgical.com/en/anatomy/atrioventricular-node/)
- [Left atrium](https://durgical.com/en/anatomy/left-atrium/)

## Related 7

- [Arterial pulse: rate, rhythm and amplitude](https://durgical.com/en/clinical-exam/arterial-pulse-rate-rhythm-and-amplitude/)
- [Cardiac auscultation: the areas and the order](https://durgical.com/en/clinical-exam/cardiac-auscultation-the-areas-and-the-order/)
- [Chest pain: ischemic, pericardial, pleural and other patterns](https://durgical.com/en/clinical-exam/chest-pain-ischemic-pericardial-pleural-and-other-patterns/)
- [Orthostatic vital signs](https://durgical.com/en/clinical-exam/orthostatic-vital-signs/)
- [Hyperthyroidism and hypothyroidism: the signs](https://durgical.com/en/clinical-exam/hyperthyroidism-and-hypothyroidism-the-signs/)
- [Dyspnea: acute or chronic, heart or lung, and grading (mMRC, NYHA)](https://durgical.com/en/clinical-exam/dyspnea-acute-or-chronic-heart-or-lung-and-grading/)
- [Anemia syndrome](https://durgical.com/en/clinical-exam/anemia-syndrome/)

## Related conditions 8

- [Atrial fibrillation](https://durgical.com/en/conditions/atrial-fibrillation/)
- [Supraventricular tachycardia (AVNRT, AVRT)](https://durgical.com/en/conditions/supraventricular-tachycardia/)
- [Premature atrial and ventricular contractions](https://durgical.com/en/conditions/premature-atrial-and-ventricular-contractions/)
- [Ventricular tachycardia](https://durgical.com/en/conditions/ventricular-tachycardia/)
- [Wolff-Parkinson-White syndrome](https://durgical.com/en/conditions/wolff-parkinson-white-syndrome/)
- [Graves disease (hyperthyroidism)](https://durgical.com/en/conditions/graves-disease/)
- [Panic disorder](https://durgical.com/en/conditions/panic-disorder/)
- [Phaeochromocytoma](https://durgical.com/en/conditions/phaeochromocytoma/)

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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](https://medlineplus.gov/ency/article/003081.htm) (MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine, 2025); [Palpitations](https://www.msdmanuals.com/professional/cardiovascular-disorders/symptoms-of-cardiovascular-disorders/palpitations) (MSD Manual Professional Edition, 2025).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/clinical-exam/palpitations-what-the-patient-feels-what-to-ask-and-the-danger-signs/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/palpitations-what-the-patient-feels-what-to-ask-and-the-danger-signs/