Q&A 026 : Heart Palpitations

⏱ 10 min read

Dr. Hayes Q&A · No. 026

By Eleanor Hayes, M.D. · Hospitalist

Heart palpitations feel like a skipped beat, a hard thump, or a sudden stretch of racing. Most of the time they are harmless. But “most of the time” is a statement about a crowd, not about you. This one is about the line between the two.

The Question

“For a few months now my chest has been fluttering. It feels like my heart skips, then comes back with one hard thump. Every so often it races for a few minutes and then stops. I figured it was the coffee, so I cut down to one cup a day, and nothing changed. Is this something I need to see a doctor about, or can I let it go?”

— Name withheld

The Short Answer

Most heart palpitations are not dangerous. But whether you can safely wait is decided less by what the feeling is like and more by who is having it and under what conditions. A 58-year-old man with runs of fast beating that last minutes and a blood pressure on the edge is worth one proper look: an ECG and a wearable heart monitor. If palpitations ever come with fainting, chest pain, or shortness of breath, that is not a wait-and-see situation. That is the emergency room.

Are Heart Palpitations Dangerous? What the Evidence Says

The causes are wider than people expect. In a prospective study that followed 190 people who came to a university medical center with heart palpitations for a year, the cause turned out to be the heart in 43 percent, anxiety or panic in 31 percent, something else in 10 percent, and nothing identifiable in 16 percent. Rates of death and stroke over that year were low, but the symptoms came back for most people. (Weber and Kapoor, prospective cohort study of palpitations) So “it is usually nothing” is true. So is the fact that close to half the time, it really is coming from the heart.

The clues that tip it toward the heart. In that same study, four things independently pointed toward a true rhythm problem: being male, describing the beat as irregular, a history of heart disease, and episodes lasting longer than five minutes. (European Heart Rhythm Association position paper on palpitations) The reader is male, and his fast runs last minutes. That is two of the four. It is why I cannot simply tell him not to worry.

The most common culprit is an early beat. The “skip, then thump” feeling is usually a premature beat, an extra contraction from the upper or lower chambers that arrives ahead of schedule. The heart pauses briefly afterward, the chamber fills with a little more blood than usual, and the next beat lands hard. That hard beat is the thump you feel. Nearly everyone has some of these over the course of a day. When they become very frequent, though, they are worth tracking in their own right.

Coffee is less of a villain than its reputation. This is where cutting back to one cup and feeling no difference starts to make sense. In a study of 1,388 older adults who wore 24-hour heart monitors, habitual coffee, tea, and chocolate were not linked to more premature beats from either the upper or lower chambers. (caffeinated products and cardiac ectopy, JAHA) A later randomized trial found coffee did not increase early beats from the upper chambers, though it did raise early beats from the lower chambers somewhat. (randomized trial of coffee and heart rhythm, NEJM) Caffeine can matter for some people. Giving it up just fixes the problem less often than most assume.

The weekend pattern is a clue. When heart palpitations cluster on Friday and Saturday nights, the first thing I think about is alcohol. In a study of 100 people with a history of atrial fibrillation who wore an alcohol sensor and a heart monitor for four weeks, an episode was linked to about twice the odds of one drink, and more than three times the odds of two or more drinks, in the four hours before it began. (acute alcohol consumption and atrial fibrillation events, Annals of Internal Medicine) A heart that acts up only on weekends may not be following the calendar. It may be following the glass.

Match the test to how often it happens. The frustrating part of heart palpitations is that they rarely show up while you are sitting in a clinic. A normal ECG taken between episodes does not rule a rhythm problem out. That is why the monitor is chosen by how often the symptom comes.

Basic blood work usually goes alongside: thyroid function, potassium and magnesium, and a check for anemia. An overactive thyroid is one of the causes that gets missed most often, and I covered the thyroid test itself in the question on thyroid and fatigue. A smartwatch tracing is not a diagnosis, but it is a useful thing to bring to the appointment. For a sense of what a monitor can catch that a clinic visit cannot, see the case of a Holter monitor and a nine-second pause.

What I See in the Hospital

There is a scene I see again and again. Someone comes in after the episode has already passed. The ECG at that moment is normal. They are told nothing was found, and they go home remembering it as “my heart is fine.” Those are not the same sentence.

And another. On the inpatient floor, the place atrial fibrillation gets discovered for the first time is often not a palpitations clinic. It is the monitor of someone admitted with a stroke, or with an artery suddenly blocked in an arm or leg, as in the case of a blocked arm artery and atrial fibrillation. Looking back, there was often a mention of an occasional flutter. The next question picks up exactly there.

Plain-Language Reference

What to Actually Do

· When it happens, write down the time, how long it lasted, whether it felt regular, and what you were doing just before: drinking, exercising, short on sleep.
· If episodes last more than a few minutes or feel irregular, ask your primary care physician for an ECG and a wearable monitor.
· Look at alcohol before coffee. If there is a weekend pattern, try two to three weeks without drinking and see what changes.
· If palpitations ever come with fainting, chest pain, or shortness of breath, do not wait. Call 911.

This article is for general information only and does not constitute medical advice. Reading it creates no provider-patient relationship. The reader’s situation is a composite and does not represent any specific person. If palpitations come with fainting, chest pain, or shortness of breath, call 911 or go to the nearest emergency room without delay. Decisions about testing and treatment belong with a qualified licensed professional who knows your history.

Take care of yourself. Nobody else will do it for you.
— Eleanor Hayes, M.D.