Michael G. Kienzle, MD
Division of Cardiovascular Diseases
University of Iowa Hospitals and Clinics

First Published: March 2000
Last Revised: December 2003
Peer Review Status: Internally Peer Reviewed

The symptoms of palpitations vary from patient to patient with some common features. A perception of irregularity of the pulse, an uneasiness in the chest, a flip-flopping in the chest; frequently people describe their palpitations as "my heart stops." Certainly a feeling of strong pulse throughout the chest, head and neck could well be described as a palpitation. Occasionally palpitations can be perceived in unusual ways including a general sense of uneasiness, and quite often the palpitations are associated with lightheadedness or even loss of consciousness.

Can some drug interactions cause palpitations? How can this be avoided?

The most common substance associated with palpitations is caffeine. Frequently reducing or eliminating beverages that contain caffeine such as coffee or soda can improve palpitations. Some patients complain of palpitations when they eat too much chocolate, and some patients respond with palpitations around the holiday when they tend to drink too much alcohol, particularly red wine. In terms of over-the-counter medications, cold and allergy remedies often can precipitate palpitations. Frequently, palpitations occur without any obvious precipitating factor, although fatigue and getting behind on your sleep also cause palpitations to occur or worsen.

How does the physician evaluate palpitations?

The evaluation usually starts like any other complaint, with a good history focused on things like the types of food, beverages, over-the-counter medications. This is followed by a thorough physical examination focusing on the heart and lungs. In terms of laboratory studies, those will be determined by the overall condition and the findings of the physical exam. In most cases, palpitations have a very benign origin, and nothing more than a thorough history and physical examination and perhaps some basic blood lab work is needed. If the patient's symptoms are more severe, such as significant lightheadedness or loss of consciousness associated with palpitations, a more comprehensive evaluation is warranted. That type of evaluation might well involve electrocardiogram (EKG), an ultrasound of the heart, a treadmill test, more sophisticated blood tests including thyroid tests, and an ambulatory EKG or Holter monitor. Some patients may require invasive studies if a serious heart condition is suspected to underlie the symptom of palpitations.

Could heart palpitations along with shortness of breath be serious?

Heart palpitations can certainly be associated with shortness of breath, that is, the two symptoms together without a serious condition being present. That usually indicates that the irregularity of the heart rhythm is significant and may signal the need for a more comprehensive evaluation. In general the more serious the symptoms, such as lightheadedness, loss of consciousness, chest pain, shortness of breath, the more seriously one needs to take the problem. The more insignificant the symptoms, such as a sense of flip-flop or slight irregularity of the pulse, the less worrisome the situation. If a patient has known heart disease such as a previous heart attack or a condition called congestive heart failure (CHF), the symptoms of palpitations need to be evaluated by the patient's personal physician.

What are the health risks of experiencing heart palpitations?

The irregularity of the heart rhythm per se usually does no damage to the heart itself. Patients with a very rapid heart over a long period of time do run a risk of developing enlargement and failure of the heart. Such cases are rare. For example, a very common cause of palpitations is a condition called atrial fibrillation. Patients can be in atrial fibrillation for many years and usually it does no lasting damage to the heart whatsoever. On the other hand, there may be some increased risk of stroke because of blood clots that can form in association with atrial fibrillation. In terms of the heart rhythm causing heart damage, this rarely, if ever, occurs.

If a guy has "PVCs", how does he know if he's at risk for dropping over dead?

Premature ventricular complexes (PVC) mean that the extra beats originate from the lower pumping chamber called the ventricle. There has been much discussion over the last 10 years or so of the significance of PVCs. Early studies have demonstrated that patients in the first hours of a heart attack who have PVCs in the critical care unit (CCU) may be at slightly increased risk of having cardiac arrest as a complication of their heart attack. Unfortunately, that observation became more generalized to PVCs that occur in otherwise healthy people. This led to treatment with powerful heart rhythm medications in people who did not have a life-threatening heart rhythm disorder. In some cases, these powerful heart rhythm medications can create heart rhythm problems that they were meant to eliminate, and patients with a low risk of sudden death or cardiac arrest actually experienced cardiac arrest because of the heart medications. One famous study in patients following a heart attack with PVCs showed that the patients treated with placebos, or sugar pills, had a better survival rate than patients treated with powerful heart rhythm medications, even though the heart rhythm medications completely eliminated PVCs. In my own practice, if the PVCs are so symptomatic as to be disruptive, I make sure that I've eliminated all of the factors such as caffeine, certain foods, stress, before I consider any treatment with medications. When I do treat with medications, I try to use simple medications such as beta-blockers. Very frequently, this is enough to improve patients' symptoms. In summary, PVCs are common. In the vast majority of cases, they are of no prognostic significance and frequently go away on their own without any treatment beyond being reassured by your doctor.

I ride my bike 20 miles a day. When I'm finished I experience frequent palpitations but no other symptoms. Should I be concerned about this?

The relationship between extra beats and exercise is a complicated one. Many patients experience PVCs or palpitations before and after exercise, but not during exercise. This is because when most patients start to exercise, their own heart rate rises and the PVCs or other extra beats disappear at higher heart rates. After exercise, the body's natural adrenalin level remains high for a period of time while the heart rate begins to go down during rest. This period of time often permits the extra beats to come back, and sometimes their rate and frequency are higher than before exercise. Again, if the other symptoms are mild or not present, usually there is not any reason for serious concern. If other symptoms accompany the palpitations such as shortness of breath, chest discomfort, or severe lightheadedness or loss of consciousness, those symptoms with palpitations in any setting are a cause for concern and require further evaluation. I'm a cyclist myself, and I experience shortness of breath, but that's just because I'm not in particularly good shape, at least early in the season.

I have had an EKG and told nothing was wrong. Does an EKG tell the whole story?

An electrocardiogram is a representation of the electrical activity of the heart in multiple views. It takes about 15 sec to record and patients with palpitations may or may not have an abnormality on their EKG because the EKG is only monitoring the heart for those 15 sec, it doesnÕt do a very good job of revealing the abnormality associated with the symptoms. That is why many physicians use ambulatory EKGs or Holter monitors to try to make a diagnosis. Other approaches include using a monitor that is hooked up quickly when symptoms occur but is otherwise carried in the pocket or purse for up to a month at a time. This permits better correlation of the symptoms of palpitations and the heart rhythm at the time symptoms are being experienced. The other benefit of the standard EKG is that it may reveal evidence of other things that may be wrong with the heart such as an old heart attack or other electrical abnormalities that may provide important clues to an underlying diagnosis that the palpitations represent. So an electrocardiogram is a valuable part of a heart evaluation, but is not particularly sensitive for detecting heart rhythm abnormalities.

Can pregnancy cause heart palpitations for no apparent reason?

I have had a number of patients in my practice that had their first episode of rapid heart action and palpitation during pregnancy. This is understandable in that the state of pregnancy causes significant shifts in blood volume and also puts a new stress on the heart that may bring out a tendency for rapid heart action that was not manifest prior to pregnancy. After the pregnancy, the patient may not experience palpitations or may begin to see palpitations occur under other stressful circumstances. There certainly doesn't need to be anything wrong with the heart in order for palpitations to occur during pregnancy.

What medications are usually prescribed to prevent palpitations? Are there any herbal remedies to prevent them?

There are a large number of medications that are used by physicians that are used to treat more serious types of heart rhythm disorders. These are usually prescribed by a heart specialist because they do have significant side effects and if not used correctly can cause serious cardiovascular problems, even a cardiac arrest or sudden death. When used correctly, these powerful medications can prevent serious heart rhythm disorders from occurring and can be quite useful, although most patients would prefer not to be on them because of their cost, side effects, and they often must be taken multiple times a day. In recent years, patients with the most severe types of heart rhythm disorders have benefited from sophisticated pacemakers and devices capable of correcting the heart rhythm with an electrical shock delivered automatically after the heart rhythm disorder occurs. Obviously, these are highly specialized devices, and they are normally prescribed and tested by heart specialists. In terms of herbal remedies, I am not aware of an herbal remedy specifically effective for heart palpitation. I should say that low levels of potassium in the body may cause more frequent PVCs and occasionally even more severe heart rhythm disorders, and in those cases potassium supplements or foods high in potassium are quite helpful.

My heart sometimes palpitates when I am startled or sometimes when I bend forward. Should I worry? Also, I sometimes have panic attacks, and my heart will race--is it logical to assume that I am experiencing palpitations?

Both of the questions relate to a similar underlying mechanism, and that is the effect of substances in the body such as adrenaline which cause the heart rate to increase and the heart to beat more vigorously, creating a sensation of panic, heart pounding and heart racing. This is the experience of becoming aware of a natural or normal functioning of the nervous system. Anxiety, panic, and startling cause the adrenaline level to rise and create the sensation of palpitation. These in and of themselves are normal and natural and don't require any specific treatment in the vast majority of cases.

If a guy has PVCs on a Holter, are the ones that he's aware of more significant than the ones he's not?

There is no prognostic difference between the PVCs that are felt by the patient and those that are not. Obviously the symptomatic PVCs are of more concern to the patient because they can be annoying and distracting. Beyond that, the PVCs are all the same, prognostically. In most patients who are otherwise healthy, PVCs on a Holter are of little prognostic value regardless of whether they're experienced or not.

Should I be concerned if my 9-year-old says he notices, "Skipped beats"? Should a pediatric cardiologist examine him?

The same types of recommendations apply to children and in the vast majority of children, complaints of skipped beats are benign and do not require evaluation. As in adults, it's the severity of the symptoms that makes all the difference. If a child simply notices an occasional skipped beat and is otherwise healthy and keeps up with their friends on the schoolyard, it's unlikely that anything serious is going on. On the other hand, if they are complaining of chest pain, significant shortness of breath, lightheadedness, or fainting spells, then that is another matter. Their physician should see children with those types of complaints, and some of them will need to be seen by a pediatric cardiologist.

What do people mean by sudden death?

Sudden death is used to describe a situation in which a patient loses cardiac function and essentially will die within minutes if assistance is not provided. By assistance, I mean cardiopulmonary resuscitation (CPR) and frequently, electrical cardioversion to restore the heart rhythm to normal. Obviously, in those patients where these efforts are successful, they have not actually died, and these patients require extensive evaluation to determine the cause of cardiac arrest and to prevent it from occurring in the future. The internal defibrillator devices that have become commonplace in the care of these types of patients have proven to be very effective in preventing death from heart arrhythmias in patients who have already had one or more episode of attempted sudden death.