What are palpitations?

Palpitations are an uncomfortable awareness of one's own heartbeat — perceived as fluttering, pounding, racing, skipping or irregular. They are one of the most common cardiac symptoms, accounting for up to 16% of cardiology referrals. While the majority are benign, a subset represent significant arrhythmias requiring treatment.

How are palpitations described?

• Fluttering or rapid beating: Often SVT, AF or sinus tachycardia. Regular rapid palpitations suggest paroxysmal SVT.
• Missed or skipped beats: Classic description of ectopic beats (APCs or VPCs). Very common, usually benign.
• Slow, forceful thuds: Often post-ectopic compensatory beats felt after the pause.
• Sustained irregular racing: Raises concern for atrial fibrillation.

Cardiac causes

• Ectopic beats — atrial premature complexes (APCs) and ventricular premature complexes (VPCs). Very common, often benign.
• Atrial fibrillation — most common sustained arrhythmia. Irregular, often fast.
• Supraventricular tachycardia (SVT) — sudden onset/offset, regular, rapid
• Ventricular tachycardia (VT) — potentially life-threatening, particularly with structural heart disease
• Wolff-Parkinson-White syndrome
• Sick sinus syndrome

Non-cardiac causes

• Anxiety, panic disorder, hyperventilation
• Caffeine, alcohol, recreational drugs, decongestants
• Hyperthyroidism
• Anaemia
• Fever
• Pregnancy
• Medications — salbutamol, pseudoephedrine, digoxin toxicity

Red flag symptoms requiring urgent assessment

• Palpitations with syncope or presyncope (near-blackout)
• Palpitations with chest pain or breathlessness
• Palpitations in patients with structural heart disease
• Palpitations triggered by exercise
• Family history of sudden cardiac death

The diagnostic challenge with palpitations is capturing the rhythm during symptoms. A structured approach is required.

• 12-lead ECG: Initial assessment. May show pre-excitation (WPW), long QT, LBBB or prior MI — all risk factors for dangerous arrhythmia.
• Holter monitor (24h–14 day): The primary investigation for most patients. Correlates symptoms with rhythm. 24h monitors capture frequent episodes; longer monitoring (7–14 days) is needed for infrequent palpitations.
• External loop recorder: Patient-activated or auto-triggered. Can be worn for weeks to months.
• Implantable loop recorder (ILR): Inserted under the skin for up to 3 years. Used when symptoms are very infrequent but potentially serious (e.g. unexplained syncope).
• Echocardiogram: Identifies structural heart disease (cardiomyopathy, valve disease) which increases arrhythmia risk.
• Blood tests: Thyroid function, full blood count, electrolytes, renal function.
• Exercise stress test: If palpitations occur during or after exercise.

Benign ectopics

Most ectopic beats require no treatment. Reassurance, caffeine reduction, alcohol moderation and stress management are the mainstay. Beta-blockers can reduce symptom burden when ectopics are frequent or distressing.

SVT

• Vagal manoeuvres (Valsalva) — effective for acute termination in up to 50% of episodes
• IV adenosine — terminates most SVTs; first-line emergency treatment
• Rate-limiting medications (beta-blockers, diltiazem) for prevention
• Catheter ablation — highly effective, curative in >95% of AVNRT/AVRT

Atrial fibrillation

See the dedicated Atrial Fibrillation page for detailed management including anticoagulation, rate control and rhythm control strategies.

• Reduce or eliminate caffeine if palpitations are related
• Limit alcohol — even moderate intake can trigger arrhythmias
• Manage anxiety and stress
• Treat underlying thyroid disease or anaemia
• Ensure adequate sleep and hydration
• Regular moderate exercise (but avoid strenuous activity if exercise-induced arrhythmia is suspected until assessed)