Heart palpitations: the direct answer
Palpitations mean you notice your heartbeat in an unusual way: it may feel fast, fluttering, pounding, or as though it skips or adds a beat. You may feel it in the chest, neck, or throat, and it can last seconds, minutes, or occasionally longer [1, 2]. Most people experience palpitations at least once, and the majority of episodes are not dangerous and do not indicate heart disease [1, 2, 6, 8].
Common triggers include anxiety and stress, excess caffeine from coffee, tea, or energy drinks, lack of sleep, intense physical exertion, and dehydration [1, 2]. Hormonal shifts during menstruation, pregnancy, or menopause can also contribute [1]. At the same time, medical conditions such as anaemia and an overactive thyroid can present with palpitations and need investigation to identify the cause [1, 2].
The important question is not whether you feel palpitations but whether they come with other symptoms such as chest pain, breathlessness, dizziness, or fainting, or whether they are a passing sensation linked to exertion or stress that resolves on its own [1, 3]. The answer determines whether you need tests or can be reassured with simple measures. If palpitations occur alongside any of the warning signs described below, seek urgent medical assessment.
This article covers common and less common causes, explains what an ECG can and cannot show, outlines when longer monitoring helps, and clarifies when an internist can assess the situation versus when a cardiology referral is needed. If you have recurrent palpitations without emergency signs, consider keeping a symptom diary and arranging an assessment. If you have serious accompanying symptoms, read the emergency section first.
Common causes: from anxiety to anaemia and thyroid problems
The most common cause of palpitations is normal extra heartbeats called ectopic beats, which many people experience and which usually need no treatment [1]. They may feel like an added beat or a brief pause followed by a stronger thump. Anxiety and stress are among the most frequent triggers because the nervous system accelerates the heart in preparation for a fight-or-flight response; this is normal but can feel unsettling [1, 2].
High caffeine intake can provoke palpitations, particularly in people who are sensitive to it or who drink large amounts of coffee, tea, or energy drinks [1, 2]. Insufficient sleep, dehydration, and sudden intense exercise without adequate conditioning can all contribute [1, 2]. Smoking and nicotine are also recognised triggers [1].
Some medicines can cause palpitations as a side effect, including certain asthma inhalers, cold remedies, and some antidepressants [1]. If palpitations begin after starting a new medicine or changing a dose, inform your doctor rather than stopping the medicine yourself [1].
Important medical causes that may present with palpitations include:
- Anaemia: when haemoglobin drops, the heart compensates by beating faster, which can be felt as palpitations, especially on exertion [2]. If you have fatigue with pallor and palpitations, a complete blood count may clarify whether anaemia is present. Read anaemia symptoms and the CBC test for details [2].
- Hyperthyroidism (overactive thyroid): speeds up metabolic processes; palpitations with unintentional weight loss, nervousness, and excessive sweating are among the early signs [2]. If palpitations accompany thyroid symptoms, a TSH test with T3 and T4 helps with diagnosis. Read hyperthyroidism symptoms and causes to compare [2].
- High or low blood pressure and certain electrolyte imbalances can also be associated with palpitations in some cases [2, 3].
The key point is that palpitations are sometimes a symptom of a treatable condition rather than heart disease itself. An internist's assessment starts by identifying whether there is an obvious cause before considering the heart. That is why the first step is usually a thorough history and basic investigations [2, 3].
Heart-related causes: when do palpitations come from a rhythm disorder?
In a smaller proportion of cases, palpitations result from an actual heart rhythm disorder, known as an arrhythmia. Some types that can be associated with palpitations include [2, 3, 7]:
- Atrial fibrillation (AF): the atria quiver erratically instead of contracting in a regular rhythm, producing an irregular and often rapid pulse. It may occur in intermittent episodes or be persistent. AF matters because it raises the risk of blood clots, which makes diagnosis and follow-up important [3].
- Supraventricular tachycardia (SVT): sudden episodes of a fast heart rate that start and stop abruptly, occurring in younger people as well. SVT is usually not dangerous but can be distressing and frightening, and it may need assessment if it recurs or causes significant symptoms [3].
- Premature ventricular contractions (PVCs): extra beats from the ventricles, can occur even without known heart disease. The clinician decides whether further testing is needed based on symptoms and medical history [3, 9].
- Rarer conditions such as ventricular tachycardia (VT) can be more serious because they affect the heart's pumping ability and may require urgent intervention [3].
Not every arrhythmia is dangerous, and not every palpitation is an arrhythmia. The distinction is made through investigations, most importantly the ECG and monitoring devices, which are explained in the next section. Palpitations accompanied by dizziness, fainting, breathlessness, or chest pain call for urgent medical assessment to identify the cause, without assuming a rhythm disorder [2, 3, 7].
It is also important to know that an existing chronic condition such as high blood pressure or previous heart disease makes any new palpitation worth evaluating more promptly. If you have a family history of early heart problems or sudden death, mention this at the first visit [2, 3].
The ECG: what it can show and what it can miss
An electrocardiogram (ECG or EKG) is the first test a doctor requests when you report palpitations. It records the heart's electrical activity through adhesive patches on the skin, is painless, and takes minutes [3, 4]. An ECG can show:
- Whether the rhythm is regular or whether there is an obvious disturbance at the time of the recording - Whether there are signs of atrial fibrillation, ectopic beats, a fast rate, or a slow rate - Whether there are signals suggesting enlargement of the heart chambers or conduction abnormalities
The critical point, however, is that an ECG records only what happens during the seconds it is running [3, 4]. If palpitations come and go, the ECG may be completely normal at the time of recording. A normal result does not mean there is no problem; it means the disturbance did not occur during that window. A normal resting ECG is a useful first step but is not sufficient on its own to exclude an intermittent rhythm disorder [3, 4].
If the clinic ECG is normal but symptoms recur, the doctor may request a wearable monitor for a longer period [3, 4]:
- Holter monitor: a small device worn for 24 to 48 hours or more that records every heartbeat. The doctor asks you to keep a diary noting the times of symptoms and activities. The diary is then compared with the recording to see whether palpitations correlate with an actual rhythm abnormality [4].
- Event recorder: worn for a longer period, sometimes a week or a month. It records when you press a button at the moment you feel palpitations, or automatically if it detects an abnormal rhythm. It is useful when palpitations happen a few times a week or less [3, 4].
The symptom diary you keep alongside any monitoring device is very important. Record the time of each episode, whether you were resting or active, whether caffeine or anxiety preceded it, and any accompanying symptoms such as dizziness or breathlessness. This record helps the doctor link your sensation to the electrical recording [4]. Without a diary, even if the device captures extra beats, it may not be possible to confirm whether those beats are responsible for the feeling.
A symptom diary: how to record palpitations usefully
Even before seeing a doctor, a simple symptom diary can save considerable time in reaching a diagnosis [4]. It does not need to be elaborate, but should include:
- The date and time of each episode - Whether you were resting, walking, exercising, or had sudden exertion - Whether you had coffee, tea, or an energy drink in the preceding hours - Whether you were stressed, anxious, or had slept poorly the night before - The sensation itself: fast? pounding? fluttering? a momentary pause? - Duration: seconds, minutes, or longer - Any accompanying symptoms: dizziness, breathlessness, chest pain, sweating, general weakness - Medicines and supplements you take, including anything new
A diary is not a substitute for clinical assessment, but it gives the doctor a much clearer picture of the pattern [4]. Sometimes the pattern reveals that palpitations happen only after a third morning coffee or after a night of poor sleep, which directly guides the plan. In other cases, palpitations occur at complete rest without an obvious trigger, which makes investigations more important.
If you have a smartwatch or a device that measures your pulse, the reading can be useful as additional information but it does not replace an ECG or a medical monitoring device [3]. Smartwatches measure the pulse rate but do not record the electrical activity with the same precision as medical devices, and they can produce false alarms. If your watch alerts you to an abnormal rhythm, note the time in your diary and inform your doctor, but do not interpret the reading yourself.
Internist or cardiologist: where to start?
In most cases, an internist is the appropriate starting point for evaluating palpitations [2]. The reason is that many causes are not cardiac at all: anaemia, thyroid dysfunction, electrolyte disturbances, medications, or even chronic anxiety. An internist can perform a clinical examination, request a complete blood count, thyroid function tests, electrolytes and potassium, and an ECG in the clinic. This is usually sufficient as a first step to determine the direction [2, 3].
If basic investigations reveal anaemia or a thyroid problem, treatment targets the cause and monitoring of palpitations becomes part of the treatment plan. If you feel you have many overlapping symptoms and do not know where to start, read internist or specialist: how to choose when symptoms are mixed for more guidance [2, 3].
A cardiologist is needed in certain situations:
- The ECG shows a clear rhythm disorder - Palpitations are accompanied by fainting or recurrent severe dizziness - There is a previous history of heart disease or cardiac surgery - Palpitations are persistent and do not respond to initial management - There is a family history of sudden death or early heart disease [2, 3]
A cardiology referral is a clinical decision made by the internist after the initial assessment, not a decision made by the patient based on fear or internet searches. Equally, if the internist has reassured you but you remain concerned, you have the right to seek a second opinion, but start with the cause that the investigations have identified [2, 3].
An important point: not every palpitation requires an echocardiogram or a coronary scan. Advanced investigations are appropriate based on the results of the initial assessment, not as a routine for every person with a fleeting palpitation [3]. Ask the doctor: which investigations are appropriate for my case based on the symptoms and history?
When are palpitations an emergency? Signs that need immediate action
Most palpitations are not emergencies. However, certain signs appearing alongside palpitations mean you should go to the nearest emergency department immediately, without waiting [1, 2, 3]:
- Chest pain, pressure, or tightness with the palpitations - Severe shortness of breath - Marked dizziness or a feeling that you are about to faint - Actual fainting or loss of consciousness, even briefly - Sudden profuse sweating - A rapid, chaotic pulse that does not settle on its own and continues for many minutes
These symptoms may signal a serious rhythm disturbance or a cardiac problem that needs immediate assessment [1, 2, 3]. Do not wait to visit a clinic or book an appointment; go to the nearest hospital emergency department. If someone with you has these symptoms, help them reach the hospital or call an ambulance.
An important point: chest pain with palpitations can be caused by anxiety, such as a panic attack, but it can also be genuinely cardiac. There is no way to distinguish between the two at home with complete safety. The emergency department is the right place to make that distinction [1, 2]. Do not assume it is merely anxiety if you have not been previously diagnosed.
If palpitations come and go but keep recurring or become more frequent, happen with mild exertion, or are accompanied by unusual fatigue, weight loss, or pallor, arrange a prompt medical review even if it is not an emergency [1, 2]. Arrange assessment according to the symptom pattern and associated signs; seek urgent care if a warning sign develops.
Practical steps to reduce palpitations before and after your visit
If the doctor has excluded serious causes and the palpitations are transient, several steps may help [1, 2]:
- Reduce caffeine: try cutting back on coffee or tea gradually and notice whether palpitations decrease. Complete elimination is not always necessary, but if you notice that caffeine triggers your symptoms, reducing it may help. Caffeine affects people differently, so pay attention to your own response rather than a fixed number of cups [1, 2, 10].
- Adequate sleep: poor sleep is one of the most overlooked triggers. Aim for a consistent number of hours and avoid screens before bed [1].
- Stress management: slow, deep breathing when you feel palpitations can help. If stress is chronic and affecting your daily life, that is a sufficient reason to discuss it with a doctor [1, 2].
- Hydration: dehydration can be associated with a fast heart rate, particularly in hot weather; drink fluids appropriate to your health needs and follow any prescribed fluid restriction [5].
- Smoking: if you smoke, smoking increases both palpitations and cardiovascular risk in general. This is an additional reason to stop [1].
- Avoid sudden intense exertion without building up gradually, especially if you are not used to exercise. Regular moderate activity is better than a sudden sprint [1, 2].
Palpitations can occur with anxiety and settle as it eases, but that pattern alone does not establish the cause or rule out a rhythm problem [1, 2]. However, if anxiety itself is affecting your day, you may benefit from speaking with a professional because it is a condition that responds to help. There is no shame in telling the doctor you are anxious about the palpitations themselves, because anxiety about anxiety can create a vicious cycle.
If the doctor has prescribed treatment for a specific cause such as anaemia or a thyroid disorder, treating the cause and following up may help the palpitations improve [2]. If palpitations return after a period of improvement, inform your doctor so the plan can be reviewed.
Palpitation assessment in Maadi
If palpitations are not an emergency and you want a structured assessment, you can book an internal medicine consultation with Dr Mohab Ashraf Fouad at La Rose Clinics in Maadi on Saturday, 4 to 7 pm. The branch is at 14 Al Mokhtar Street, off Al Nasr Street, behind QNB Bank, New Maadi. Call or WhatsApp 010 4066 1893; the appointment is confirmed at booking.
During the visit, the doctor takes a medical history, performs a clinical examination and ECG, and requests basic investigations as indicated: a complete blood count, thyroid function tests, and electrolytes. The results determine whether the palpitations have a treatable cause such as anaemia or a thyroid disorder, or whether monitoring devices or a cardiology referral are needed. For a broader view of the internal medicine consultation at the branch, read internist in Maadi.
If you have emergency signs such as chest pain with palpitations, severe breathlessness, or fainting, do not wait for a clinic appointment. Go to the nearest hospital emergency department immediately [1, 2, 3].
