Heart Palpitations: Causes, Symptoms & When to See a Doctor

✍️ Marcin Góras, Master of Public Health, Specialization in Emergency Medical Services
📅 Reading time: ~13 min  |

Published: March 26, 2026  |

Introduction

Heart palpitations — the unpleasant awareness of one’s own heartbeat — are among the most common cardiovascular complaints encountered in both primary care and emergency settings. Patients describe them variously as a racing, pounding, fluttering, skipping, or thumping sensation in the chest, throat, or neck. While the experience is often alarming, the vast majority of palpitations are benign and self-limiting.

Nevertheless, palpitations can occasionally serve as the presenting symptom of serious cardiac arrhythmias, structural heart disease, or significant systemic illness. A thorough clinical evaluation is therefore essential to distinguish benign from potentially dangerous causes. This article provides a comprehensive, evidence-based overview of the causes of heart palpitations, their characteristic features, associated symptoms, and clear guidance on when to seek medical attention.

For context, palpitations account for approximately 16% of presenting complaints in general practice and up to 6% of emergency department visits in developed countries. Their aetiology is remarkably diverse — spanning cardiac, metabolic, pharmacological, psychiatric, and lifestyle-related causes.

How the Heart Normally Works — and Why You Feel Palpitations

Under normal circumstances, the heart beats 60–100 times per minute in a regular, coordinated rhythm initiated by the sinoatrial (SA) node — the heart’s natural pacemaker, located in the right atrium. The electrical impulse travels through the atria, is briefly delayed at the atrioventricular (AV) node, and then spreads via the His-Purkinje system to cause ventricular contraction. This elegant sequence happens silently and continuously throughout life, rarely noticed by the individual.

Palpitations arise when this normal unawareness breaks down — either because the heart is beating faster, slower, or less regularly than usual, or because a person becomes hypersensitive to a heartbeat that is objectively normal. The subjective experience does not reliably distinguish between benign and dangerous causes, which is why clinical evaluation is indispensable.

1. Cardiac Causes of Heart Palpitations

Cardiac causes represent a minority of all palpitation presentations — estimates suggest 10–15% in primary care — but they carry the greatest clinical significance and must be systematically excluded. For a broader overview of heart rhythm disorders, see our comprehensive guide to cardiac arrhythmias.

1.1 Premature Atrial and Ventricular Contractions (PACs / PVCs)

Premature contractions are by far the most common cardiac cause of palpitations in the general population. Premature atrial contractions (PACs) originate outside the SA node in the atrial tissue; premature ventricular contractions (PVCs) arise from ectopic foci in the ventricular myocardium. Both produce an early beat followed by a compensatory pause, which the patient often experiences as a “skipped beat,” a “flip-flop,” or a heavy thud in the chest.

In structurally normal hearts, isolated PACs and PVCs are almost universally benign. However, frequent PVCs (more than 10,000 per 24 hours, or >10% of total beats) can occasionally be associated with PVC-induced cardiomyopathy, and warrant further evaluation. Read our detailed article on premature ventricular contractions for more information.

1.2 Atrial Fibrillation (AF)

Atrial fibrillation is the most common sustained cardiac arrhythmia, affecting an estimated 37 million people worldwide. It is characterised by chaotic, disorganised electrical activity in the atria, resulting in an irregularly irregular ventricular response. Patients typically describe an irregular, rapid, or fluttering heartbeat, sometimes accompanied by breathlessness, fatigue, reduced exercise tolerance, or chest discomfort.

AF carries significant clinical importance beyond palpitations — it is a major risk factor for stroke (5-fold increased risk) and heart failure. Paroxysmal AF (coming and going spontaneously) may be particularly challenging to capture on a standard ECG. A Holter monitor or event recorder is often required. For a comprehensive overview, see our dedicated article on atrial fibrillation.

1.3 Atrial Flutter

Atrial flutter is characterised by rapid, regular atrial activity (typically 250–350 beats per minute) with a characteristic “sawtooth” pattern on ECG. The ventricular rate depends on the degree of AV block — most commonly 2:1, producing a ventricular rate of approximately 150 bpm. Patients experience rapid, regular palpitations that may be associated with dyspnoea, chest tightness, or haemodynamic compromise. See our article on atrial flutter for clinical details.

1.4 Supraventricular Tachycardia (SVT)

Supraventricular tachycardias encompass a group of arrhythmias originating above the bundle of His. The most common form — AVNRT (atrioventricular nodal re-entrant tachycardia) — presents with sudden onset and offset of rapid, regular palpitations (typically 150–250 bpm), often accompanied by a sensation of pulsation in the neck (“frog sign”), lightheadedness, and occasionally near-syncope. SVT is more common in younger, otherwise healthy individuals and is rarely life-threatening, though it can be very distressing. Our article on supraventricular tachycardia covers this topic in depth.

1.5 Ventricular Tachycardia (VT)

Ventricular tachycardia — a rapid rhythm originating in the ventricles — is among the most serious causes of palpitations. It presents with rapid, often regular palpitations (>100 bpm) and may be associated with haemodynamic compromise (hypotension, syncope, cardiac arrest). Non-sustained VT (lasting less than 30 seconds and terminating spontaneously) may cause brief, alarming palpitations without immediate haemodynamic consequence, but requires urgent investigation. Sustained VT is a medical emergency. See our guide on ventricular tachycardia.

1.6 Ventricular Fibrillation (VF)

Ventricular fibrillation represents the most severe end of the ventricular arrhythmia spectrum. It causes immediate haemodynamic collapse and loss of consciousness — patients do not “feel” VF as palpitations, but survivors of resuscitated cardiac arrest may recall palpitations immediately preceding the event. Ventricular fibrillation is the commonest cause of sudden cardiac death.

1.7 Atrioventricular Blocks and Bradyarrhythmias

Paradoxically, slow heart rhythms can also cause palpitations — patients with atrioventricular blocks or bradycardia may experience each heartbeat as heavy or prominent due to increased stroke volume per beat. Escape rhythms following pauses can produce sudden, forceful palpitations. Second- and third-degree AV block require urgent evaluation and often pacemaker implantation.

1.8 Structural Heart Disease

Palpitations in the context of structural heart disease — including heart failure, hypertrophic cardiomyopathy, mitral valve prolapse, or post-myocardial infarction remodelling — carry greater clinical significance than in structurally normal hearts. Structural disease creates an arrhythmogenic substrate that increases the risk of life-threatening arrhythmias. Echocardiography is an essential investigation in this context.

2. Non-Cardiac Causes of Heart Palpitations

The majority of palpitations presenting in primary care are not primarily cardiac in origin. Non-cardiac causes are diverse and often more easily addressable than arrhythmias.

2.1 Anxiety, Stress, and Panic Disorder

Psychological causes are among the most prevalent triggers of palpitations, particularly in younger patients. During anxiety or panic, the sympathetic nervous system releases catecholamines (adrenaline, noradrenaline), which accelerate heart rate, increase contractility, and can trigger ectopic beats. Patients may enter a vicious cycle in which awareness of palpitations amplifies anxiety, which in turn worsens palpitations.

Panic attacks can produce particularly dramatic palpitations, often accompanied by chest tightness, dyspnoea, paraesthesia, and a sense of impending doom — a constellation that closely resembles a cardiac emergency. A diagnosis of anxiety-related palpitations should only be made after cardiac causes have been appropriately excluded, as the two conditions can coexist.

2.2 Thyroid Disorders

The thyroid gland profoundly influences cardiac function. Hyperthyroidism (overactive thyroid) — whether from Graves’ disease, toxic nodular goitre, or thyroiditis — causes a hyperadrenergic state characterised by tachycardia, palpitations, heat intolerance, weight loss, tremor, and anxiety. Even subclinical hyperthyroidism (suppressed TSH with normal free T4/T3) can cause significant palpitations and increase the risk of atrial fibrillation.

Conversely, hypothyroidism can cause palpitations through a mechanism of compensatory increase in stroke volume and forceful heartbeat. Thyroid function tests (TSH, free T4, free T3) are a standard component of palpitation workup.

2.3 Anaemia

Anaemia — defined as haemoglobin below 130 g/L in men and 120 g/L in women — reduces the oxygen-carrying capacity of the blood. The cardiovascular system compensates by increasing cardiac output (faster heart rate, greater stroke volume), which patients perceive as palpitations, particularly on exertion. Associated symptoms include fatigue, pallor, dyspnoea, and reduced exercise tolerance. Common causes include iron-deficiency anaemia, B12/folate deficiency, chronic disease, and blood loss. A full blood count (FBC/CBC) is essential in the evaluation of palpitations.

2.4 Dehydration and Electrolyte Imbalances

Dehydration reduces intravascular volume, triggering a compensatory tachycardia. Electrolyte disturbances — particularly hypokalaemia (low potassium), hypomagnesaemia (low magnesium), hypercalcaemia, and less commonly hypernatraemia — can directly impair cardiac conduction and trigger arrhythmias including AF, PVCs, and in severe cases, potentially life-threatening ventricular arrhythmias such as Torsade de Pointes.

These disturbances are particularly relevant in patients with eating disorders, those taking diuretics, patients with diarrhoea or vomiting, or following vigorous exercise. Serum electrolytes are a routine component of palpitation investigations.

2.5 Stimulants: Caffeine, Nicotine, and Energy Drinks

Caffeine is the world’s most widely consumed psychoactive substance. At moderate doses (up to approximately 400 mg/day in healthy adults), it does not significantly increase arrhythmia risk in the general population — but in sensitive individuals, it can trigger PACs, PVCs, and AF. Energy drinks, which combine caffeine with taurine, guarana, and other stimulants, carry a more pronounced cardiovascular risk and have been associated with serious arrhythmias even in young, otherwise healthy people.

Nicotine — through its sympathomimetic effects — increases heart rate and can trigger ectopic beats. Illicit stimulants including cocaine and amphetamines are potent arrhythmia triggers and should be considered in the differential diagnosis, particularly in younger patients.

2.6 Medications and Drugs

A wide range of prescription and over-the-counter medications can cause palpitations as a direct pharmacological effect or as a consequence of QT prolongation (which predisposes to Torsade de Pointes). Clinically important examples include:

• Beta-2 agonists (salbutamol/albuterol, salmeterol) — commonly used in asthma; cause tachycardia and palpitations
• Decongestants (pseudoephedrine, phenylephrine) — sympathomimetic effects
• Thyroid hormone replacement — particularly if dose is excessive
• Digoxin toxicity — can cause almost any arrhythmia
• QT-prolonging drugs — certain antibiotics (azithromycin, fluoroquinolones), antipsychotics (haloperidol, quetiapine), antihistamines (terfenadine — now withdrawn), and antiarrhythmics (amiodarone, sotalol)
• Stimulant medications (methylphenidate, amphetamine salts used in ADHD)
• Alcohol — acute intoxication and withdrawal both cause palpitations; “holiday heart syndrome” refers to AF triggered by binge drinking
• Cannabis — can cause tachycardia and, less commonly, bradycardia or atrial fibrillation

2.7 Fever and Infection

Fever causes sinus tachycardia through increased metabolic demand and direct sympathetic stimulation — heart rate typically increases by approximately 10–15 beats per minute for each degree Celsius of temperature elevation. Severe sepsis and septic shock can cause rapid, irregular rhythms including new-onset AF. Myocarditis — viral inflammation of the heart muscle — is a particularly important cause of palpitations, chest pain, and arrhythmias in young patients following viral illness (including COVID-19, influenza, and enteroviruses).

2.8 Hormonal Changes: Pregnancy and Menopause

Pregnancy causes significant cardiovascular adaptation — cardiac output increases by 30–50%, heart rate rises by 10–20 bpm, and blood volume expands substantially. Palpitations are common, affecting up to 60% of pregnant women, and are usually benign. However, new-onset arrhythmias in pregnancy require evaluation as some antiarrhythmic treatments are teratogenic and clinical management differs significantly from the non-pregnant state.

Perimenopausal hormonal fluctuations — particularly declining oestrogen levels — are associated with increased sympathetic activity and palpitations. These often coincide with hot flashes and disturbed sleep, and can be mistaken for cardiac symptoms.

2.9 Hypoglycaemia

Low blood glucose triggers a counter-regulatory sympathetic response, releasing adrenaline and causing tachycardia, palpitations, tremor, diaphoresis, and anxiety — symptoms that closely mimic a panic attack. This is particularly relevant in patients with diabetes on insulin or sulfonylurea therapy, but can also occur in non-diabetic individuals through reactive hypoglycaemia, prolonged fasting, or alcohol consumption.

2.10 Anaesthetic and Postoperative Context

New-onset palpitations and atrial fibrillation are among the most common complications in the postoperative period, particularly following cardiac surgery, thoracic surgery, and major non-cardiac operations. Contributing factors include sympathetic activation, electrolyte shifts, pain, hypoxia, and systemic inflammation. Postoperative AF typically resolves spontaneously within 48–72 hours but requires monitoring and, in haemodynamically significant cases, pharmacological or electrical cardioversion.

2.11 Phaeochromocytoma

Phaeochromocytoma — a rare catecholamine-secreting tumour of the adrenal medulla — is an important, if uncommon, cause of episodic palpitations, hypertension, headache, and diaphoresis. The “classic triad” of episodic headache, diaphoresis, and palpitations should prompt biochemical screening (urinary or plasma metanephrines). Though rare, missing this diagnosis has potentially fatal consequences.

3. Palpitations at Night: Special Considerations

Nocturnal palpitations are a common and particularly distressing complaint. The quiet nighttime environment amplifies awareness of the heartbeat, and lying in the left lateral decubitus position (on the left side) places the heart in closer contact with the chest wall, enhancing perception of cardiac activity.

Beyond positional and perceptual factors, specific conditions are more likely to cause nocturnal palpitations:

• Obstructive sleep apnoea (OSA) — intermittent hypoxia and sympathetic surges during apnoeic episodes can trigger AF and other arrhythmias; OSA is strongly associated with atrial fibrillation
• Acid reflux (GERD) — vagal stimulation from oesophageal acid exposure can trigger arrhythmias, particularly at night
• Nocturnal hypoglycaemia — in diabetic patients on insulin
• Autonomic neuropathy — impaired heart rate regulation leading to unpredictable rhythm changes
• Alcohol consumption — “holiday heart” AF classically presents in the early morning hours after evening drinking

4. Red Flag Symptoms: When Palpitations Are Serious

The clinical challenge in evaluating palpitations is distinguishing the benign majority from the potentially dangerous minority. The following features should raise concern and prompt urgent evaluation:

5. Clinical Assessment and Diagnostic Approach

5.1 History — The Most Important Diagnostic Tool

A careful, structured history remains the cornerstone of palpitation evaluation. Key questions to establish include:

• Character: Racing? Irregular? Skipping? Fluttering? Pounding?
• Onset and offset: Sudden or gradual? Does it stop abruptly or wind down?
• Duration: Seconds, minutes, hours?
• Frequency: Daily, weekly, occasional?
• Triggers: Exertion, caffeine, alcohol, stress, meals, posture?
• Associated symptoms: Chest pain, dyspnoea, syncope, dizziness, sweating?
• Termination: Spontaneous? Vagal manoeuvres (bearing down, cold water)?
• Cardiac history: Known arrhythmias, structural disease, prior cardiac investigations?
• Family history: Sudden cardiac death, arrhythmias, cardiomyopathy?
• Medications and substances: Full drug history including OTC, supplements, recreational drugs

5.2 Physical Examination

Examination during palpitations is diagnostically most valuable but rarely possible. Between episodes, examination should include heart rate and rhythm assessment, blood pressure (both arms to exclude aortic dissection if relevant), auscultation for murmurs (suggesting valvular disease or HCM), signs of thyroid disease (goitre, tremor, exophthalmos), signs of anaemia (pallor, conjunctival pallor), and signs of heart failure (oedema, elevated JVP, basal crepitations).

5.3 Investigations

6. Summary Table: Common Causes of Palpitations

Frequently Asked Questions (FAQ)

When to Seek Medical Attention: A Summary

Conclusion

Heart palpitations are a common, heterogeneous symptom with a broad differential diagnosis. The majority of cases — driven by anxiety, ectopic beats, stimulants, or physiological states — are benign and require only reassurance, lifestyle modification, and basic investigation. However, a clinically important minority of palpitations reflect underlying cardiac arrhythmias, structural heart disease, or significant systemic illness that require prompt investigation and treatment.

The key clinical principle is that the subjective experience of palpitations does not reliably predict their underlying cause or severity. A patient with dramatic, terrifying palpitations may have a completely benign aetiology, while a patient with mild, brief flutters may harbour a dangerous ventricular arrhythmia. Systematic clinical evaluation — guided by the history, examination, 12-lead ECG, and targeted investigations — remains the only reliable way to distinguish between these possibilities.

If you are experiencing palpitations, particularly if they are new, frequent, prolonged, or associated with any of the red flag features outlined in this article, consult a qualified healthcare professional. Do not attempt to self-diagnose based on symptom descriptions alone.

Related Articles on HealthOnWorld

• Cardiac Arrhythmias: A Comprehensive Medical Guide for Patients
• Atrial Fibrillation: Understanding the Most Common Heart Rhythm Disorder
• Atrial Flutter: Understanding This Important Heart Rhythm Disorder
• Supraventricular Tachycardia: Understanding Rapid Heart Rhythms Above the Ventricles
• Ventricular Tachycardia: Understanding This Critical Heart Rhythm Emergency
• Premature Ventricular Contractions: Understanding Heart Rhythm Irregularities
• Torsade de Pointes: A Life-Threatening Cardiac Arrhythmia
• Bradycardia: Understanding Slow Heart Rate
• What Does an Abnormal ECG Actually Mean?
• Is a Cardiac Stress Test Dangerous? Risks and What to Expect
• Heart Failure: Complete Medical Guide

References and Further Reading

This article was prepared with reference to the following peer-reviewed publications, clinical guidelines, and authoritative medical resources.

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