Palpitations refers to an individual’s awareness of their own heartbeat as if it’s racing, fluttering, or pounding. Naturally, your mind jumps to all sorts of conclusions—Is this a heart attack? Is my heart failing? Should I rush to the hospital?

Palpitations, although often harmless, can be unsettling because they draw attention to a vital organ—your heart. It can induce fear even when the cause is benign, which is understandable, especially since palpitations may be linked to conditions like arrhythmias, anxiety, or even structural heart disease.

In this Blog, we’ll try to understand why do they happen, what causes them? when should you worry? and how to manage?

The Basics of Heart

To fully Understand the concept, we must first know how the heart functions. Your heart is an electrical organ that beats in a regulated rhythm due to electrical signals originating from the sinoatrial (SA) node, often called the heart’s natural pacemaker. This node sends electrical impulses that spread through the atria (upper chambers) and the ventricles (lower chambers), causing them to contract in a coordinated fashion. This cycle repeats with every heartbeat.

Palpitations occur when there is a disruption in this normal rhythm, and they can feel like your heart is beating too fast, too slow, or irregularly.

The Nervous System

The autonomic nervous system also plays a crucial role in regulating heart rhythm. The sympathetic nervous system, responsible for the ‘fight or flight‘ response, can increase heart rate and contractility, potentially leading to palpitations.

Conversely, the parasympathetic nervous system, which promotes ‘rest and digest‘ functions, can slow down the heart rate.

Causes

There are various reasons why the disruption in normal rhythm and heart rate might occur:

Physiological

• Exercise or Physical Activity: During exertion, your heart beats faster to meet the increased oxygen demand of your muscles. This is a normal physiological response, but the sudden awareness of a pounding heart can feel like palpitations.
  
  
• Stress and Anxiety: Emotional stress triggers the release of hormones like adrenaline, which can increase your heart rate. The fight-or-flight response is designed to prepare your body for action, and palpitations are a part of that response.
  
  
• Dehydration: Dehydration reduces blood volume, which can make the heart work harder to pump blood, leading to palpitations.
  
  
• Electrolyte Imbalances: Electrolytes like potassium, calcium, and magnesium are crucial for proper heart function, and imbalances can cause irregular heart rhythms.

Cardiac Causes

• Arrhythmias: Arrhythmias refer to any irregularity in the heart’s rhythm, irregular heartbeats that can be too fast, too slow, or erratic, such as atrial fibrillation, atrial flutter, (where the heart’s upper chambers or atria beat irregularly, leading to an uneven heart rate.), or ventricular tachycardia.
  
  
• Thyroid Dysfunction: The thyroid gland regulates metabolism and heart rate. Hyperthyroidism, or an overactive thyroid, can cause the heart to race or beat irregularly.
  
  
• Anemia: A lack of red blood cells reduces oxygen delivery to tissues, causing the heart to work harder, which may lead to palpitations.
  
  
• Heart Disease: Conditions like coronary artery disease (CAD), congestive heart failure, or valve disorders (when heart valves do not open or close properly) they can disrupt normal blood flow, resulting in excessive heartbeat.

Non-Cardiac Causes

• Caffeine and Nicotine: Both caffeine and nicotine stimulate the nervous system, causing an increase in heart rate and sometimes palpitations.
  
  
• Medications: Certain medications, including decongestants, asthma inhalers, and some antidepressants, can have palpitations as a side effect.
  
  
• Alcohol: Alcohol, particularly in large quantities, can trigger atrial fibrillation, leading to palpitations.
  
  
• Substance Abuse: Stimulant drugs like cocaine can also cause serious arrhythmias.

Types

Palpitations aren’t all the same. They can differ based on their frequency, duration, and the underlying cause. Here are a few common types:

1. Premature Atrial Contractions (PACs): These are early beats originating in the atria. They’re often felt as a brief pause followed by a stronger beat. PACs are typically benign and can be triggered by stress, caffeine, or alcohol.
   
   
2. Premature Ventricular Contractions (PVCs): These are extra beats that originate in the ventricles. Similar to PACs, they often feel like a skipped or extra beat. PVCs are also usually harmless, although they can be more concerning in people with existing heart disease.
   
   
3. Atrial Fibrillation (AFib): AFib is a common type of arrhythmia where the atria beat irregularly and out of sync with the ventricles. It can cause palpitations that are rapid and irregular. AFib increases the risk of stroke and other complications.
   
   
4. Supraventricular Tachycardia (SVT): SVT is a fast heart rate that starts above the ventricles and can cause palpitations lasting from a few minutes to hours. SVT is usually not life-threatening, but persistent episodes should be evaluated by a doctor.
   
   
5. Ventricular Tachycardia (VT): VT is a rapid heart rate originating from the ventricles. It is more serious than SVT and requires immediate medical attention, as it can lead to sudden cardiac arrest.

How To Approach

When evaluating a patient with palpitations, the history-taking process is crucial to identifying potential causes and guiding diagnosis. Here’s a structured approach

Common Questions:

• Ask the patient to describe their palpitations (racing, pounding, fluttering, skipping).
  
• Determine the onset, frequency, and duration of episodes.
  
• Inquire if the palpitations are regular or irregular.

• Explore what circumstances precipitate the palpitations, such as physical activity, stress, caffeine, or alcohol.
  
• Ask about any emotional triggers like anxiety or panic.
  
• Any Associated symptoms like chest pain, shortness of breath, dizziness, or syncope (fainting), which may indicate more serious underlying conditions.

Medical History

• Ask about any history of heart disease, thyroid disorders, anemia, or use of medications known to affect heart rhythm.
  
• Inquire about family history of arrhythmias or sudden cardiac death.

Lifestyle Factors:

• Discuss the patient’s caffeine, alcohol, and nicotine intake, as these can trigger palpitations.
  
• Ask about any recent changes in exercise or hydration habits.

Medication

Review current medications (e.g., stimulants, decongestants) and any use of recreational drugs that may affect heart rhythm.

Physical Examination:

A thorough physical examination of a patient is essential for identifying potential cardiovascular or systemic causes.

General Appearance:

• Assess the patient’s overall well-being, looking for signs of distress, anxiety, or discomfort.
  
• Observe for signs of dehydration or malnutrition, which can contribute to palpitations.

Vital Signs:

• Heart rate: Check for tachycardia, bradycardia, or irregular pulse.
  
  
• Blood pressure: Assess for hypertension or hypotension.
  
  
• Respiratory rate: Look for abnormal breathing patterns that might indicate a cardiovascular or pulmonary cause.
  
  
• Temperature: Check for fever, which could suggest infection as a trigger.

Cardiovascular Exam:

• Inspection: Look for signs of cyanosis, edema, or jugular venous distention (JVD), which can indicate heart failure or vascular issues.
  
  
• Auscultation: Listen for heart murmurs, extra heart sounds (S3, S4), or irregular rhythms (arrhythmias).
  
  
• Peripheral pulses: Assess for irregular or weak peripheral pulses, indicating circulation issues.

Respiratory Exam:

• Listen to the lungs for crackles, wheezing, or diminished breath sounds, which might indicate a pulmonary cause like heart failure or lung disease.

Thyroid Exam:

• Palpate the thyroid gland for enlargement or nodules, which could point to hyperthyroidism as a cause of palpitations.

Abdominal Exam:

• Check for organomegaly (enlarged liver or spleen), which could be associated with systemic causes like anemia or infections.

Neurological Exam:

• Assess for any neurological symptoms like dizziness, confusion, or syncope, which might suggest cardiovascular or circulatory issues impacting brain perfusion.

Investigations

Blood Tests:

• Complete blood count (CBC): Identify anemia, infections, or other systemic issues.
  
• Thyroid function tests: Rule out hyperthyroidism or hypothyroidism.
  
• Electrolyte panel: Check for imbalances in potassium, calcium, or magnesium, which can affect heart rhythm.
  
• Cardiac enzymes: Consider these if myocardial ischemia (heart attack) is suspected.

Electrocardiogram (ECG):

• Perform a 12-lead ECG to evaluate the heart’s electrical activity.
  
• Look for arrhythmias, conduction blocks, ischemic changes, or structural abnormalities.
  
• Consider performing an exercise stress test if palpitations are associated with physical activity.

Holter Monitor:

• Use a Holter monitor for continuous ECG monitoring over 24-48 hours to capture intermittent palpitations.
  
• Ideal for patients whose palpitations are infrequent but concerning.

Echocardiogram:

• Perform an echocardiogram (heart ultrasound) to assess the structure and function of the heart.
  
• Detects conditions like valvular heart disease, cardiomyopathy, or heart failure that might explain palpitations.

Chest X-ray:

• Assess for cardiomegaly (enlarged heart), pulmonary congestion, or other signs of heart failure or lung disease that might cause palpitations.

Electrophysiology Study (EPS):

• If arrhythmias are suspected but not confirmed by other tests, an EPS maps the electrical pathways in the heart to identify and possibly treat the abnormal rhythm.

How To Manage

Treatment depends on the underlying cause. In many cases, palpitations are harmless and don’t require treatment beyond lifestyle adjustments. However, when they are linked to arrhythmias or other underlying issues, more targeted therapies are necessary.

Lifestyle Modifications

• Stay Hydrated: Proper hydration and maintaining electrolyte balance can prevent palpitations caused by dehydration or electrolyte disturbances.
  
  
• Reduce Caffeine and Stimulants: Limiting caffeine, alcohol, and nicotine intake can prevent palpitations for those sensitive to these triggers.
  
  
• Manage Stress: Stress-relief techniques like mindfulness, meditation, and yoga can reduce anxiety-induced palpitations.
  

Medications

• Beta-blockers or Calcium Channel Blockers: These medications slow the heart rate and are commonly prescribed for arrhythmias.
  
  
• Anti-arrhythmic Drugs: These drugs help control or prevent abnormal heart rhythms in patients with more serious arrhythmias.
  
  
• Blood Thinners: In cases of AFib, blood thinners like warfarin or newer anticoagulants are often prescribed to reduce the risk of stroke.

Procedures

• Catheter Ablation: For patients with recurring arrhythmias like SVT or AFib, catheter ablation is a procedure that destroys the abnormal electrical pathways in the heart responsible for the arrhythmia.
  
  
• Pacemaker or Implantable Cardioverter-Defibrillator (ICD): In severe cases, a pacemaker or ICD may be implanted to regulate heart rhythm or deliver shocks if a life-threatening arrhythmia occurs.

Conclusion

Palpitations are a common but often misunderstood sensation. While they can be alarming, they are frequently harmless and can be managed through lifestyle adjustments. However, understanding the underlying cause is crucial, as some palpitations signal more serious cardiac issues.

If you’re experiencing palpitations, don’t ignore them—listen to your heart, both literally and figuratively, and take action to protect your well-being.