Palpitations: Diagnosis and Treatment

How doctors classify palpitations

For help deciding what to do about palpitations you are having now, see the heart palpitations symptom guide.

Who is at higher risk of a serious cause

• known structural heart disease, heart failure or a previous heart attack
• palpitations with fainting or during exercise
• family history of sudden cardiac death, cardiomyopathy or inherited arrhythmia
• an abnormal resting ECG, such as pre-excitation (Wolff-Parkinson-White), long QT or Brugada pattern
• older age with stroke risk factors, raising suspicion of atrial fibrillation

Diagnosis

History

The most useful questions are how episodes start and stop (abrupt or gradual), the rate and regularity (tapping it out helps), triggers, duration, and associated symptoms. Doctors also ask about caffeine, alcohol, drugs, supplements and medicines, and family history.

Examination and ECG

A 12-lead ECG is recorded for everyone. It may show the rhythm itself if you have symptoms at the time, or clues such as a short PR interval and delta wave in Wolff-Parkinson-White syndrome, a long QT interval or signs of heart enlargement.

Blood tests

Full blood count, thyroid function, electrolytes including potassium and magnesium, kidney function, and sometimes glucose.

Ambulatory monitoring

The choice depends on how often symptoms happen:

Other tests

• Echocardiogram: checks heart structure and valves.
• Exercise stress test: for palpitations triggered by exertion.
• Electrophysiology study: catheters inside the heart to trigger and map an arrhythmia, often done with ablation.

Treatment

Extra beats and sinus tachycardia

• Explanation and reassurance when the heart is structurally normal.
• Reduce caffeine, alcohol and nicotine; improve sleep; treat anxiety.
• Treat the cause: anemia, thyroid disease, dehydration or medicine side effects.
• Beta-blockers for troublesome symptoms.
• Very frequent ventricular extra beats (for example more than 10% of all beats) are monitored for effects on heart function and may be treated with medicine or ablation.

Supraventricular tachycardia

Vagal maneuvers can stop an episode. In hospital, adenosine is given through a vein. Long term, options are beta-blockers or calcium channel blockers, or catheter ablation, which cures most cases and is often first choice. See paroxysmal supraventricular tachycardia.

Atrial fibrillation

Treatment has three aims: preventing stroke with anticoagulants when risk scores support it, controlling heart rate, and restoring rhythm with medicines, cardioversion or ablation in selected people. See atrial fibrillation.

Ventricular arrhythmias

Ventricular tachycardia in heart disease is treated by a cardiologist with medicines, ablation and often an implantable cardioverter-defibrillator (ICD).

Outlook

People with palpitations, a normal ECG, a normal echocardiogram and no red flags have an excellent outlook. Studies show most are found to have benign causes. Where an arrhythmia is found, modern treatment usually controls symptoms well, and ablation can be curative for SVT.

Frequently asked questions

What tests are done for palpitations?

Almost everyone has an ECG and blood tests for anemia, thyroid function and electrolytes. If episodes are frequent, you may wear a Holter monitor for 24 to 48 hours; if less frequent, a patch or event monitor for 1 to 2 weeks, or an implantable loop recorder. An echocardiogram checks heart structure.

What does it mean if my Holter monitor is normal?

If you had symptoms during monitoring and the rhythm was normal, your palpitations are very unlikely to be from a dangerous arrhythmia. If you had no symptoms while wearing it, a longer monitor may be needed to capture an episode.

How are palpitations treated?

Treatment depends on the cause. Benign extra beats usually need only reassurance and less caffeine or alcohol, sometimes a beta-blocker. Arrhythmias such as SVT or atrial fibrillation are treated with medicines, cardioversion or catheter ablation, and atrial fibrillation may need blood thinners.

Can a smartwatch detect the cause of palpitations?

Some smartwatches can record a single-lead ECG and detect atrial fibrillation. A recording taken during symptoms can help your doctor. However, they can miss some rhythms and give false alarms, so they do not replace medical monitoring.