Rhythm & Palpitations

Palpitations are caused by: benign ectopic beats (premature atrial or ventricular contractions — the most common cause); atrial fibrillation (irregularly irregular rhythm — most important to exclude due to stroke risk); supraventricular tachycardia or SVT (sudden racing heart at 150–250 bpm, typically paroxysmal); ventricular tachycardia (dangerous — associated with structural heart disease); sinus tachycardia from anxiety, anaemia, thyrotoxicosis, or fever; and sick sinus syndrome or heart block (slow rate causing bradycardia sensation). ECG and Holter monitoring are required to identify the cause.

Most palpitations are benign — caused by ectopic beats, anxiety, or caffeine in a structurally normal heart. However, some arrhythmias carry real risk: atrial fibrillation (5× increased stroke risk — requires anticoagulation); ventricular tachycardia (risk of sudden cardiac death, especially with structural heart disease); and complete heart block (may cause syncope and require pacemaker). The distinction between benign and dangerous requires ECG, Holter monitoring, and echocardiography — not clinical assessment alone.

See a cardiologist promptly if palpitations are accompanied by breathlessness, chest pain, or dizziness; cause fainting (syncope) or near-fainting; feel very rapid (>150 bpm); are irregular rather than just fast; occur during exercise; occur after age 40; or occur in a patient with known structural heart disease (heart failure, prior MI, cardiomyopathy, or family history of sudden cardiac death). Palpitations in a healthy young person without structural disease are more likely benign, but still require ECG and Holter before reassurance can be given.

The standard diagnostic workup for palpitations begins with a resting 12-lead ECG to capture any arrhythmia at the time of evaluation. If the resting ECG is normal, a 24-hour Holter monitor is the next step — it records every heartbeat over a full day and night, allowing correlation of symptoms with actual rhythm. If palpitations are infrequent, extended monitoring with a 7-day patch recorder or an implantable loop recorder (ILR) may be used. A 2D echocardiogram is always performed to assess structural heart disease, ejection fraction, and valve function. Blood tests to check thyroid function, anaemia, and electrolyte imbalances complete the evaluation.

Yes — both caffeine and alcohol are well-known triggers for palpitations. Caffeine is a stimulant that increases heart rate and can provoke ectopic beats (PVCs and PACs) in susceptible individuals. The effect varies widely — some people experience palpitations after a single cup of coffee while others tolerate multiple cups. Alcohol, particularly binge drinking, can precipitate atrial fibrillation — known as 'holiday heart syndrome' — as well as other arrhythmias. Both substances can also worsen existing arrhythmias such as AF or SVT. Reducing or eliminating caffeine and alcohol is a simple first step in managing palpitations. If symptoms persist despite avoidance, formal cardiac evaluation is needed.

Palpitations are common during pregnancy due to the significant physiological changes — increased blood volume (up to 50%), elevated heart rate (10–20 bpm above baseline), hormonal shifts, and the mechanical effects of the growing uterus on venous return. Most palpitations in pregnancy are benign and caused by increased awareness of normal sinus tachycardia or benign ectopic beats. However, pregnancy can also unmask or worsen underlying arrhythmias such as SVT or AF. Any palpitations associated with chest pain, breathlessness, dizziness, or fainting require urgent cardiac evaluation. ECG and Holter monitoring are safe during pregnancy. Most antiarrhythmic medications can be used with appropriate precautions after cardiology and obstetric consultation.

Palpitations are the sensation of feeling your heartbeat — whether it feels fast, pounding, fluttering, or irregular. They are a symptom, not a diagnosis. An arrhythmia is an actual abnormality of the heart's electrical rhythm — such as atrial fibrillation, supraventricular tachycardia, or ventricular tachycardia — that can be documented on ECG or Holter monitoring. Not all palpitations are caused by arrhythmias — increased awareness of a normal heartbeat (sinus tachycardia) due to anxiety, anaemia, or fever also causes palpitations without any rhythm disorder. The distinction between a benign symptom and a clinically significant arrhythmia requires ECG documentation, which is why 24-hour Holter monitoring is the standard diagnostic test.

Yes — stress and anxiety are among the most common causes of palpitations. The sympathetic nervous system response to stress releases adrenaline, which increases heart rate and the force of contraction, and can trigger ectopic beats (premature ventricular or atrial contractions). Panic attacks can produce heart rates of 120–160 bpm, along with chest tightness, hyperventilation, and a sense of impending doom — closely mimicking dangerous arrhythmias. However, it is critical to complete a cardiac evaluation before attributing palpitations to anxiety, as the symptoms of VT, SVT, and AF can be identical. Once cardiac causes are excluded, stress management, cognitive behavioural therapy, and relaxation techniques can significantly reduce symptom burden.