Heart palpitations

Definition
Heart palpitations are the sensation of feeling your own heartbeat, which may be perceived as pounding, fluttering, racing, skipping, or irregular. They can occur at rest, during exertion, or even while lying down. Palpitations are a common symptom and are often benign, but in some cases, they may signal underlying cardiac or systemic disease.

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Causes

1. Cardiac causes

• Arrhythmias: atrial fibrillation, atrial flutter, supraventricular tachycardia, ventricular ectopics, ventricular tachycardia

• Structural heart disease: cardiomyopathy, valvular heart disease, congenital defects

• Post-myocardial infarction or ischemia

2. Non-cardiac causes

• Stimulants: caffeine, nicotine, alcohol, recreational drugs (e.g., cocaine, amphetamines)

• Medications: β-agonists (salbutamol), theophylline, thyroid medication, certain antidepressants, decongestants

• Hormonal: hyperthyroidism, pregnancy, menopause

• Systemic: fever, hypoglycemia, anemia, dehydration, hypovolemia, electrolyte imbalances (low potassium, magnesium, calcium)

• Psychological: anxiety, panic disorder, stress

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Symptoms

• Rapid, pounding, or irregular heartbeat

• Fluttering sensation in chest or throat

• Dizziness, lightheadedness, or fainting (syncope)

• Chest discomfort or pain

• Shortness of breath

• Fatigue

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Diagnosis

• History & physical examination: onset, duration, triggers, associated symptoms

• Electrocardiogram (ECG): essential to detect arrhythmias

• Holter monitor (24–48 hours) or event recorder: for intermittent palpitations

• Echocardiography: assesses structural heart disease

• Blood tests: thyroid function, electrolytes, hemoglobin

• Exercise stress testing: if exertion-related

• Electrophysiology studies: in complex arrhythmias

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Treatment

Treatment depends on the underlying cause.

Lifestyle & General Management

• Avoid stimulants: reduce caffeine, nicotine, alcohol, recreational drugs

• Stress management: relaxation techniques, mindfulness, CBT for anxiety

• Adequate hydration and electrolyte balance

Pharmacological Treatments

• Arrhythmias

  • Beta-blockers (e.g., propranolol, metoprolol; typical dose 40–120 mg/day propranolol; 25–100 mg/day metoprolol in divided doses)

  • Calcium channel blockers (e.g., verapamil 120–240 mg/day; diltiazem 120–360 mg/day)

  • Antiarrhythmics (e.g., amiodarone 200–400 mg/day, flecainide 50–150 mg/day, depending on arrhythmia type)

• Thyrotoxicosis-related: antithyroid drugs (carbimazole 20–40 mg/day, propylthiouracil 100–200 mg/day)

• Anemia-related: iron supplementation (ferrous sulfate 200 mg orally TDS)

• Anxiety-related: SSRIs (sertraline 50–200 mg/day), benzodiazepines short-term if severe (diazepam 2–10 mg up to TDS)

Interventional Treatments

• Electrical cardioversion (for atrial fibrillation/flutter if unstable)

• Catheter ablation (for SVT, AF, or other refractory arrhythmias)

• Pacemaker/ICD insertion (for bradyarrhythmias, ventricular tachyarrhythmias, or high-risk patients)

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Contraindications & Precautions

• Beta-blockers: avoid in asthma, severe bradycardia, AV block

• Calcium channel blockers: avoid in heart failure with reduced EF

• Amiodarone: monitor thyroid, liver, lung function (risk of toxicity)

• Flecainide: contraindicated in structural heart disease

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Drug Interactions

• Beta-blockers with other negative chronotropes (digoxin, verapamil) → risk of bradycardia

• Amiodarone increases levels of warfarin, digoxin, statins → risk of toxicity

• SSRIs + MAO inhibitors → serotonin syndrome

• Theophylline with caffeine/nicotine → enhanced stimulation

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Precautions

• Patients with syncope, chest pain, or family history of sudden cardiac death need urgent cardiology referral

• Pregnant women require safer alternatives (beta-blockers like labetalol preferred)

• Regular follow-up ECG and labs in patients on long-term antiarrhythmics