Palpitations: A Cardiologist's Guide to What That Fluttering Heartbeat Means and How We Sort It Out

A woman in her forties sits down across from me and apologizes before she even starts, sure I’m going to tell her she’s wasting my time. For a few weeks now her heart has been doing a little flip-flop in the evenings, a skip and then a thud that makes her catch her breath. She’s been lying awake feeling for it. She wants to know if she’s having a heart attack, or worse. By the time she leaves, she understands what’s happening, she’s had the right tests, and the fear has lifted. That’s the usual arc with palpitations, and it’s a good one.

Palpitations are one of the most common things I see. Up to one in five people in a general clinic will mention them. The feeling can be a flutter, a pound you can hear in your ears, a skipped beat, or a sudden gallop that comes out of nowhere. The reassuring headline is that most palpitations are harmless. A small minority point to a rhythm problem worth treating, and a smaller group still flag something that needs prompt attention. My job is to tell those apart with a sensible, low-stress evaluation, and to send you home knowing what your heart is actually doing. This guide walks through what palpitations are, what causes them, the handful of warning signs that change the urgency, and how the workup unfolds.

What Palpitations Actually Are

A palpitation is simply an awareness of your own heartbeat. Most of the time you don’t feel your heart at all. A palpitation is the moment you suddenly do, whether the beat is extra, early, fast, irregular, or just unusually forceful.

People describe palpitations in a handful of ways, and the words you use give me real clues. Some feel a single skipped beat, as if the heart paused and then gave a harder thump to catch up. Some feel a flutter, like a bird’s wings in the chest. Some feel a sudden racing that switches on and off like a light. Others just notice a strong, steady pounding when they’re lying still at night. All of these are palpitations, and they don’t all mean the same thing.

The heart has its own electrical system that sets the pace and keeps the four chambers beating in order. A palpitation happens when something interrupts that smooth rhythm, or when a perfectly normal rhythm becomes loud enough to notice. The cause can sit in the heart’s wiring, or it can come from outside the heart entirely, from your thyroid, your stress level, a cup of coffee, or a poor night’s sleep. Sorting out which one is behind your symptoms is the whole point of the visit.

The Reassuring Big Picture

For most people who come in with palpitations, the heart is structurally normal and the rhythm is either benign or easily explained. That’s true often enough that I lead with it, so you’re not carrying more worry than the situation calls for.

It helps to know the lay of the land before we talk specifics. When researchers follow large groups of people with palpitations, the most common findings by far are harmless extra beats and ordinary fast rhythms triggered by something identifiable. Anxiety and a heightened sense of a normal heartbeat account for a large share as well. The serious rhythm problems are real and worth ruling out, and they make up the minority of cases.

None of that means I brush palpitations off. The opposite, actually. The way to earn that reassurance is to do the evaluation properly, find the cause, and confirm there’s nothing dangerous hiding underneath. Reassurance with a workup behind it is worth a great deal. Reassurance without one is just a guess. So we look, and the looking is usually quick and noninvasive.

The Common, Harmless Causes

Most palpitations trace back to three friendly culprits: extra beats that feel like skips or thumps, a normal heart speeding up for a reason, and anxiety that turns up the volume on an ordinary heartbeat. These are the everyday explanations, and they rarely signal trouble.

The single most frequent cause is an early extra beat. When it starts in the upper chambers, we call it a premature atrial contraction, or PAC. When it starts in the lower chambers, it’s a premature ventricular contraction, or PVC. Both feel the same to you: a skipped beat, a pause, then a firmer thump as the heart resets. Almost everyone has these now and then, often without noticing. When they cluster, you feel them more. In a heart that’s otherwise healthy, occasional PACs and PVCs are a normal part of being human and don’t shorten your life. You can read more in my guide to PVCs.

The second common cause is a normal rhythm running fast, which we call sinus tachycardia. This is your heart doing exactly what it’s supposed to do, just at a higher gear. The triggers are familiar: caffeine, stress, pain, fever, dehydration, anemia, an overactive thyroid, certain medications, alcohol, and stimulants of any kind. The fix here is finding the trigger and addressing it, not treating the heart. When a few drinks set off a night of palpitations, that has its own name, which I cover in holiday heart syndrome.

The third is anxiety and panic. Stress can make you acutely aware of a heartbeat that was always there, and a panic attack can send the heart racing on its own. Palpitations that come with a sense of choking, tingling in the hands, or a wave of dread often have an anxiety component. I take that seriously rather than dismissing it. Anxiety is a real cause of real symptoms. We confirm the heart is sound first, then we can treat the anxiety with confidence on both sides.

The Rhythm Problems We Look For

A subset of palpitations comes from a true rhythm disturbance worth diagnosing and treating. The main ones are SVT, atrial fibrillation, and atrial flutter. Each has a fingerprint in how it feels and how it shows up on a tracing.

The first is supraventricular tachycardia, or SVT, an umbrella term for a few fast rhythms that start above the ventricles. The classic story is a sudden racing that switches on out of nowhere and then stops just as abruptly, sometimes with a strong pounding felt up in the neck, and occasionally followed by a trip to the bathroom as the heart releases a hormone that makes you pass urine. SVT is rarely dangerous, and it’s very treatable, sometimes with a simple breathing trick and sometimes with a curative procedure. I cover both in my guides to SVT and the vagal maneuvers that can stop an episode.

The second is atrial fibrillation, or AFib, the most common sustained abnormal rhythm we treat. It tends to feel irregular, like the heartbeat has lost its steady cadence, and it grows more common with age. Its cousin, atrial flutter, runs fast but usually regular. Both can sometimes slow for a moment with a vagal maneuver, which itself is a clue. AFib matters not so much for how it feels as for its link to stroke risk, which is why catching it changes the plan. My guide to atrial flutter versus AFib walks through how we tell them apart and what each one needs.

These rhythms are worth finding precisely so we can do something useful about them. The treatments are good, from medications to ablation procedures that can fix the problem at its source. A racing or irregular heartbeat that turns out to be SVT or AFib is not bad news. It’s a diagnosis with a clear path forward.

The Cannot-Miss Patterns

A small number of palpitations connect to conditions that carry real risk, and these are the ones the whole evaluation is designed to catch. They tend to announce themselves with specific clues: fainting, exercise as a trigger, or a family history of sudden death.

The first is ventricular tachycardia, a fast rhythm arising from the lower chambers. It shows up most often in people who have a weakened or scarred heart muscle, such as after a prior heart attack, and it produces a distinctive wide pattern on the tracing. This is the rhythm that most deserves prompt attention, and it’s covered in my guide to ventricular tachycardia.

The second is a pre-excitation pattern called Wolff-Parkinson-White, where an extra electrical connection between the upper and lower chambers can let a rhythm run dangerously fast. The reassuring part is that it leaves a telltale signature on a resting ECG, so a simple tracing often spots it before it ever causes a problem.

The third group is the channelopathies, a set of inherited conditions with names like long QT, Brugada, and CPVT, where the heart’s electrical channels are wired in a way that raises the risk of dangerous rhythms. These run in families, can be linked to fainting during exertion, and often show a characteristic pattern on the ECG. A family history of a young, unexplained, or sudden death is the clue that puts these on my radar. You can read more in my guide to long QT, Brugada, and CPVT. Hypertrophic cardiomyopathy, a thickening of the heart muscle covered in my HCM guide, belongs in this same conversation.

These conditions are uncommon. The reason I lay them out is that the workup, especially the ECG and the questions I ask about fainting and family history, is built to flush them out early. Finding one of these before it causes harm is one of the most valuable things a palpitations evaluation can do.

What Your Story Tells Me

Before any test, the description of your symptoms does a lot of the diagnostic work. How the palpitations start, how they feel, what sets them off, and what comes with them all point toward different causes.

A few patterns are worth knowing, because they help you describe what you feel in a way that speeds up the diagnosis. Isolated skipped beats point toward harmless extra beats. A racing that starts and stops suddenly suggests SVT. A rapid pounding felt in the neck fits with SVT or strong extra beats. An irregular, sustained fast heartbeat raises the question of atrial fibrillation. Palpitations that stop when you bear down or hold your breath suggest an SVT that responds to a vagal maneuver.

The features that raise my attention are different ones. Palpitations that come on during or right after exercise get a closer look. So do palpitations that arrive together with fainting, near-fainting, chest pain, or breathlessness. A family history of sudden cardiac death or an inherited heart condition shifts the whole evaluation up a gear. Symptoms wrapped in choking, tingling, and a sense of doom point toward anxiety, though I confirm the heart first. None of these single features makes a diagnosis on its own. Together they build a picture that tells me how fast to move and which tests to order.

This is why the visit starts with a conversation. The more precisely you can describe what your heart does, when it does it, and what else you feel, the faster we land on the answer. Keeping a short log on your phone, noting the time, the trigger, and how long it lasts, is one of the more useful things you can do before we meet.

How We Evaluate Palpitations

The workup is methodical and gentle. It usually starts with a resting ECG and a few blood tests, adds an ultrasound of the heart when something warrants it, and leans on a wearable monitor to catch the rhythm while you go about your life. The aim is to record your heart in the act of doing what it does.

The first test is almost always a 12-lead ECG, a quick, painless tracing of the heart’s electrical activity. At rest it catches a diagnosis somewhere between a few and a quarter of the time, and the yield jumps to nearly half if we happen to record it while you’re having symptoms. The resting tracing earns its place by screening for the cannot-miss patterns: pre-excitation from Wolff-Parkinson-White, a long or short QT, a Brugada pattern, signs of a prior heart attack, and thickening of the heart muscle.

Next come a few blood tests, since the heart often races for reasons that have nothing to do with its wiring. I check a blood count for anemia, a metabolic panel, thyroid function, and magnesium, and a pregnancy test in women of reproductive age. Cardiac biomarkers aren’t part of a routine palpitations workup. We add them only when there’s concern for a sustained arrhythmia, reduced blood flow to the heart, or instability.

An echocardiogram, an ultrasound of the heart, comes into play when the exam or the ECG is abnormal, when palpitations come with fainting, or when there’s a family history of hypertrophic cardiomyopathy or sudden death. It shows the heart’s structure and pumping function and confirms whether the muscle and valves are sound. For many people with a normal exam and a normal ECG, an echocardiogram isn’t needed at all.

The workhorse of the palpitations evaluation is ambulatory monitoring, a recorder you wear that captures your heartbeat over time. The right choice depends on how often your symptoms strike. For daily palpitations, a 24 to 48 hour Holter monitor can do the job, though its yield is modest because it only listens for a day or two. For palpitations of unknown cause, a continuous patch worn for about two weeks hits the sweet spot, catching the rhythm in 70 to 85 percent of cases at a sensible cost. For episodes that come weeks apart, or that come with fainting, a longer-term event monitor or an implanted loop recorder can listen for months or years. The strategy is simple. We match the length of the recording to the frequency of your symptoms, so we’re listening when your heart misbehaves.

A stress test rounds out the toolkit when palpitations show up during or right after exercise, or when there’s a question of reduced blood flow to the heart. Watching the rhythm and the heart’s response under the controlled stress of a treadmill can surface a rhythm that hides at rest.

Where Wearables Fit In

The smartwatch on your wrist has quietly become a useful partner in this. Consumer devices that record a single-lead ECG and flag an irregular rhythm can capture an episode that would otherwise come and go before you reach a doctor.

I’ve had more than a few patients walk in with a recording from their watch that showed exactly what their heart was doing during an episode. For a symptom as fleeting as a palpitation, that’s genuinely helpful. A watch tracing that captures a sudden racing or an irregular rhythm gives us a real head start, and some devices are accurate enough to suggest atrial fibrillation worth confirming.

A few honest caveats keep this in perspective. Consumer devices record a simpler signal than a full medical ECG, they sometimes flag rhythms that turn out to be nothing, and they’re a screening aid rather than a diagnosis. The right way to use one is as an extra set of ears. Capture what you can, bring it to your visit, and let your cardiologist confirm what it found. Used that way, a wearable shortens the path to an answer rather than replacing the people who interpret it.

Red Flags That Mean Get Checked Promptly

Most palpitations can wait for a routine appointment. A handful of features change that, and they’re worth knowing so you can act on them.

• Fainting or near-fainting along with the palpitations
• Palpitations brought on by exercise, especially in a younger person
• A racing pulse that won’t settle, or a heartbeat over about 120 that stays up at rest
• Chest pain, severe breathlessness, or a feeling of collapse with the episode
• A family history of sudden cardiac death or an inherited heart condition
• Known heart disease, such as a weakened heart muscle or a prior heart attack, with new palpitations

If palpitations come with fainting, chest pain, or a sense that something is seriously wrong, treat it as an emergency and call for help rather than waiting it out. For the other red flags, they don’t mean disaster, they mean your evaluation should happen sooner and lean more thorough. My guide to lightheadedness versus passing out goes deeper on the fainting piece, which is the one that most often changes the urgency.

What You Can Do Before and Between Visits

A few simple habits make both your symptoms and your evaluation easier. Most of them cost nothing and start helping right away.

Start by trimming the obvious triggers and seeing what happens. Cut back on caffeine and alcohol for a couple of weeks, protect your sleep, and notice whether the palpitations ease. Stay well hydrated and don’t skip meals, since low fluids and low blood sugar both nudge the heart to race. If you use stimulants, including some pre-workout supplements and over-the-counter decongestants, those are common and overlooked culprits worth pausing.

Keep a short symptom log. Jot down when an episode hits, what you were doing, what it felt like, how long it lasted, and whether anything stopped it. If you have a smartwatch with an ECG feature, capture a tracing during an episode if you can. This record turns a vague complaint into a sharp clinical picture, and it often points straight at the cause.

Learn one vagal maneuver if your palpitations are the sudden-racing type. Bearing down as if you’re having a bowel movement, or blowing hard against a closed airway for fifteen seconds, can stop an SVT episode. My guide to vagal maneuvers walks through the technique. A maneuver that reliably stops your episodes is useful in the moment. It also gives me a strong clue about what the rhythm is.

When to See a Cardiologist

If your palpitations are frequent, getting worse, coming with fainting or chest pain, triggered by exercise, or paired with a family history of sudden death, a cardiology evaluation is the right call. The same is true if a wearable has flagged an irregular rhythm, or if you simply want the peace of mind that comes from a proper look rather than a guess.

If you’d like help sorting out what’s behind your palpitations, our office is glad to see you. To get in touch, visit our practice website. For coordinated cardiac care across San Diego, we work with the team at San Diego Cardiovascular Associates. For related reading, see my guides to SVT, atrial flutter versus AFib, and PVCs.

Common Questions Patients Ask Me

Are heart palpitations dangerous?

Most are not. The large majority come from harmless extra beats, a normal heart speeding up for a reason, or anxiety. A minority point to a rhythm worth treating, and a small group connect to conditions that need prompt care. The way to know which kind you have is a short evaluation, and most people come out reassured.

Why do I feel my heart skip a beat?

That skip is usually an early extra beat, a PAC or a PVC, followed by a short pause and then a firmer thump as the heart resets. Nearly everyone has these. In an otherwise healthy heart, occasional skipped beats are normal and not a sign of disease. They feel more noticeable when you’re tired, stressed, or lying still at night.

When should I go to the emergency room for palpitations?

Go right away if your palpitations come with fainting or near-fainting, chest pain, severe shortness of breath, or a feeling that you might collapse. A very fast heartbeat that won’t settle also warrants urgent care. For palpitations without these features, a routine appointment is usually fine.

Can anxiety cause heart palpitations?

Yes, and commonly. Stress and panic can make you sharply aware of a normal heartbeat or send the heart racing on its own. Palpitations that come with choking, tingling, or a wave of dread often have an anxiety component. I confirm the heart is structurally sound first, then anxiety can be treated with confidence.

What test finds the cause of palpitations?

It usually starts with an ECG and a few blood tests. The most productive tool for intermittent palpitations is a wearable monitor, often a patch worn for about two weeks, which records your heart while you live your normal life and catches the rhythm in most cases. An echocardiogram and a stress test are added when the situation calls for them.

Can my smartwatch help diagnose palpitations?

It can help. A watch that records a single-lead ECG can capture an episode that would otherwise pass before you reach a doctor, and some can flag atrial fibrillation. Treat it as a screening aid, not a final answer. Capture what you can during an episode and bring it to your visit for confirmation.

References

1. Gauer, Robert L., Michael F. Thomas, Ryan A. McNutt. “Palpitations: Evaluation, Management, and Wearable Smart Devices.” American Family Physician 110, no. 3 (2024): 259-269.

2. Wexler, Randell K., Adam Pleister, Subha V. Raman. “Palpitations: Evaluation in the Primary Care Setting.” American Family Physician 96, no. 12 (2017): 784-789.

3. Steinberg, Jonathan S., Niraj Varma, Iwona Cygankiewicz, et al. “2017 ISHNE-HRS Expert Consensus Statement on Ambulatory ECG and External Cardiac Monitoring/Telemetry.” Heart Rhythm 14, no. 7 (2017): e55-e96.

4. Peng, Grace, Paul C. Zei. “Diagnosis and Management of Paroxysmal Supraventricular Tachycardia.” Journal of the American Medical Association 331, no. 7 (2024): 601-610.

5. Page, Richard L., Jose A. Joglar, Mary A. Caldwell, et al. “2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia.” Heart Rhythm 13, no. 4 (2016): e136-e221.

6. Al-Khatib, Sana M., William G. Stevenson, Michael J. Ackerman, et al. “2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.” Journal of the American College of Cardiology 72, no. 14 (2018): e91-e220.

Published on damianrasch.com. The above information was composed by Dr. Damian Rasch, drawing on individual insight and bolstered by digital research and writing assistance. The information is for educational purposes only and does not constitute medical advice.