Chest palpitations are a common cardiovascular symptom characterized by an abnormal awareness of the heartbeat. Patients often describe this sensation as fluttering, pounding, racing, or irregular heartbeats. While palpitations are often benign, they can sometimes indicate underlying heart disease or other systemic conditions requiring prompt evaluation and management.
This article offers a detailed exploration of the symptoms, causes, and treatment of chest palpitations from the perspective of a cardiovascular cardiologist. The goal is to provide a comprehensive, factual, and clear guide for both patients and healthcare providers.
What Are Chest Palpitations?
Definition and Clinical Presentation
Chest palpitations refer to the sensation of a heartbeat that is noticeable, irregular, or abnormally rapid or slow. These sensations can occur at rest or during activity and may last seconds to minutes or persist longer. Some patients feel palpitations in the neck or throat due to transmitted pulse waves.
Common descriptors include:
- Fluttering
- Skipped beats
- Pounding
- Rapid or racing heartbeat
- Irregular or uneven heartbeat
When to Be Concerned About Palpitations
While many palpitations are benign, warning signs that warrant urgent medical evaluation include:
- Chest pain or pressure
- Shortness of breath
- Dizziness or syncope (fainting)
- Palpitations accompanied by sweating or weakness
- Known structural heart disease
These symptoms may indicate serious arrhythmias or ischemic heart disease and require prompt cardiology assessment.
Causes of Chest Palpitations
Cardiac Causes
Cardiac causes are the most important to identify due to their potential severity. They include:
1. Arrhythmias
Atrial Fibrillation: Irregular and often rapid heartbeat causing palpitations and sometimes stroke risk.
Atrial Flutter: Rapid atrial rate with regular ventricular response, causing fluttering palpitations.
Supraventricular Tachycardia (SVT): Sudden episodes of very fast heart rate originating above the ventricles.
Ventricular Tachycardia: Fast ventricular rhythm that can be life-threatening and requires immediate intervention.
Premature Atrial or Ventricular Contractions: Extra beats that create skipped or pounding sensations.
2. Structural Heart Disease
- Valvular heart disease (e.g., mitral valve prolapse) may provoke palpitations.
- Cardiomyopathies causing abnormal heart muscle function.
- Heart failure with altered conduction and arrhythmia risk.
3. Ischemic Heart Disease
Coronary artery disease can cause palpitations either due to ischemia-induced arrhythmias or myocardial irritability.
Non-Cardiac Causes
1. Anxiety and Stress
One of the most frequent non-cardiac causes is anxiety, panic attacks, or psychological stress. Sympathetic nervous system activation leads to increased heart rate and heightened heartbeat awareness.
2. Endocrine Disorders
Hyperthyroidism: Excess thyroid hormone causes increased metabolism and tachycardia.
Pheochromocytoma: Rare adrenal tumor causing episodic catecholamine surges and palpitations.
Hypoglycemia: Low blood sugar can stimulate sympathetic activity, resulting in palpitations.
3. Medications and Substances
- Stimulants like caffeine, nicotine, and certain recreational drugs.
- Decongestants and some asthma medications.
- Antiarrhythmic drugs causing proarrhythmia.
4. Electrolyte Imbalances
Low potassium, magnesium, or calcium levels can predispose to arrhythmias and palpitations.
5. Other Causes
- Anemia causing compensatory tachycardia.
- Fever and infections increasing heart rate.
- Hormonal changes during pregnancy or menopause.
Symptoms of Chest Palpitations
Subjective Sensations
Patients typically report a range of subjective experiences related to palpitations, including:
- A sense of the heart skipping beats or “flip-flopping”
- A feeling of a racing heartbeat (tachycardia)
- A pounding or forceful heartbeat sensation, especially in the chest or neck
- Irregular or chaotic heartbeat perception
- Chest discomfort or mild pain accompanying palpitations
Associated Symptoms
Palpitations may occur alone or alongside other symptoms:
- Lightheadedness or dizziness
- Syncope or near syncope episodes
- Shortness of breath
- Fatigue or weakness
- Anxiety or panic
The presence of associated symptoms often helps differentiate benign from potentially serious causes.
Physical Signs Noticed by Clinicians
During clinical evaluation, signs that may accompany palpitations include:
- Irregular pulse
- Tachycardia (heart rate >100 bpm)
- Bradycardia (heart rate <60 bpm, if excessive)
- Extra heart sounds (premature beats)
- Murmurs suggestive of structural heart disease
Diagnosis of Chest Palpitations
Clinical History
A detailed patient history is crucial to identify the cause:
- Character, duration, and frequency of palpitations
- Associated symptoms (chest pain, syncope, dyspnea)
- Triggers such as exercise, stress, or medication
- Past medical history including cardiac disease or thyroid problems
- Family history of sudden cardiac death or arrhythmias
Physical Examination
Includes assessment of:
- Vital signs: heart rate and rhythm, blood pressure
- Cardiac auscultation for murmurs or extra sounds
- Signs of heart failure or systemic disease
Electrocardiogram (ECG)
ECG is the cornerstone diagnostic tool to detect arrhythmias, conduction abnormalities, and ischemic changes. A resting ECG is often the first test.
Ambulatory Heart Monitoring
When palpitations are intermittent, devices such as:
- Holter monitor (24-48 hours)
- Event recorder (up to 30 days)
- Implantable loop recorder (long-term)
can capture transient arrhythmias not seen on resting ECG.
Laboratory Tests
Blood tests help evaluate systemic causes:
- Thyroid function tests
- Electrolytes (potassium, magnesium, calcium)
- Complete blood count for anemia or infection
- Blood glucose level
Additional Cardiac Testing
- Echocardiography to assess structural heart disease
- Exercise stress testing if exertional palpitations are present
- Electrophysiology studies in complex arrhythmias
Treatment of Chest Palpitations
General Principles
Treatment depends on the underlying cause and severity of symptoms. The primary goal is to relieve symptoms and prevent complications.
Lifestyle Modifications
- Avoidance of stimulants such as caffeine, nicotine, and illicit drugs
- Stress management through relaxation techniques, mindfulness, or counseling
- Regular exercise to improve cardiovascular health
- Adequate hydration and correction of electrolyte imbalances
Medical Treatment
1. Pharmacological Therapy for Arrhythmias
Beta-blockers: Reduce heart rate and control arrhythmias
Calcium channel blockers: Alternative to beta-blockers for rate control
Antiarrhythmic drugs: Used for rhythm control in atrial fibrillation or ventricular arrhythmias
Anticoagulation: For stroke prevention in atrial fibrillation
2. Treatment of Underlying Conditions
- Thyroid hormone normalization in hyperthyroidism
- Correction of anemia or electrolyte disturbances
- Management of ischemic heart disease with medications or interventions
Procedural and Surgical Treatment
Catheter Ablation: Minimally invasive procedure to eliminate arrhythmogenic foci, especially in SVT or atrial fibrillation
Pacemaker implantation: For bradyarrhythmias or conduction blocks causing palpitations
Implantable Cardioverter Defibrillator (ICD): For patients at high risk of sudden cardiac death from ventricular arrhythmias
Treatment of Anxiety-Related Palpitations
Psychological support, cognitive-behavioral therapy, and occasionally anxiolytic medications may be needed for patients whose palpitations are linked to anxiety or panic disorders.
When to Seek Medical Help for Palpitations
Patients experiencing palpitations should seek prompt medical care if they experience:
- Chest pain or pressure
- Severe shortness of breath
- Dizziness, fainting, or near fainting
- Rapid or irregular heartbeat lasting more than a few minutes
- Palpitations with known heart disease
Conclusion
Chest palpitations are a frequently encountered symptom in cardiology that requires thorough assessment to determine their cause. A careful clinical approach combining history, examination, and diagnostic testing allows identification of benign versus dangerous causes. Treatment is individualized and ranges from reassurance and lifestyle changes to complex interventions such as ablation or device implantation. Early recognition and management improve patient outcomes and quality of life.
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