A Symptom Almost Everyone Has Experienced
Heart palpitations — the awareness of your own heartbeat as fast, slow, irregular, fluttering, or pounding — are among the most common reasons adults visit primary care. In most cases the underlying cause is benign. But because the same sensation can also signal serious arrhythmias, the workup deserves a careful, structured approach.
At Zimmer Medical Group, we evaluate palpitations regularly and can usually determine the cause and risk level without specialist referral.
What Palpitations Feel Like
Patients describe palpitations in many ways:
- A "skipped beat" or pause followed by a strong thump
- Rapid pounding in the chest or neck
- A flutter that feels like a butterfly
- An irregular, chaotic rhythm
- A racing heart at rest or with minimal activity
The same underlying rhythm can feel different to different people, which is why physical exam alone rarely tells the whole story.
The Most Common Causes
Premature Beats (PACs and PVCs)
Premature atrial contractions (PACs) and premature ventricular contractions (PVCs) are the most common cause of palpitations. They feel like a skipped beat (because the next normal beat is delayed slightly) followed by a thump (because the heart fills more during the pause and beats stronger). Most healthy adults have some PACs and PVCs, and they are usually benign — particularly when there is no underlying heart disease.
See our companion article on PVCs for a deeper dive on when premature ventricular beats need workup.
Atrial Fibrillation
Atrial fibrillation causes a chaotic, irregular rhythm. Patients often describe a fluttering sensation. AFib increases stroke risk significantly and warrants evaluation when detected.
Sinus Tachycardia
A normal but rapid heart rate from physiologic causes — anxiety, dehydration, fever, anemia, hyperthyroidism, pain, or stimulants. The rhythm itself is normal; the rate is fast.
Supraventricular Tachycardia (SVT)
A sudden onset of rapid, regular heartbeat that may end abruptly. Episodes can last minutes to hours. Often triggered by sudden movements or postural changes. Generally not life-threatening but can be disruptive and may benefit from definitive treatment (ablation).
Ventricular Tachycardia
Less common but more concerning — particularly in patients with structural heart disease or coronary artery disease. Requires prompt evaluation.
When Palpitations Are More Concerning
Seek prompt evaluation — often urgent care or ER — when palpitations are accompanied by:
- Chest pain or pressure
- Shortness of breath beyond what you would expect
- Lightheadedness or fainting
- Confusion
- Sustained rapid heart rate that does not slow within minutes
- Symptoms during exercise (rather than at rest)
- A history of structural heart disease, prior heart attack, or significant heart failure
Palpitations triggered by exercise are particularly worth investigation because exercise-induced arrhythmias can be more dangerous.
Common Triggers Patients Underestimate
Many patients with palpitations have one or more identifiable triggers:
- Caffeine — coffee, tea, energy drinks, dark chocolate, pre-workout supplements
- Alcohol — particularly binge drinking; "holiday heart" is a real phenomenon
- Stimulant medications — pseudoephedrine, ADHD medications, some weight loss supplements
- Dehydration — particularly common in Florida heat
- Poor sleep
- Anxiety and panic attacks — see our guide on panic vs. generalized anxiety
- Hyperthyroidism
- Anemia
- Sleep apnea
- Hormonal changes — perimenopause, pregnancy, premenstrual
A two-week diary of palpitation episodes — with notes on what you ate, drank, slept, and felt before — often reveals patterns.
What Your Doctor Will Order
Initial Workup
- Detailed history and physical exam
- 12-lead ECG (often normal between episodes — palpitations are often intermittent)
- Basic labs: CBC (anemia), TSH (thyroid), basic metabolic panel (electrolytes), often magnesium
Capturing the Rhythm During Symptoms
Because palpitations often don't happen on demand, several monitoring options exist:
- 24–48 hour Holter monitor — captures every beat for 1–2 days; useful when symptoms are frequent
- Event monitor or patch monitor (Zio patch, Bardy CAM) — worn 14–30 days; records when symptoms occur
- Loop recorder — for very infrequent but concerning symptoms; can be implanted for years
- Wearable devices — Apple Watch and similar can capture single-lead ECGs during symptoms
The choice depends on how often symptoms occur and how concerning the suspected rhythm is.
Further Cardiac Evaluation When Needed
- Echocardiogram — assesses heart structure and function
- Stress test — when exercise-induced symptoms or coronary disease is suspected
- Electrophysiology study — for confirmed concerning arrhythmias requiring detailed mapping
What Most Workups Reveal
In primary care, the majority of palpitation evaluations find:
- Benign PACs or PVCs
- Sinus tachycardia from identifiable triggers
- Anxiety-related symptoms
- Subclinical thyroid disease
- Occasionally, atrial fibrillation or SVT
Serious arrhythmias requiring urgent intervention are less common but worth ruling out.
Treatment Approach
Once the cause is known, treatment is tailored:
- Trigger modification for benign PACs/PVCs — often dramatically reduces symptoms
- Beta blockers for symptomatic frequent PVCs or sinus tachycardia
- Anticoagulation and rate/rhythm control for atrial fibrillation
- Catheter ablation for SVT, AFib in selected patients, or symptomatic frequent PVCs
- Treatment of underlying conditions — thyroid, anemia, sleep apnea, anxiety
What Quietly Drives Palpitations Here, and How to Catch One
Most of the palpitation workups I do in St. Petersburg end with a benign answer and a specific cause. A few patterns come up over and over.
Heat, fluids, and electrolytes
A summer afternoon outdoors pulls fluid and salt out faster than people realize, and a heart that is compensating for low volume beats faster and throws more extra beats. Anyone on a diuretic for high blood pressure, such as hydrochlorothiazide, is more exposed, because potassium and magnesium go out with the water and low levels of either make premature ventricular contractions more frequent. A basic metabolic panel and a magnesium level are cheap, and rehydration with something that contains electrolytes often ends the episode. The NHLBI's arrhythmia overview explains why electrolytes matter so much to heart rhythm.
Thyroid and hormones
An overactive thyroid is one of the classic hidden causes, and it does not always come with the weight loss and tremor people expect; in older adults hyperthyroidism can show up as nothing but a fast or irregular pulse. Perimenopause is the other big one in women in their forties and fifties, when hot flashes and a pounding heart at 3 a.m. often travel together, as our perimenopause guide describes. Both are found on labs and history, not on a monitor.
Catching the episode
The single most useful thing you can do is document the rhythm while it is happening. Put two fingers on your wrist and note whether the beat is fast and regular, slow, or chaotic and uneven; if you own a watch with an ECG feature, record a strip and note the time. Write down what you were doing, what you had eaten or drunk, and how long it lasted. MedlinePlus has a practical checklist of what to record. An irregular, chaotic rhythm that persists is atrial fibrillation until proven otherwise and needs to be seen promptly, and any episode with chest pain, fainting, or severe breathlessness is a 911 call. Our cardiovascular team arranges monitoring when the office ECG is normal but the story is not.
When to Just Make an Appointment
For palpitations without warning features:
- Schedule an appointment within a few weeks
- Keep a brief log of episodes
- Note triggers, frequency, duration, and any associated symptoms
- Bring a list of all medications and supplements
- Note caffeine and alcohol intake
The American Heart Association provides excellent additional patient resources on arrhythmias and palpitations.
Frequent or unsettling palpitations? Contact Zimmer Medical Group for a structured evaluation, the right type of monitoring, and a clear plan based on what we find.
