Heart Palpitations
Symptoms, Causes & Treatment
Understanding heart palpitations: what causes them, when they are harmless, when they need investigation, and how they are treated.
What Are Heart Palpitations?
Heart palpitations are the sensation of your heart beating in a way that feels abnormal -- pounding, fluttering, racing, or skipping beats. They are one of the most common reasons people seek medical advice about their heart, and the vast majority are harmless.
During a palpitation you become aware of your heartbeat in a way you normally would not. Some people describe a rapid fluttering in the chest, others a pounding that they can feel in the neck or throat, and others a sensation that the heart has briefly "stopped" or "skipped a beat" before resuming with a noticeable thud. Episodes may last a few seconds, several minutes, or occasionally longer.
In most cases, palpitations are caused by extra heartbeats (ectopic beats) or a temporary increase in heart rate driven by adrenaline, caffeine, stress, or hormonal changes. These are not dangerous. However, palpitations can occasionally be a symptom of an underlying heart rhythm disorder (arrhythmia) that requires investigation and treatment, which is why clinical assessment is important -- particularly when palpitations are frequent, prolonged, or accompanied by other symptoms.
Palpitations are extremely common. Population studies suggest that up to 16% of the general population report palpitations at some point, with the true figure likely higher, since many episodes go unreported. They affect all age groups and are slightly more common in women.
What Do Palpitations Feel Like?
Palpitations vary in character depending on their cause. Describing the onset, duration, regularity, and triggers accurately to a clinician is crucial for diagnosis.
Palpitations felt as fluttering, pounding, racing, or skipped beats · Awareness of heartbeat at rest · Palpitations triggered by caffeine, alcohol, stress, or exercise · Brief episodes lasting seconds to minutes · Associated dizziness or light-headedness · Chest discomfort during palpitations
Palpitations with syncope (fainting) or near-fainting · Palpitations with severe chest pain · Palpitations lasting more than 30 minutes · Known heart disease with new palpitations · Irregular pulse that is very fast (over 150bpm) — call 999
Call 999 if palpitations are accompanied by fainting · severe chest pain · sudden breathlessness · very fast irregular pulse over 150bpm that does not resolve within minutes.
What Causes Palpitations?
The causes of palpitations range from entirely benign lifestyle factors to significant cardiac arrhythmias. Accurate diagnosis depends on capturing the heart rhythm during symptoms.
Ectopic beats (extra beats) are the most common cause of palpitations — usually benign. They feel like a skipped or extra beat and are often felt at rest or in the evening.
Atrial fibrillation (AF) causes an irregularly irregular rapid heartbeat. It significantly increases stroke risk and requires anticoagulation and rate/rhythm control.
Caffeine, alcohol, recreational drugs, anxiety, dehydration, and vigorous exercise are common triggers for benign palpitations. Identifying and removing the trigger often resolves symptoms.
SVT (supraventricular tachycardia) causes sudden-onset rapid heart rate of 140–250bpm that stops abruptly. Episodes last seconds to hours and may be terminated by Valsalva manoeuvres or adenosine in A&E.
Thyroid disorders are a common and reversible cause of palpitations. Hyperthyroidism causes fast, irregular palpitations and atrial fibrillation. Hypothyroidism may paradoxically cause palpitations via bradycardia-related ectopics.
Anaemia reduces oxygen-carrying capacity, causing the heart to compensate by beating faster. This produces awareness of heartbeat (palpitations), breathlessness on exertion, and fatigue.
Key Risk Factors
How Are Palpitations Investigated?
The key to diagnosing palpitations is capturing the heart rhythm during symptoms. A resting ECG is always the first test but may be normal between episodes. Thyroid function and electrolytes should be checked in all cases.
How Are Palpitations Treated?
Treatment targets the specific underlying cause. Benign ectopics require only reassurance and trigger avoidance. AF requires rate or rhythm control and stroke prevention.
Supportive Measures
For benign palpitations, avoiding triggers — caffeine, alcohol, dehydration, stress — is most effective. For AF, strict adherence to anticoagulation medication significantly reduces stroke risk.
Recurrent or Persistent Palpitations
If palpitations persist, further investigations including an event recorder, echocardiogram, or electrophysiology study may be required. Persistent AF may be treated with cardioversion or catheter ablation.
When Should You Seek Medical Advice?
Palpitations with fainting or near-fainting · Palpitations with severe chest pain · Persistent rapid irregular heartbeat over 150bpm that does not resolve · Palpitations in someone with known structural heart disease — call 999.
Frequent or prolonged palpitations not yet investigated · Palpitations with dizziness or breathlessness · AF diagnosis without anticoagulation · Medication that may cause arrhythmia.
How Can You Reduce Palpitations?
For the majority with benign palpitations, lifestyle measures are highly effective.
Reduce caffeine, alcohol, and recreational drugs. Manage anxiety through CBT, exercise, and stress reduction. Most benign palpitations resolve when triggers are identified and addressed.
AF carries a significantly elevated stroke risk. If diagnosed, ensure you are appropriately anticoagulated. Do not stop anticoagulation without medical advice.
Vagal manoeuvres (bearing down, cold water to the face, carotid sinus massage) can terminate SVT episodes. Learning these techniques gives patients immediate management during acute episodes.
Reduce or eliminate caffeine, energy drinks, and alcohol. Avoid recreational stimulants. These are responsible for the majority of benign ectopic beats and palpitations in otherwise healthy individuals.
Treat hyperthyroidism, anaemia, dehydration, and electrolyte imbalances — all of which cause palpitations that resolve completely once the underlying condition is corrected.
Manage anxiety through regular exercise, mindfulness, adequate sleep, and CBT. Anxiety amplifies ectopic beat awareness and is a major driver of health anxiety around palpitations.
Speak to a Clinician About Palpitations
A licensed clinician at The GP Service can assess your palpitations, arrange an ECG referral and thyroid function tests, and advise on next steps from the comfort of home.
Expert clinical advice, when you need it.
Heart Palpitations FAQs
Most palpitations are benign, particularly ectopic beats (extra heartbeats) which feel like a ‘thump’ or ‘flip-flop’ in the chest and are very common. However, palpitations caused by atrial fibrillation (AF) carry a real risk of stroke and require clinical assessment and treatment. You should see a clinician if palpitations are frequent, prolonged, associated with dizziness or breathlessness, or if you have known heart disease. An ECG during symptoms is the most useful diagnostic test.
Ectopic beats feel like a ‘thump’, ‘flip-flop’, or ‘missed beat’ in the chest. They occur when the heart produces an extra beat earlier than expected, followed by a compensatory pause. This pause is what creates the thumping sensation. Ectopic beats are extremely common — most people experience them at some point — and are almost always benign in people with structurally normal hearts. They often worsen when lying in bed, at rest, or after caffeine. While distressing, they are not dangerous in most people. Reassurance, trigger avoidance, and (if severe) beta-blockers are the management options.
Atrial fibrillation (AF) produces an irregularly irregular heart rhythm — the heartbeat has no pattern and is completely unpredictable. This is distinct from regular fast rhythms (SVT) or extra beats (ectopics). AF carries a significantly elevated stroke risk because blood can pool in the left atrial appendage and form clots. This is why anticoagulation with apixaban, rivaroxaban, or warfarin is a central part of AF management. The CHA₂DS₂-VASc score calculates your individual stroke risk and determines whether anticoagulation is indicated. All patients with AF should have this risk formally assessed.
Rate control aims to reduce the heart rate in AF to below 110bpm at rest (usually with beta-blockers or rate-limiting calcium channel blockers like diltiazem) without necessarily restoring sinus rhythm. Rhythm control aims to restore and maintain normal sinus rhythm using antiarrhythmic drugs (flecainide, amiodarone) or cardioversion/catheter ablation. Both strategies are effective. Rhythm control is now preferred for younger patients and those with symptoms, as it offers a better quality of life and may reduce long-term complications.
A stroke is the most serious complication of untreated AF. Additionally, longstanding uncontrolled AF can cause AF-induced cardiomyopathy — a weakening of the heart muscle due to persistently fast, irregular rates. Hypertensive heart disease is the most common cause of hospitalisation in uncontrolled high blood pressure. Aortic dissection (a tear in the main blood vessel from the heart) is a rare but catastrophic complication of chronic severe hypertension. These risks underscore why treating both AF and hypertension is a cardiovascular priority.
Yes. Left ventricular hypertrophy (LVH) — thickening of the heart wall due to the increased work of pumping against high blood pressure — is a significant hypertension complication detectable on ECG or echocardiogram. Target organ damage from hypertension also affects the kidneys (hypertensive nephropathy — microalbuminuria, reduced eGFR), eyes (hypertensive retinopathy), and brain (white matter changes, lacunar infarcts). Checking for target organ damage at diagnosis and monitoring annually ensures appropriate treatment intensity.
Yes. Hypertension in pregnancy — particularly pre-eclampsia (hypertension with proteinuria after 20 weeks) — is a serious condition affecting 2–5% of pregnancies. It can cause maternal complications (seizures, stroke, organ failure) and fetal growth restriction or preterm birth. Safe antihypertensives in pregnancy include labetalol, nifedipine, and methyldopa. ACE inhibitors and ARBs must be avoided in pregnancy due to fetal toxicity. Women with pre-existing hypertension should have their medication reviewed before or at the start of pregnancy.
The most common causes of bilateral ankle swelling are venous insufficiency (varicose veins and poor venous return), medications (particularly calcium channel blockers such as amlodipine), and inactivity. Heart failure is an important cause that must be excluded, particularly if accompanied by breathlessness. Bilateral swelling is rarely DVT — DVT almost always affects one leg at a time. If both ankles swell consistently at the end of the day and improve overnight, venous insufficiency and medication side effects are the most likely explanations.