Many of us have experienced the feeling of our heart pounding, racing, or “skipping a beat.” Changes to our heart rhythm and heart rate can be caused by a range of reasons, including exercise, stress, hormone shifts, or a heart condition. So how can people tell if palpitations are harmless or due to a more serious issue?

“Palpitations are a real symptom, and they should never be ignored,” explains Dr. David Slotwiner, an electrophysiologist and chief of cardiology at NewYork-Presbyterian Queens. “The key question is whether the palpitations are due to an abnormal heart rhythm or if it is the patient’s normal heart rhythm beating more quickly or more strongly,”

Health Matters spoke with Dr. Slotwiner about the causes of heart palpitations, which symptoms may suggest a more serious condition, and what to expect during diagnosis and treatment.

What is a heart palpitation? Is that the same as an irregular heartbeat?

Palpitations are the sensation of your heart pounding, racing, or skipping a beat. People experiencing the symptom often describe a fluttering or flip-flopping feeling in the chest or throat, or a strong or fast heartbeat.

While a palpitation is a symptom that may have many causes, an arrhythmia is the condition of an abnormal heart rhythm. A normal rhythm starts at the top of our heart from our natural pacemaker and the electricity conducts down the nerves, causing the atria, the heart’s upper chambers, to contract first, followed by the ventricles, or lower chambers. Anything that takes a different pathway or starts in a different place is what we would call an abnormal heartbeat, an abnormal rhythm, or arrhythmia.

Many people will have occasional single “extra” or “early” heartbeats that start from somewhere other than our normal pacemaker. These are common and rarely a cause for concern. Some people are very aware of these extra beats, while other people do not feel them. The most common abnormal heart rhythm is atrial fibrillation, which generally occurs as we age. Supraventricular tachycardia (SVT) is the most common abnormal heart rhythm among younger patients.

What are the potential causes of heart palpitations?

An arrhythmia is a potentially serious condition that causes palpitations, but there are many other causes, including some that are benign. When we’re under stress, our body releases hormones like adrenaline, which triggers the fight or flight response, causes our heart’s natural pacemaker to speed up, and increases the strength of the heart’s contractions. This will cause many people to feel palpitations. Other causes can include:

• Anemia
• Electrolyte imbalances
• Hormonal changes
• Fever
• Lack of sleep
• Pregnancy
• Consuming alcohol or food and drinks high in caffeine, sugar, or carbohydrates
• Certain cough and cold medicines containing pseudoephedrine, or certain prescription drugs, including asthma inhalers with albuterol 

How can you diagnose the cause of palpitations?

The best way is by recording the heart rhythm when the palpitations are occurring, which gives us a precise recording of the electrical conduction at the moment symptoms are happening. This allows us to observe if the rhythm is originating at the heart’s normal pacemaker and conducting down the normal nerve pathways, or there is an abnormality. It usually involves the patient wearing a heart monitor, such as a 24-hour Holter monitor or a 30-day extended heart monitor, depending on how often the palpitations are occurring. If it’s very infrequent, like once every six months, we can implant a loop recorder under the skin that will record the heart rhythm remotely for up to three years.

We also ask questions about the history of the symptoms. Did the palpitations start suddenly or gradually? Does it feel like one skipped beat or is it continuous? And do they happen while you are walking around or when you are lying in bed? If it happens with a gradual onset, especially while you’re lying in bed, that generally isn’t dangerous. Lying in bed is a very common time people feel palpitations because other stimuli have quieted down.

If we’re worried that the palpitations are caused by a dangerous arrhythmia, we can do more invasive tests to try to reach a diagnosis more quickly, such as an electrophysiology study (EP), which uses catheters to look at the heart’s electrical activity.

What other symptoms might suggest an arrhythmia?

If palpitations are occurring along with fainting, that’s an indication that there could be a potentially dangerous heart rhythm. Feeling chest pain or shortness of breath with palpitations also raises the level of concern.

What are the treatment options for palpitations?

For patients who feels palpitations when their heart rhythm is normal, we reassure them that what they’re feeling is their normal heart rhythm. I strongly discourage putting patients on medications, such as beta blockers, to treat symptoms caused by a normal heart rhythm.

Some patients will have palpitations because they are experiencing single extra heartbeats. These are also almost always benign, and so again, I’ll try to help those patients understand what’s causing it so that they’re not afraid. If those single extra beats are very frequent and really bothering the patient, there are medications we can consider. In rare cases, there are even catheter-based procedures we can perform.

If the cause is an arrhythmia, the treatment options could range from medical therapy to catheter ablation.

Even if palpitations seem to be linked to stress or anxiety, it is very important not to dismiss them. A lot of people are told they’re just having anxiety episodes when they’re really having an arrhythmia. You have to take each of these patients individually and very seriously.