Palpitations

Palpitations are the patient’s experience of symptoms. These palpitations may occur in the presence of a normal rhythm (such as a normal feeling of “pounding” after exercise where the heart rate is high or just before sleep when the heart rate is low). Palpitations may also occur in the presence of arrhythmia (or an abnormal rhythm such as atrial fibrillation or ectopic beats).

Curiously some patients who suffer from arrhythmia, may not actually develop palpitations, particularly if the arrhythmia is well rate controlled. For example, a patient who has atrial fibrillation with an average heart rate of 80bpm may not actually experience any palpitations! Instead, the only symptom of atrial fibrillation is the increased fatigue or slight exertional breathlessness, or perhaps nothing at all!

Tiredness is a form of stress – and given that stress can affect the autonomic nervous system, it can cause palpitations. In my experience, patients often experience a particular form of palpitations, ectopic beats (both atrial ectopic beats and ventricular ectopic beats) when transitioning from a state of extreme exercise to rest. For example, several hours after a heavy workout, following a large meal at dinner, palpitations may be felt whilst going to sleep.

This is due to the rapid transition between a flight or fight state (sympathetic) to a rest-and-digest (parasympathetic or vagus), and this transition creates the changing autonomic state that triggers heart rhythm abnormalities.

Not necessarily. During a heart attack its possible to feel a sensation of “palpitations” as the heart beatmay race and be felt as beating stronger. However, having palpitations alone is not usually a sign that you are developing a heart attack. More typical symptoms of a heart attack include chest pain, shortness of breath, feeling nauseous or sweaty.

The first step that needs to be taken is to make a diagnosis. It’s important to know if there is an underlying heart rhythm abnormality that is causing palpitations. These diagnostic steps start usually with a clinical history and examination, but includes some diagnostic tests such as an ECG, Holter, echocardiogram. Rarely palpitations (which occur once every few weeks or months) may be more difficult to capture on a short term recording – in these cases, it may be good for you to purchase a mobile ECG recording device such as an Apple Watch series 4 or above or an AliveCor Kardia Mobile device, both of which can record a medical grade ECG and store this on your phone to show your doctor.

Once a diagnosis is clarified, then your doctor can either reassure you (if palpitations are associated with a “normal” rhythm) or treat you with appropriate medications, or more invasive approaches like a catheter ablation, which can often lead to a “cure” for palpitations such as a supraventricular tachycardia  or atrial flutter

If the palpitations are persistent and cause fainting, extreme lightheadedness, chest pain or shortness of breath, please do call the emergency services and consider getting yourself admitted to hospital for urgent care.

It depends on what your palpitations are. It is a good idea to learn how to check your pulse rate. If you have a normal heart rate, and have intermittent palpitations only, then it may well be safe to exercise, but try not to exert yourself to your maximal capacity. However, if you have a resting heart rate that is already above 100bpm (for example in Atrial Flutter or Atrial Fibrillation) then you should only consider doing mild to moderate exercise, keeping your heart rate under observation if you can through a monitor, or learn how to check your pulse so you can keep an eye on your heart rate.

In general, you should not aim to push your heart rate beyond your maximum target heart rate. The formula for this is simple. 220 – age. For example if you are 50 years old, your maximum target heart rate should be 220-50 = 170bpm.
In general, the aerobic (fat burning) level of exercise maintains your heart rate between 60-80% of your maximum target heart rate. Again if you are 50 years old, then keeping your heart rate at 60% – 80% of 170bpm is a range between 102 to 136bpm.

Yes it can. Anxiety creates significant stress, and this triggers release of adrenaline and cortisol, which may drive a higher-than-normal heart rate and also trigger arrhythmia. If the stress and anxiety is significant, then palpitations may be felt all day

In general it is useful to know your triggers. You may recognize specific food triggers of palpitations, for example spicy foods, caffeinated drinks, or alcohol, then avoiding these types of triggering foods is recommended. However, there are other situations which may trigger palpitation in relation to food intake which are not specific to any particular food product.

This can be mainly to do with a full stomach, for example when having a very large meal. Other non-meal factors, such as heavy exercise or a heavy long day at work, followed by a reasonably large meal, can be the trigger of palpitations later on in the evening or at night, when there is a significant transition between the fight-or-flight to the rest-and-digest components of the autonomic nervous system.

Emergency doctors can help make you arrive at a clear diagnosis with a simple ECG. Please do take a copy or if not, capture a photograph of that all-important ECG on your phone. It may be the only documentation of the palpitation you may get ! This is crucially important for your cardiologist (specifically electrophysiologist – a cardiologist with a specialized interest in palpitations) to be able to make appropriate onward treatment recommendations at a later stage.

If you are in persistent tachycardia, the emergency doctor can give you specific treatment for your condition. For example if you have a supraventricular tachycardia (SVT), you can be given a drug called adenosine which is highly successful at terminating or stopping the SVT. You can usually be started on a drug immediately such as a beta blocker (something that ends in a – olol, e.g. bisoprolol, metoprolol, or calcium blocker such as verapamil or diltiazem) to help minimize further recurrences, and should be asked to be sent an outpatient urgent appointment to see an electrophysiologist.

Typically, unless you are significant recurrent symptoms that cannot be resolved in accident and emergency, you will be discharged home the same day or the day after with an appointment made to see a cardiologist afterwards.

If you have atrial fibrillation or atrial flutter diagnosed during the admission, you may be asked to start taking anticoagulant medications. These are drugs such as apixaban, edoxaban, rivaroxaban, and dabigatran.