What Are Palpitations?
Palpitations are the awareness of your own heartbeat. This includes sensations of the heart beating too fast, too hard, irregularly, or seeming to skip or flip. They can be felt in the chest, throat, or neck. They are extremely common — almost everyone experiences them at some point — and in the majority of cases are entirely benign. However, because the heart is involved, they naturally generate anxiety, which itself can worsen the sensation and create a cycle of concern.
Understanding when palpitations are simply an awareness of normal cardiac activity, when they reflect a benign arrhythmia, and when they indicate a condition requiring investigation or treatment is the key question — and the answer depends heavily on associated symptoms, timing, and context.
Common Benign Causes
Anxiety and Stress
The most common cause of palpitations in otherwise healthy people is the physiological response to stress and anxiety. When the sympathetic nervous system is activated — by stress, fear, anxiety, or panic — adrenaline causes the heart to beat faster and more forcefully. This is entirely normal. In people with anxiety disorders, this can be a chronic, recurrent experience that feels alarming but is not evidence of cardiac disease. Treating the underlying anxiety reduces palpitation frequency more effectively than cardiac investigation in this group.
Caffeine
Caffeine is a cardiac stimulant that increases heart rate and can trigger or worsen palpitations, particularly at higher doses. Coffee, tea, energy drinks, pre-workout supplements, and some medications all contain significant caffeine. Reducing or eliminating caffeine is a simple first intervention in people with new or worsening palpitations, particularly those who have recently increased their intake.
Exercise
The heart beating faster and more forcefully during and immediately after exercise is normal. Some people become more aware of their heartbeat during exercise and experience this as palpitations. This is not concerning. Palpitations that occur at rest after exercise has stopped, that are accompanied by chest pain or near-fainting, or that prevent completion of activity do warrant evaluation.
Dehydration and Electrolyte Imbalance
Low magnesium, low potassium, and low blood volume from dehydration can all trigger palpitations and arrhythmias. This is particularly relevant in people who sweat heavily, use diuretics, have gastrointestinal illness with vomiting or diarrhoea, or have very restricted dietary intake. Ensuring adequate hydration and electrolyte intake is a basic step worth addressing before any investigation.
Alcohol
Alcohol, particularly in excess, is a well-documented trigger for atrial fibrillation — a phenomenon sometimes called “holiday heart” in the context of binge drinking. Even moderate regular alcohol consumption increases arrhythmia risk. Palpitations the morning after heavy drinking are common and may represent brief runs of atrial fibrillation or other arrhythmias.
Hormonal Changes
Palpitations are frequently reported in association with the menstrual cycle — both premenstrually and during menstruation — as oestrogen and progesterone fluctuations affect cardiac electrophysiology. Pregnancy, the postpartum period, and the menopausal transition are all associated with increased palpitation frequency. Thyroid disorders (both hypo- and hyperthyroidism) are an important and often missed cause — the thyroid gland profoundly affects cardiac rate and rhythm, and thyroid function testing is an essential part of the evaluation of unexplained palpitations.
When Palpitations May Indicate a Heart Problem
Certain features of palpitations make cardiac investigation more urgent. The following warrant prompt medical evaluation:
- Palpitations accompanied by chest pain, pressure, or tightness
- Palpitations with breathlessness that is out of proportion to activity
- Palpitations associated with dizziness, near-fainting (presyncope), or actual loss of consciousness (syncope)
- Palpitations that are regular and very rapid (sudden onset racing heart at 150–200 beats per minute that starts and stops abruptly — suggesting SVT or other tachycardia)
- Palpitations in someone with known structural heart disease, previous heart attack, heart failure, or cardiomyopathy
- Palpitations in someone with a family history of sudden cardiac death or inherited arrhythmia syndromes
- Palpitations at rest without any identifiable trigger
Common Arrhythmias Causing Palpitations
Ectopic Beats (Premature Atrial or Ventricular Contractions)
The most common arrhythmia causing palpitations is isolated ectopic beats — extra heartbeats originating from an abnormal site in the atria (PACs) or ventricles (PVCs). They are felt as a “thump,” “flip,” or “skipped beat” — usually the pause after the ectopic and the forceful normal beat that follows it. They are extremely common, increase with caffeine, stress, and fatigue, and are almost always benign in people with no structural heart disease. Frequent PVCs in people with a structurally normal heart do not require treatment unless highly symptomatic. In the presence of structural heart disease, frequent PVCs require further evaluation.
Atrial Fibrillation (AF)
AF is the most common sustained cardiac arrhythmia, in which the atria beat chaotically at 300–600 impulses per minute, producing an irregular and often rapid ventricular rate. It is felt as an irregular, fast heartbeat. AF significantly increases stroke risk (blood pools in the fibrillating atria and can clot) and heart failure risk. It can be paroxysmal (coming and going), persistent (lasting more than 7 days), or permanent. All people with confirmed AF require assessment for stroke risk and anticoagulation if indicated.
SVT (Supraventricular Tachycardia)
SVT encompasses several arrhythmias characterised by sudden-onset regular rapid heartbeat (typically 150–250 bpm) that starts and stops abruptly. The patient typically feels a sudden “switch” from normal to very fast rhythm. SVT is uncomfortable and can cause breathlessness and lightheadedness but is not immediately life-threatening in people without structural heart disease. Episodes can often be terminated by Valsalva manoeuvre (bearing down or blowing against a closed mouth). Recurrent symptomatic SVT is treated with medications (beta-blockers, calcium channel blockers, flecainide) or catheter ablation — a procedure that permanently eliminates the abnormal electrical pathway, with cure rates above 90%.
Investigation
A 12-lead ECG is the first investigation — it identifies arrhythmias present at the time of recording and provides baseline cardiac information. If palpitations are intermittent (most are), a 24-hour Holter monitor or longer ambulatory ECG monitoring (7-day or 30-day patch monitor) captures the heart rhythm during daily activities and is likely to record an episode if palpitations are occurring at least several times a week. Echocardiography (heart ultrasound) assesses cardiac structure and function. Blood tests should include thyroid function, electrolytes, full blood count, and glucose as a minimum.
The Bottom Line
Most palpitations are benign and reflect normal physiology or simple triggers that can be addressed. However, the symptoms that accompany palpitations — not the palpitations themselves — determine urgency. Any palpitation associated with chest pain, syncope, severe breathlessness, or significant haemodynamic compromise is a reason for emergency assessment. Otherwise, palpitations that are new, persistent, or anxiety-provoking enough to affect quality of life warrant a planned appointment with a clinician, an ECG, and basic blood tests as a starting point.