Got a “butterfly” sensation in your chest? It could be because you’re newly in love, but it could also be because you’re experiencing palpitations. Palpitations are among the most common problems encountered by internists and cardiologists alike, accounting for up to 16 percent of outpatient visits annually. Even though the cause of the majority of palpitations is benign, occasionally they can be a sign of a more serious condition that should be evaluated by your physician.
The Basics
Here’s a fun cocktail party fact that will impress your friends: The average human heart beats 115,200 times per day. Although somewhat debatable, there’s a general consensus that a normal human heart rate in adults is somewhere between 60 and 100 beats per minute. The average heart rate range is between 43 and 102 beats per minute in men and 47 and 103 beats per minute in women. The machinery behind heart rate is nothing short of fascinating. Essentially, your heart has a built-in conduction “superhighway” composed of specialized electrical tissue that maintains your heartbeat. The conductor of this highly choreographed sequence of events is the sinoatrial (SA) node, a specialized region of tissue that sits in the upper right chamber of the heart. The main job of the SA node is to set the pace of your heart rate. When everything happens according to plan, the SA node ensures that each heartbeat occurs in a regular fashion at a set time interval (similar to a metronome). It’s important to note, however, that there are other parts of the heart, both within and outside this superhighway, that can affect your heart rate. Whenever these alternative pacemakers kick in, or the SA node isn’t functioning properly, your heart’s rhythm becomes abnormal, referred to by physicians as an arrhythmia. And so to recap, the two most important points to consider when thinking about whether your heartbeat is normal are: (1) what is the heart rate (slow, normal or fast) and (2) are the beats occurring at regular or irregular intervals (remember the metronome analogy?). Arrhythmias occur when one or both of these factors are abnormal.
[See: The Facts on Heart Disease.]
What Are Palpitations, Exactly?
Palpitations are a sensory symptom triggered by an aberration (often transient) in the heart’s electrical conduction. Normally your heartbeat isn’t noticeable to you, but when you have palpitations, you experience an often unpleasant awareness of a more forceful, rapid or irregular heartbeat. In the majority of cases, palpitations occur because of a minor hiccup in conduction. Think of it as a transient kink in the metronome, after which it resets itself and continues at its original pace. People tend to experience palpitations in different ways, but some common descriptions include a rapid fluttering in the chest, a flip-flopping of the heart or a pounding in the neck or throat. Palpitations occur commonly alongside a whole host of other symptoms, including chest discomfort, light-headedness and even fainting spells, although they may also occur with no other associated symptoms.
What Are Some of the Common Causes of Palpitations?
It’s important to recognize that your heart’s conduction system may be influenced by several different factors, both internal and external to the heart. When thinking about factors intrinsic to the heart, it’s helpful to consider three broad categories where there might be a problem: (1) a heart muscle problem, (2) a heart valve problem or (3) a problem within the conduction system itself. The list of external factors influencing the heart is equally broad, and includes things such as your autonomic nervous system, circulating hormones, certain medications, caffeine, electrolyte levels and even certain psychiatric conditions that affect your mood and stress level. The impact of the autonomic nervous system consisting of its sympathetic and parasympathetic branches (responsible for “fight or flight” and “rest and digest,” respectively) can’t be underestimated, as it serves as the gatekeeper that either revs up or cycles down your heart’s conduction system. A very common scenario encountered almost daily is exercise, during which your sympathetic nervous system goes into a relative overdrive, and the adrenaline released directly impacts the conduction system and speeds up the heart.
Accordingly, health care professionals tend to think about the different causes of palpitations in two main groups: noncardiac and cardiac causes (i.e., those not related to your heart and those related to your heart). Recognize that in each one of these categories, there’s a spectrum of severity, ranging from benign conditions to more severe conditions, and that the majority of causes (whether cardiac or noncardiac) will end up being benign and won’t require specific treatment. An exact cause of your palpitations may not be discovered in each and every scenario. In one study, among 190 patients evaluated at a university medical center for palpitations, physicians determined a cause in only 84 percent of the cases. A cardiac cause was identified in 43 percent and a noncardiac cause was identified in 41 percent of patients.
Is it in My Heart or Head?
It turns out that in the same study just described, the investigators identified the common factors as predictors of palpitations from a cardiac cause. These included male gender, a prior history of heart disease and symptoms described as an irregular heartbeat lasting beyond five minutes. The more of these factors present, the higher the likelihood of having a cardiac cause behind the palpitations, which in this particular study was most often a benign arrhythmia. Whether palpitations stem from an isolated psychiatric cause (in the absence of a cardiac issue) is sometimes a bit more difficult to discern, especially because many patients have both psychiatric and cardiac issues. Not surprisingly, when palpitations accompany a sense of anxiety or panic, it’s hard to tell whether the anxiety or panic preceded or resulted from the palpitations — a classic chicken and egg scenario. And so, the take-home point is that before chalking up your symptoms entirely to nerves, it’s a good idea to have at least a basic evaluation to make sure there’s nothing else going on.
[See: The 12 Best Heart-Healthy Diets.]
What Tests May My Doctor Order?
If you seek medical advice for your palpitations, your physician should begin with a detailed history and physical examination. Before going to your appointment, take some time to note your symptoms in a journal, so that you have an exact recollection of the timing, provoking situations and any other associated symptoms you may have been feeling with your palpitations. This is especially important because a specific description of your symptoms can be immensely helpful in guiding your physician’s diagnostic approach right off the bat. Your physician will also perform a comprehensive physical examination, with a specific emphasis on your vital signs, and a cardiovascular exam, which will include listening to your heart with a stethoscope and ensuring that the pulses in your major arteries are intact. Your physician will also likely perform an electrocardiogram (EKG or ECG), which provides a 10-second snapshot of your heart rate and rhythm. The test may also provide some insight into other potential abnormalities within your heart’s conduction system, and in many cases, reassure your physician that everything looks OK.
It’s important to recognize, however, that most people who seek medical attention for palpitations will have a normal heartbeat and ECG at the time of their evaluation. Therefore, in some cases, longer ECG monitoring may be required using devices such as Holter monitors, continuous loop event recorders or implantable loop recorders. A Holter monitor is a battery-operated, portable device about the size of a small camera that measures and records your heart’s activity (ECG) continuously for 24 to 48 hours. The entire device is external and can be worn comfortably with your regular clothing. A continuous loop event recorder is similar to a Holter monitor, except it can be worn for longer periods of time and only saves data when triggered to do so by the patient, typically at the onset of symptoms. An implantable loop recorder, as the name suggests, requires a minor procedure for the device to be implanted under the skin (typically on the left side of the chest), and has even longer-term recording capabilities. These devices are typically recommended in cases when patients pass out without any clear explanation and not for “run of the mill” palpitations.
Depending on the results of this initial evaluation, your physician may also order blood tests to look for things such as electrolyte imbalances, thyroid hormone abnormalities or a low blood count (anemia). If, on the basis of your history and physical examination, your physician suspects either a heart muscle problem or a heart valve problem, then you may undergo an echocardiogram (ultrasound of the heart). If none of these investigations results in a diagnosis and you continue to experience symptoms, then your physician may refer you to a specially trained cardiologist called an electrophysiologist, whose expertise is in disturbances of the heart’s conduction system.
When Should I Worry?
We already mentioned some of the features that may prompt you to think that your palpitations stem from a cardiac source (sorry, gentlemen). But it’s important to remember that even most of the cardiac causes of palpitations are generally benign. Indicators that perhaps your palpitations are linked to a serious heart condition (a potentially life-threatening arrhythmia, for example) would be if they occur with fainting spells, chest discomfort or difficulty breathing, or if you have family members who’ve passed out or even died suddenly. Reassuringly, even some of the more serious cardiac causes of palpitations are treatable, either via medications alone or with a combination of medications and procedures. But a prompt evaluation and diagnosis soon after onset of symptoms is key.
Addressing the Elephant in the Room: Is it Because of Too Much Caffeine?
The effects of caffeine on heart rate are variable from person to person, but in general, caffeine tends to increase most people’s heart rates. If you’re experiencing palpitations, then one of the first suggestions your physician may make is to reduce your caffeine intake, and oftentimes this does the trick. However, there is no clearly established maximum caffeine dose that increases the risk for developing an arrhythmia. And while the overall cardiovascular effects of high caffeine intake are still being studied, generally speaking, moderate caffeine consumption (one to two cups of coffee per day) doesn’t appear to be harmful.
[See: The Best Foods for Lowering Your Blood Pressure.]
Take-Home Points:
The electrical “superhighway” of your heart, with the SA node as its conductor, is responsible for maintaining a normal heart rate and rhythm. It’s influenced by a wide range of factors, both within and outside the heart.
Most cases of palpitations, be they due to cardiac or noncardiac causes, are entirely benign and don’t require further investigation or treatment. Many palpitations are due to a small hiccup in the heart’s electrical conduction system, interrupting the metronome momentarily and then resetting and resuming normal conduction.
Palpitations that occur with fainting spells, chest discomfort or shortness of breath, or that happen in patients with family members who’ve died suddenly and inexplicably, may be an indicator of a more serious underlying heart condition. This should prompt urgent evaluation by a health care professional.
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If Your Heart Is Racing, You Probably Don’t Need to Worry originally appeared on usnews.com
