Today we’re talking about palpitations. What are they? In simple terms, palpitations are the feeling of your own heartbeat. In your day-to-day life, your heart beats in the background and you generally don’t notice it. However, when you suddenly feel your heart pounding in your chest and you notice that it feels abnormal, that is a heart palpitation.
There’s a huge spectrum of types of palpitations and their causes, with some being relatively minor, and others being more serious. As an ER physician, I see heart palpitations nearly every shift. The vast majority of these cases are relatively benign, but some patients present with more serious symptoms that need further evaluation. If you are experiencing your own palpitations it is difficult to tell the severity without proper medical evaluation, I would recommend getting a medical evaluation with either your primary care physician or in the emergency department when you’re experiencing palpitations.
Palpitations can arise at any age, but as we age as women, cardiac issues come up more frequently, especially after and during menopause. Throughout our lives, estrogen acts as a guard fortifying our bodies against heart disease, but when we experience menopause and our estrogen levels decrease, our hearts become more susceptible to heart disease. The classic symptoms of chest pain and shortness of breath that you generally associate with heart disease do not always follow suit and women tend to have atypical symptoms. So palpitations can sometimes be a symptom of underlying cardiovascular disease.
Let’s explore the nuances of palpitations and what steps to take when confronted with this unsettling sensation.
Self-Assessment at Home
Many things cause palpitations and there are many types of palpitations. The heart may beat too fast, too slow, irregularly, or experience extra beats. Distinguishing between a normally fast-beating heart and an abnormally triggered heartbeat is important, and timely evaluation is essential when these symptoms persist.
As you experience palpitations, the first step is to ask yourself some key questions:
- Am I dizzy or lightheaded?
- Do I have chest pain?
- Is it difficult for me to breathe?
If any of these symptoms accompany palpitations, you must seek immediate medical attention by heading to the emergency room as these symptoms often indicate a more serious medical issue.
If you aren’t experiencing other symptoms, take a second to become in tune with what is going on with your heart. If you have access at home to either a smartwatch or are able to take your blood pressure, those tools can provide quick and accurate readings. If not, simply use your fingers to check your pulse on your chest, wrist, or neck.
Check for the following:
- Heart Rate:
- Is your heart racing excessively (over 120-150 bpm)?
- Is it unusually slow (under 50 bpm)?
- Does the rhythm appear regular, or is it irregular?
- Are you feeling a half beat between beats?
- Is your heart skipping a beat?
It’s important to gather this information in real time because sometimes by the time you get to the emergency department, you may no longer be having the symptoms. You can provide this information to the emergency department physician, who will then help piece together what might be happening. I would say in general, that if your symptoms are persisting more than 10 to 15 minutes, you should really go in because then we’re more likely to be able to catch what’s going on.
Medical Evaluation in the ER
If you end up in the emergency department, what are the doctors going to do? First, we’re going to take your vital signs, to see your blood pressure and your pulse because sometimes people feel some palpitations and the heart rate is beating normally. Next, we’re going to ask you some questions and dive into your history. We will ask about the following potential triggers of heart palpitations
Health symptoms that can cause palpitations:
- Hot Flashes
- Poor sleep
- Cold or fever
External factors that can cause palpitations:
- Cocaine & Methamphetamines
- OTC cold medication
- Any stimulant medications
If I understand what some of the potential triggers are, then I can kind of move forward to figure out what’s going on. We put you on a monitor, we get an EKG. And we’re kind of looking for certain things that are most commonly causing palpitations.
Spectrum of Palpitations
In the ER, we use the EKG and cardiac monitors to focus on identifying specific arrhythmias.
Some of the most common I see in my ER are:
Sinus Tachycardia: Excessively fast heart rate
Your heart rate is going fast but in a normal rhythm. Sinus Tachycardia can be totally normal, in the setting of stress, exercise, or perhaps you’re sick. But then there are also things like thyroid disease, or perhaps in the setting of drug use, where your heart is beating in a sinus tachycardia. Your heart beats too fast and can be unsafe and cause stress on the heart. If you have existing heart disease, and your heart rate is going super fast, it may trigger chest pain or, or kind of heart damage. So we want to tease out what’s the cause of the sinus tachycardia.
Sinus Bradycardia: Unusually slow heart rate
Sinus Bradycardia is when the heart beats too slowly. Sinus Bradycardia can mean many things. It can also be a sign that the intrinsic electrical activity of the heart is not working appropriately, called sick sinus syndrome. It can be a sign of aging, where the heart goes too slow and leads to dizziness which sometimes calls for a pacemaker. It can also be attributed to being an athlete where it is normal for athletes to have a slow heartbeat as low as the 40s 50s bpm. Sinus bradycardia can be normal or can be pathologic
Atrial Fibrillation: Irregular and disorganized heart rhythm
Atrial fibrillation is an irregular and disorganized heartbeat which can be a normal rate or it can be going super fast. It becomes more common as we age. It can be caused by valvular heart disease, dehydration, electrolyte imbalances, and heavy alcohol use. This is significant, while generally not acutely dangerous unless your heart is going exceedingly fast or you have chest pain with it. But long-term atrial fibrillation can also lead to stroke. So we need to address it, evaluate it, and put you on medications to protect you from some of the long-term consequences
Supraventricular Tachycardia (SVT): Excessively fast heart rate
SVT is a rapid and regular rhythm originating above the heart’s ventricles. Your heart can be going upwards of 180 to 200 bpm. We see this in young healthy patients, we see this in older patients, and people are oftentimes born with this electrical conduction pathway. It can be treated relatively simply with medication or sometimes with vagal maneuvers. SVT is generally harmless and can be triggered by many things, including stress, anxiety, or changes in sleep patterns. SVT episodes may require monitoring, if the issue persists you need to go into the emergency department because nobody does well with a heart rate and the two hundreds for extensive periods
Ventricular Tachycardia: excessively fast heart rate
Ventricular Tachycardia is a rapid and regular rhythm originating in the heart’s ventricles. Ventricular Tachycardia is very serious and can be a sign you are having a heart attack, or it can just be an unstable rhythm that can degenerate into ventricular fibrillation which can lead to cardiac arrest. Ventricular tachycardia is associated with heart diseases, structural abnormalities, and genetic factors. Unlike sinus tachycardia, ventricular tachycardia is not a physiological response, but a pathological condition. This condition requires prompt medical attention due to its potential to progress to more severe arrhythmias or cardiac events.
Premature Atrial (PACs) or Premature Ventricular Contractions (PVCs)
These heartbeats make up the majority of cases in the emergency room. These beats originate from different parts of the heart and cause the heart to squeeze differently atypically in the chest which results in being able to feel your heart. It generally results in a too-early beat. They’re not dangerous and there are some medications to treat it. But often just some lifestyle modifications can solve them from better sleep, managing stress, or drinking less caffeine.
Given the similarity in how different palpitations may feel, it’s hard to tease out their cause at home. Experiencing palpitations doesn’t immediately mean you’re experiencing a medical crisis and about to die, even if it may feel that way. Remember, about 80% of the cases I see in the ER are benign. However, it is important to have these symptoms evaluated by a medical professional so that they can determine the root cause and severity of the palpitations.
HRT and Heart Palpitations
As we discussed before, sometimes, symptoms of menopause such as night sweats, hot flashes, anxiety, and sleeplessness, can cause palpitations. Thus, since HRT often mitigates those symptoms it may help treatment of the palpitations. Moreover, existing data suggests that HRT’s sustained hormonal support in boosting estrogen may contribute to reducing the risk of chronic cardiovascular diseases and cardiac events in women, adding another layer of benefit when considering if HRT is right for you.
Overall, palpitations are very common, and experiencing them, though uncomfortable, is not always life-threatening. However, due to the vast range in severity, it is important to be medically examined if you are experiencing palpitations. I have experienced palpitations many times in my life. When I was pregnant I had SVT and when I don’t sleep well I get PVCs and PACS. If I have one too many cups of coffee I sometimes get sinus tachycardia. There are great treatments out there and innovative diagnostics. Getting down to the root cause and type of palpitation early is essential to ensuring positive health outcomes.