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Palpitations and skipped beats
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In one pass Palpitations mean you have become aware of your own heartbeat.
Educational content, not medical advice — consult a clinician.
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Chapter 1
What palpitations are, and how risky
Palpitations mean you have become aware of your own heartbeat. Your heart beats all the time without you noticing; with palpitations it feels fast, heavy, irregular, or as if it skipped a beat. You may feel it in your chest, or in your neck or throat.
They are common and mostly not dangerous. One study followed 190 consecutive people who saw a doctor about palpitations: 43% had a cause in the heart, 31% a psychological cause such as anxiety, 10% some other cause, and in 16% none was found. After a year, 1.6% had died and 1.1% had had a stroke; but 75% had had palpitations again during the year.
So this story is not here to frighten you. It covers two things: which palpitations need action right away, and how to catch one in the act so a doctor can see which kind it is.
If palpitations don't stop, or come with chest pain, shortness of breath, feeling faint or fainting, go to the emergency department now, and don't drive yourself.
They are common and mostly not dangerous. One study followed 190 consecutive people who saw a doctor about palpitations: 43% had a cause in the heart, 31% a psychological cause such as anxiety, 10% some other cause, and in 16% none was found. After a year, 1.6% had died and 1.1% had had a stroke; but 75% had had palpitations again during the year.
So this story is not here to frighten you. It covers two things: which palpitations need action right away, and how to catch one in the act so a doctor can see which kind it is.
If palpitations don't stop, or come with chest pain, shortness of breath, feeling faint or fainting, go to the emergency department now, and don't drive yourself.
Evidence · Anxious or not, check the heart first
Among those 190 people, 40% of causes were found with the history, an examination, one ECG or a few blood tests.Anxiety is the most common cause outside the heart, but being anxious does not mean the palpitations come from anxiety: among people whose symptoms looked psychological, up to 13% turned out to have another cause. So doctors start by looking for a heart cause in everyone who comes in with palpitations.
Two features make a rhythm problem less likely: episodes that last under five minutes, and a family history of panic disorder. They lower the odds; they cannot rule one out.
Chapter 2
The skip is the beat after
Each heartbeat starts with an electrical signal from the sinus node in the right atrium. It spreads across the atria to the atrioventricular node, then down the conduction pathways into both ventricles. Now and then, another spot in the atria or ventricles fires early, and the heart beats ahead of time. This is a premature beat, or ectopic beat.
Oddly, what you feel is often not the premature beat itself. The beat that follows a single premature beat is unusually forceful, and the skipped beat or thump people describe is often this one.
Premature beats are extremely common: most people who wear a heart monitor for long enough show ventricular premature beats. They are more frequent with older age, taller height, higher blood pressure, heart disease, less physical activity and smoking.
Whether you notice them is not quite the same as how many you have. People who sit a lot, or are anxious or low in mood, notice them more; active, cheerful people tend to notice them less. Premature beats are also often noticed when you are at rest.
Oddly, what you feel is often not the premature beat itself. The beat that follows a single premature beat is unusually forceful, and the skipped beat or thump people describe is often this one.
Premature beats are extremely common: most people who wear a heart monitor for long enough show ventricular premature beats. They are more frequent with older age, taller height, higher blood pressure, heart disease, less physical activity and smoking.
Whether you notice them is not quite the same as how many you have. People who sit a lot, or are anxious or low in mood, notice them more; active, cheerful people tend to notice them less. Premature beats are also often noticed when you are at rest.
Mechanism · When a premature beat needs more checking
Atrial and ventricular premature beats are both common, in people with and without heart disease. Single ventricular premature beats that all look the same are more likely to be harmless; ones that come in runs or in varied shapes deserve a closer look.For ventricular premature beats, the doctor needs to answer two questions:
Is the heart's structure normal? This usually takes an echocardiogram. In people with structural heart disease, premature beats mean something different, and that disease is treated first.What share of all heartbeats are premature? This is counted with a heart monitor. At 25% or more, the risk that the heart muscle is worn down and weakened goes up.
If the heart's structure is normal, the premature beats are few and the symptoms mild, a doctor will usually explain what they are and leave them untreated. Bad symptoms can be treated with medicine or with catheter ablation.
Chapter 3
Coffee, alcohol and short sleep
Many people cut out coffee the moment they get palpitations. A 2023 trial fitted 100 adults with a continuous ECG for 14 days and texted them each day, at random, to drink coffee or avoid caffeine that day:
Atrial premature beats: 58 a day on coffee days versus 53 without, not a significant difference.Ventricular premature beats: 154 a day versus 102, about half again as many.On coffee days people took 1058 more steps, but slept 36 fewer minutes at night.
Another study looked at 1388 older adults with an average age of 72: how much coffee, tea or chocolate they usually had was not linked to the number of premature beats over 24 hours.
Taken together, coffee is not a master switch for palpitations. It may briefly raise ventricular premature beats in some people, and it eats into sleep, and short sleep is a common trigger in its own right. It is worth watching in yourself, not banning across the board.
Other common triggers are hard exercise, stress and anxiety, alcohol, nicotine and recreational drugs. Some medicines can do it too, such as asthma reliever inhalers and ADHD medicines, so check the leaflet. Palpitations are also common around the menopause and in pregnancy.
Atrial premature beats: 58 a day on coffee days versus 53 without, not a significant difference.Ventricular premature beats: 154 a day versus 102, about half again as many.On coffee days people took 1058 more steps, but slept 36 fewer minutes at night.
Another study looked at 1388 older adults with an average age of 72: how much coffee, tea or chocolate they usually had was not linked to the number of premature beats over 24 hours.
Taken together, coffee is not a master switch for palpitations. It may briefly raise ventricular premature beats in some people, and it eats into sleep, and short sleep is a common trigger in its own right. It is worth watching in yourself, not banning across the board.
Other common triggers are hard exercise, stress and anxiety, alcohol, nicotine and recreational drugs. Some medicines can do it too, such as asthma reliever inhalers and ADHD medicines, so check the leaflet. Palpitations are also common around the menopause and in pregnancy.
In practice · Run a small test on yourself
If you suspect coffee, borrow the trial's design: alternate coffee days and no-coffee days, and note how many times you get palpitations each day. This beats going on impressions, because palpitations come and go anyway. It is a method borrowed from a trial design, not a guideline recommendation.When no illness is behind the palpitations, avoiding triggers helps in itself: stress, smoking, caffeine and alcohol.
If you take a beta-blocker (such as metoprolol), don't stop it suddenly yourself: stopping suddenly can itself cause palpitations. If you want to cut down, talk to the doctor who prescribed it first.
Chapter 4
Racing that starts and stops suddenly
Another kind of palpitation is a heartbeat that suddenly races, fast and regular, then suddenly stops a while later, as if someone flicked a switch. This is often paroxysmal supraventricular tachycardia (SVT): the electrical signal circles round a loop inside the heart, and the heart beats once for each lap.
It looks a lot like a panic attack, so it is often mistaken for one. One study looked back at 107 people diagnosed with this tachycardia:
67% had symptoms that met the diagnostic criteria for panic disorder.55% were not recognized at their first medical evaluation, and the delay had a median of 3.3 years.Among them, 54% had their symptoms put down to panic, anxiety or stress by non-psychiatrist doctors, women more often than men (65% versus 32%).After treatment, mostly catheter ablation, symptoms went away in 86%.
The difference often lies in how it starts and stops: tachycardia tends to switch on and off abruptly, while palpitations from anxiety usually build up gradually, with a regular beat that is only slightly fast, often with tingling in the hands and face.
If your palpitations are switch-like, say so clearly at the appointment.
It looks a lot like a panic attack, so it is often mistaken for one. One study looked back at 107 people diagnosed with this tachycardia:
67% had symptoms that met the diagnostic criteria for panic disorder.55% were not recognized at their first medical evaluation, and the delay had a median of 3.3 years.Among them, 54% had their symptoms put down to panic, anxiety or stress by non-psychiatrist doctors, women more often than men (65% versus 32%).After treatment, mostly catheter ablation, symptoms went away in 86%.
The difference often lies in how it starts and stops: tachycardia tends to switch on and off abruptly, while palpitations from anxiety usually build up gradually, with a regular beat that is only slightly fast, often with tingling in the hands and face.
If your palpitations are switch-like, say so clearly at the appointment.
In practice · A move to learn once diagnosed
The vagus nerve can slow the heart, and one group of moves works by stimulating it. The most used is the Valsalva manoeuvre: holding your breath and straining. Doctors can teach people with diagnosed SVT to do it themselves.A trial in English emergency departments compared two versions:
Standard: straining hard for 15 seconds while semi-reclined (held at 40 mmHg with a pressure gauge in the trial). Normal rhythm returned within 1 minute in 17%.Modified: the same strain, then lying flat straight away while someone raises your legs. This brought it to 43%, with no serious adverse events.
Use this move yourself only after a doctor has made the diagnosis and taught you. Don't use it as a self-test for undiagnosed palpitations; if an attack comes with chest pain, breathlessness or feeling faint, go straight to the emergency department. For episodes that are rare and stop on their own, no treatment is also an option to discuss with your doctor.
appelboam-2015-revert-valsalva
Chapter 5
Catch it while it happens
The hardest thing about palpitations is that by the time you see a doctor, they have usually stopped. A normal ECG taken between episodes cannot rule out a rhythm problem. So the key is to leave a record in the moment:
Feel your pulse there and then, or tap the rhythm out with your fingers: fast or slow, regular or irregular.Write it down: did it start suddenly or gradually, how long did it last, what were you doing, was there chest pain, breathlessness or dizziness?If your watch can record an ECG, take a recording as soon as an episode starts. One study taught 59 people with palpitations to record a 30-second single-lead ECG on their watch when symptoms began; of 77 tracings received, 95% were readable and 78% showed an arrhythmia.
Hospital tests are chosen by how often episodes come, too: for near-daily episodes, a 24- to 48-hour Holter monitor; for infrequent ones, an event recorder that can be worn for about 30 days. In the SVT study above, Holter monitoring caught it in 9%, an event recorder in 47%.
Feel your pulse there and then, or tap the rhythm out with your fingers: fast or slow, regular or irregular.Write it down: did it start suddenly or gradually, how long did it last, what were you doing, was there chest pain, breathlessness or dizziness?If your watch can record an ECG, take a recording as soon as an episode starts. One study taught 59 people with palpitations to record a 30-second single-lead ECG on their watch when symptoms began; of 77 tracings received, 95% were readable and 78% showed an arrhythmia.
Hospital tests are chosen by how often episodes come, too: for near-daily episodes, a 24- to 48-hour Holter monitor; for infrequent ones, an event recorder that can be worn for about 30 days. In the SVT study above, Holter monitoring caught it in 9%, an event recorder in 47%.
Clinical · Watch alerts and blood tests
What if your watch flags an irregular pulse? In a study of 419,000 people, only 0.52% got an alert; those who then wore an ECG patch, on average 13 days later, had atrial fibrillation in 34%. Don't ignore it and don't panic: get an ECG. Atrial fibrillation is irregular with no pattern at all, and it raises the risk of stroke.Problems elsewhere in the body can also make the heart fast or irregular: an overactive thyroid, anaemia, low blood sugar, abnormal potassium or magnesium, pregnancy. If palpitations come on when you stand up, have your blood pressure and heart rate measured lying down and standing. The usual first blood tests are a full blood count plus kidney function and electrolytes; thyroid function is added when atrial fibrillation is new or there are signs of an overactive thyroid.
These are found with blood tests and measurements, not by trying a magnesium or potassium tablet first.
perez-2019-apple-heart-study
Chapter 6
When to see a doctor
Go to the emergency department now (don't drive yourself; call an ambulance or get someone to take you):
Palpitations that don't stop.Palpitations with chest pain, shortness of breath, feeling faint or fainting.
Contact a doctor the same day:
The symptoms above have already stopped.Palpitations come on with exercise.A newly irregular heartbeat with no pattern.A resting heart rate above 120 or below 45 beats a minute (if the episode is still going on, go to the emergency department as above).
See a doctor soon for an ECG:
Palpitations keep coming back, are happening more often, or last more than a few minutes at a time.You already have a heart condition, or someone in your family has heart problems or died suddenly at a young age.
Take all the medicines you use with you, along with your notes on the episodes.
Palpitations that don't stop.Palpitations with chest pain, shortness of breath, feeling faint or fainting.
Contact a doctor the same day:
The symptoms above have already stopped.Palpitations come on with exercise.A newly irregular heartbeat with no pattern.A resting heart rate above 120 or below 45 beats a minute (if the episode is still going on, go to the emergency department as above).
See a doctor soon for an ECG:
Palpitations keep coming back, are happening more often, or last more than a few minutes at a time.You already have a heart condition, or someone in your family has heart problems or died suddenly at a young age.
Take all the medicines you use with you, along with your notes on the episodes.
References · 9
- Weber, B. E., & Kapoor, W. N. (1996). Evaluation and outcomes of patients with palpitations. The American Journal of Medicine, 100(2), 138–148. Prospective cohort of 190 consecutive patients presenting with palpitations at a university medical center; cause found in 84%: cardiac 43%, psychiatric 31%, miscellaneous 10%, unknown 16%; 40% of causes found with history, examination, ECG and/or lab tests; 1-year mortality 1.6% and stroke 1.1%; 75% had recurrent palpitations within the year; 89% reported health the same or better at 1 year (abstract, PMID 8629647). 10.1016/s0002-9343(97)89451-x
- NHS. (2026). Heart palpitations. Heartbeat feels racing, irregular with skipped or extra beats, pounding or fluttering, in the chest, neck or throat; lasts seconds, minutes or longer; usually harmless. Common causes: strenuous exercise, lack of sleep, stress and anxiety, medicines, alcohol, caffeine, nicotine and recreational drugs; sometimes menopause or pregnancy; can be caused by iron deficiency anaemia, an overactive thyroid, an arrhythmia or other heart problems. See a GP if they keep coming back or happen more often, last longer than a few minutes, you have a heart condition, or there is a history of heart problems in your family. Call 999 or go to A&E if palpitations do not go away or come with chest pain, shortness of breath, feeling faint or fainting; if these symptoms have stopped, ask for an urgent GP appointment. Do not drive to A&E. Avoiding triggers such as stress, smoking, caffeine and alcohol can help when no condition is the cause; an ECG helps find the cause (page last reviewed 17 March 2026). www.nhs.uk/symptoms/heart-palpitations
- Wexler, R. K., Pleister, A., & Raman, S. (2011). Outpatient approach to palpitations. American Family Physician, 84(1), 63–69. Narrative review: palpitations are described as flutter, flip-flop, pounding or skip; tapping out the rhythm helps; anxiety is the most common noncardiac cause, but a psychiatric comorbidity does not mean the cause is noncardiac (a nonpsychiatric cause in up to 13%); palpitations lasting under five minutes and a family history of panic disorder lower the likelihood of an arrhythmia; stimulants such as caffeine, thyroid disease, alcohol, pregnancy, anemia, nicotine, beta-blocker withdrawal, fever and hypoglycemia are other causes; a normal resting ECG does not exclude an arrhythmia; Holter for 24-48 h when episodes are frequent, event (loop) monitor for about 30 days when infrequent; palpitations with exertion warrant exercise testing because of higher risk; premature atrial and ventricular contractions are common in healthy people, isolated monomorphic ventricular ones more likely benign, and at least 25% of beats being ventricular premature contractions raises the risk of cardiomyopathy; atrial fibrillation is typically irregularly irregular and raises stroke risk; SVT, long QT, VT and palpitations with syncope go to a cardiologist (full text, aafp.org). www.aafp.org/pubs/afp/issues/2011/0701/p63.html
- Govender, I., Nashed, K. K., Rangiah, S., Okeke, S., & Maphasha, O. M. (2022). Palpitations: Evaluation and management by primary care practitioners. South African Family Practice, 64(1), e1–e8. Narrative review: with an isolated extrasystole the patient may perceive the augmented post-extrasystolic beat as the 'skipped' beat rather than the premature beat itself; awareness is heightened in sedentary, anxious or depressed people and reduced in active ones; extrasystoles feel like skipping a beat, at rest; tachycardia starts suddenly; anxiety-related palpitations start gradually, are regular and slightly fast, with tingling hands and face; caffeine, alcohol, nicotine and sympathomimetics, asthma reliever inhalers and ADHD medicines can cause palpitations; high-output states (anaemia, pregnancy, sepsis, hyperthyroidism), hypoglycaemia and abnormal potassium, calcium or magnesium are other causes, and fatigue with heavy periods points to anaemia, and palpitations on standing occur in orthostatic hypotension and POTS; red flags: fainting or near-fainting, chest pain or shortness of breath, new irregular rhythm, resting heart rate over 120 or under 45, underlying heart disease, family history of sudden death; selected patients with suspected or documented SVT can be taught the Valsalva manoeuvre; primary-care blood tests are a full blood count and urea, creatinine and electrolytes, with thyroid function when atrial fibrillation is new or there are symptoms of hyperthyroidism (full text PMC8905373). 10.4102/safp.v64i1.5449
- Marcus, G. M. (2020). Evaluation and management of premature ventricular complexes. Circulation, 141(17), 1404–1418. PVCs are extremely common, found in most people who undergo long-term ambulatory monitoring; older age, taller height, higher blood pressure, heart disease, less physical activity and smoking predict more PVCs; often asymptomatic but can cause palpitations, breathlessness, near-fainting and fatigue; an echocardiogram is indicated with symptoms or particularly frequent PVCs; ambulatory monitoring measures how frequent they are; a higher PVC burden may be a risk factor for heart failure and death; people with no or mild symptoms, a low burden and normal heart function may be best served with reassurance (abstract, PMID 32339046). 10.1161/CIRCULATIONAHA.119.042434
- Marcus, G. M., Rosenthal, D. G., Nah, G., Vittinghoff, E., Fang, C., Ogomori, K., Joyce, S., Yilmaz, D., Yang, V., Kessedjian, T., Wilson, E., Yang, M., Chang, K., Wall, G., & Olgin, J. E. (2023). Acute effects of coffee consumption on health among ambulatory adults. The New England Journal of Medicine, 388(12), 1092–1100. Randomized case-crossover trial in 100 adults (mean age 39) wearing a continuous ECG for 14 days, randomly told by text each day to drink caffeinated coffee or avoid caffeine: premature atrial contractions 58 vs 53 a day (not significant); premature ventricular contractions 154 vs 102 a day (rate ratio 1.51); 1058 more steps and 36 fewer minutes of nightly sleep on coffee days; glucose unchanged (abstract, PMID 36947466). 10.1056/NEJMoa2204737
- Dixit, S., Stein, P. K., Dewland, T. A., Dukes, J. W., Vittinghoff, E., Heckbert, S. R., & Marcus, G. M. (2016). Consumption of caffeinated products and cardiac ectopy. Journal of the American Heart Association, 5(1), e002503. 1388 older adults (mean age 72) in the Cardiovascular Health Study with a food-frequency survey and 24-hour Holter: habitual coffee, tea and chocolate intake was not associated with the number of premature atrial or ventricular contractions per hour after adjustment (full text PMC4859368). 10.1161/JAHA.115.002503
- Lessmeier, T. J., Gamperling, D., Johnson-Liddon, V., Fromm, B. S., Steinman, R. T., Meissner, M. D., & Lehmann, M. H. (1997). Unrecognized paroxysmal supraventricular tachycardia: potential for misdiagnosis as panic disorder. Archives of Internal Medicine, 157(5), 537–543. Retrospective survey of 107 consecutive patients with re-entrant PSVT referred for treatment: 67% met DSM-IV panic disorder criteria; PSVT went unrecognized after the first medical evaluation in 55%, for a median of 3.3 years, and non-psychiatrist physicians attributed the symptoms to panic, anxiety or stress in 54% of those; women more often than men (65% vs 32%); Holter monitoring caught PSVT in 9% vs 47% with an event monitor; treatment, mostly ablation, resolved symptoms in 86% (abstract, PMID 9066458). 10.1001/archinte.1997.00440260085013
- Gibiino, F., Boccadoro, A., Melpignano, A., Vitali, F., Clò, S., Canovi, L., et al. (2026). A prospective real-world study evaluating the feasibility and diagnostic yield of patient-recorded smartwatch EKGs during palpitations: the WATCHinTIME study. Journal of Clinical Medicine, 15(8), 3113. 59 adults referred to arrhythmia clinics in Ferrara for palpitations who already owned an ECG-capable smartwatch were trained to record a 30-second single-lead ECG at the onset of symptoms; 52% sent at least one tracing; of 77 tracings, 95% were interpretable and 78% showed an arrhythmia (atrial fibrillation, flutter, PSVT, premature beats, sinus tachycardia, AV block), 22% normal rhythm; the authors note palpitations often resolve before medical evaluation and a 24-hour Holter yields as little as 10-15% (abstract, PMID 42074915). 10.3390/jcm15083113