Heart palpitations: when to see a cardiologist and what information to bring

Feeling your heart race, a flutter in your chest or a beat that seems to skip is very common, and most of the time heart palpitations aren't caused by anything serious. Even so, some palpitations are arrhythmias, disturbances of the heart's rhythm, which need to be diagnosed and treated. Knowing when to see a cardiologist, when to call 112 and what to say at your appointment greatly shortens the path to a diagnosis.

What are palpitations?

They are the sensation of feeling your own heartbeat: stronger, faster, irregular or with pauses. You feel them in your chest, neck or throat, and they can last seconds or hours. The sensation doesn't always mean an arrhythmia: sometimes the rhythm is normal and what changes is how much attention we pay to it, for example when resting, in silence or on going to bed.

Among the most common causes are ectopic beats, beats that come early and feel like a "flutter" or a "skip". In a healthy heart they are usually harmless.

How they feel and what that suggests to the doctor

The pattern of the palpitations gives a lot of guidance at the appointment:

• A single flutter or a beat that "skips", followed by a pause and a stronger beat: this is the typical pattern of ectopic beats.
• A fast, regular beat that starts and stops suddenly: this may be paroxysmal tachycardia, the kind that comes and goes in episodes.
• A fast, disorganised beat with no fixed rhythm: this suggests atrial fibrillation, the most common sustained arrhythmia in adults.
• A fast but regular beat that rises and falls gradually, with nerves, exertion or a fever: this is usually the heart's normal response to that stimulus.

These are pointers, not diagnoses: only a recording of the rhythm, ideally during the episode, confirms it.

Common triggers

• Coffee, tea, energy drinks and tobacco.
• Alcohol, especially in excess.
• Stress, anxiety, panic attacks and lack of sleep.
• Intense exercise and fever.
• Some medicines, such as decongestants, and stimulant drugs, such as cocaine.
• Thyroid problems (hyperthyroidism), anaemia or potassium disorders.

Anxiety deserves a mention: it can cause palpitations, but an arrhythmia can also cause anxiety. That is why it isn't wise to put them down to nerves without having them assessed first.

When it's an emergency: call 112

Call 112 if your palpitations come with:

• Chest pain or tightness.
• Fainting or feeling that you are about to pass out.
• Severe shortness of breath.
• A cold sweat or marked dizziness.

A very fast heartbeat that doesn't settle with rest also needs urgent attention, as does any loss of consciousness during exercise.

What to do during an episode

Sit or lie down, breathe calmly and, if you are driving, stop as soon as it is safe to do so. Take your pulse and note the time. If you have already been diagnosed with an arrhythmia and your cardiologist has told you what to do, follow that advice. And if any of the warning signs appear, don't wait for it to pass.

Heart palpitations: when to see a cardiologist

Without any warning symptoms, it's a good idea to book an appointment if:

• The palpitations are new, or different from the ones you used to have.
• The episodes start and stop suddenly, as if a switch were being turned on and off.
• You feel your heartbeat fast and irregular, even if you don't feel unwell.
• They appear when you do sport.
• Your resting pulse is above 100 beats per minute with no fever, exercise or nerves to explain it.
• The ectopic beats are very frequent or come in runs.
• You have a heart condition, high blood pressure, diabetes or high cholesterol, or a family history of sudden death at a young age.

What information to bring to the cardiologist

Most often, your heart will be beating normally at the appointment. That is why your description is worth as much as a test. Write down:

• How they start and stop: suddenly or gradually.
• How long they last and how often they appear.
• What the rhythm is like: regular or irregular. A useful trick is to tap out the rhythm you feel on the table with your fingers, so you can reproduce it at the appointment.
• Your pulse during the episode: count the beats at your wrist or neck for 30 seconds and multiply by two, or use an automatic blood pressure monitor, which also shows it.
• What you were doing and what made them stop, if anything did.
• Accompanying symptoms: dizziness, breathlessness, pain, tiredness.
• Your intake of coffee, alcohol, tobacco and supplements, and all your medication.
• Family history of arrhythmias or sudden death.

If you have ever had an electrocardiogram during an episode, in an emergency department or at your health centre, ask for a copy and bring it: a recording made while you have symptoms is among the most valuable things for the diagnosis. If you have recordings from a device, bring those too, without assuming they amount to a diagnosis.

Which tests help and why

The cardiologist chooses the tests according to what you tell them, not all at once:

• The electrocardiogram is the starting point: it shows your rhythm at that moment and can reveal changes that make arrhythmias more likely even if you aren't having palpitations.
• If the episodes happen every day or almost, the Holter monitor records your heart for 24 hours or more while you go about your normal life. If they are further apart, there are recorders you can wear for more days.
• The echocardiogram is requested when it is useful to see whether the heart has any valve or muscle problem that explains the arrhythmia or changes its treatment.
• A blood test helps to rule out anaemia, thyroid problems or disorders of salts such as potassium.

With this information, many people can find out whether their palpitations are harmless and what to do to notice them less. When there is an arrhythmia to treat, the diagnosis makes it possible to choose the right treatment.

If your palpitations keep coming back or worry you, book an appointment with cardiology with your notes ready.