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cardiology

Anxiety Palpitations vs. Real Heart Problem: How to Tell

Anxiety and heart arrhythmias can both cause a racing, pounding, or fluttering heartbeat — and no one can reliably tell them apart based on feel alone, including clinicians. The only reliable way to distinguish them is an EKG recorded during an episode.

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Nina Osei, NP — Nurse Practitioner

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Why do anxiety and heart arrhythmias feel so similar?

When you feel anxious or frightened, your body releases adrenaline, which causes the heart to beat faster and sometimes more forcefully. That sensation — an awareness of your own heartbeat — is itself a palpitation. In panic disorder, these physiological changes can be intense enough to feel alarming, creating a feedback loop where noticing the palpitation causes more anxiety, which worsens the palpitation 1.

Arrhythmias, by contrast, are actual changes in the heart's electrical system that cause abnormal rhythm or rate — but they can produce a sensation that feels nearly identical. This is why the history and physical examination alone, without objective data from an EKG, cannot reliably distinguish the two.

Are there any clues that suggest one over the other?

Neither symptom pattern is diagnostic on its own, but certain features shift the probability:

Features more common with anxiety or benign palpitations: - Symptoms triggered clearly by stress, caffeine, poor sleep, or alcohol - A gradual build-up and gradual resolution - Palpitations accompanied by shortness of breath, tingling in the hands or around the mouth, chest tightness, and dread - Young age with no personal or family history of heart disease - Symptoms that resolve completely with relaxation or distraction

Features more suggestive of an arrhythmia: - Sudden, abrupt onset and abrupt termination - Palpitations that wake you from sleep - Palpitations during exercise specifically - Accompanied by dizziness, near-fainting, or actual fainting - A regular rapid rhythm versus an irregular one - Family history of sudden cardiac death or inherited arrhythmia syndromes

These features are clues — not conclusions. An EKG during an episode is the definitive test 2.

What tests are used to tell them apart?

EKG (electrocardiogram). If the heart is in an abnormal rhythm during the test, it is visible on the tracing. If the rhythm is normal during the EKG, that does not rule out arrhythmia — it may just mean the episode has passed.

Holter monitor. A wearable device that records continuously for 24–48 hours. Useful when symptoms are frequent enough to occur during that window.

Event monitor or patch monitor. Worn for 2–4 weeks. You activate it when symptoms occur, capturing the rhythm at that moment.

Blood work. Checking thyroid function, electrolytes, and complete blood count helps rule out common non-cardiac causes of palpitations (thyroid disease, anemia, low potassium).

Anxiety screening. A clinician may also use a validated tool such as the GAD-7 3 to assess whether anxiety disorder is present, as treating anxiety can substantially reduce palpitation frequency even when no arrhythmia is found.

Can you have both anxiety and an arrhythmia at the same time?

Yes — and this is not uncommon. Anxiety does not protect against arrhythmias, and an arrhythmia diagnosis does not preclude anxiety disorder. Some people have premature beats (extra heartbeats) that are clinically benign, but their anxiety amplifies their awareness of those beats and causes significant distress.

In these cases, treating both the anxiety and addressing any cardiac factor is more effective than focusing on only one. A primary care clinician is well-positioned to coordinate this approach.

What should I do if I have unexplained palpitations?

Start with a visit to a primary care clinician. They can:

1. Take a thorough history and review your medications and supplements (stimulants, decongestants, and some asthma medications can cause palpitations) 2. Order a resting EKG 3. Order blood work to check thyroid, electrolytes, and blood count 4. Assess for anxiety disorder and discuss management options 5. Refer you to a cardiologist if the EKG is abnormal, if you have risk factors for heart disease, or if symptoms include fainting

Gale's primary care clinicians can start this evaluation and coordinate onward referral when needed.

Common questions

Can deep breathing or relaxation stop palpitations?

For anxiety-driven palpitations, yes — slowing the breath activates the parasympathetic nervous system and reduces heart rate. For certain arrhythmias (like SVT), vagal maneuvers such as bearing down or cold water on the face can also help. But if palpitations are persistent, accompanied by dizziness, or do not resolve, do not rely only on relaxation techniques — seek medical evaluation.

My doctor says my EKG is normal. Does that mean my palpitations are from anxiety?

A normal resting EKG means the heart was in a normal rhythm at that moment. It does not confirm that anxiety is the cause, and it does not rule out an arrhythmia that was not happening during the recording. Extended monitoring may be needed to capture an episode before concluding the cause.

Are palpitations dangerous?

Most palpitations are not dangerous. Premature beats are the most common cause and are generally benign. However, some arrhythmias do carry real risk — particularly ventricular arrhythmias and AFib. Any palpitations accompanied by fainting, chest pain, or shortness of breath warrant prompt evaluation.

Talk to a clinician

Nina Osei, NP — Nurse Practitioner

checkups, refills & skin. Gale can match you with a licensed clinician for a visit.

Find care →

Seek emergency care for these warning signs

  • —Palpitations with fainting or loss of consciousness
  • —Palpitations with chest pain or pressure
  • —Palpitations with severe shortness of breath
  • —Very rapid heartbeat that does not slow down after several minutes
  • —Palpitations in someone with a known heart condition

Call 911 if palpitations are accompanied by chest pain, fainting, or sustained rapid heart rate that does not resolve. For palpitations without these features, schedule a prompt primary care visit.

This article is general health education and does not diagnose anxiety disorder or cardiac arrhythmia. Both conditions require proper clinical evaluation.

References

  1. 1.DeGeorge KC, Grover M, Streeter GS (2022). Generalized Anxiety Disorder and Panic Disorder in Adults. American Family Physician. PMID 35977134 ✓Physiological basis of anxiety-driven palpitations and the panic disorder feedback loop; primary care approach to anxiety and somatic symptoms
  2. 2.National Heart, Lung, and Blood Institute (2024). Arrhythmias - What Is an Arrhythmia?. NHLBI, National Institutes of Health. link ✓Role of EKG and extended monitoring in distinguishing cardiac arrhythmias from non-cardiac causes of palpitations
  3. 3.Spitzer RL, Kroenke K, Williams JBW, Löwe B (2006). A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7. Archives of Internal Medicine. doi:10.1001/archinte.166.10.1092 ✓Validated screening tool for anxiety disorder, relevant to the evaluation of palpitations that may have an anxiety component

3 sources, numbered by first appearance. General health information, not medical advice — synthetic demonstration content.