When to Worry About Heart Palpitations: Red Flags

What causes palpitations in the first place?

Palpitations are the awareness of your heartbeat — not necessarily a sign that anything is wrong with it. The heart is always beating, but most people only notice it when the rate, rhythm, or force changes. Common causes include:

• Premature atrial or ventricular contractions (PACs/PVCs) — extra beats that interrupt the normal rhythm and produce a "skipped" or "flip-flop" sensation. These are the most common arrhythmia and are usually benign, particularly in people without structural heart disease 1Ref 1Marcus GM (2020).Evaluation and Management of Premature Ventricular Complexes.Benign prognosis of idiopathic PVCs in the absence of structural heart disease; evaluation with ECG, Holter, and echocardiogram; indications for referral based on PVC burden and symptoms.
• Sinus tachycardia — a fast but regular rhythm driven by anxiety, fever, dehydration, caffeine, or physical exertion
• Anxiety and panic — often produce racing heart that can feel severe even when the rhythm is normal
• Caffeine, alcohol, or stimulant medications
• Thyroid overactivity (hyperthyroidism)
• Anemia or low blood volume — the heart beats harder to compensate
• Cardiac arrhythmias such as AFib, atrial flutter, or SVT — less common but requiring evaluation 2Ref 2Joglar JA, Chung MK, Armbruster AL, et al. (2023).2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.AFib as a cause of palpitations requiring clinical evaluation; diagnostic approach including ECG, Holter monitoring, and echocardiography

Palpitations that are usually low concern

Palpitations in this category are worth mentioning at your next primary care visit, but do not typically warrant urgent evaluation:

• Brief episodes lasting seconds, triggered by caffeine, alcohol, or a stressful day
• A "skipped beat" sensation that resolves immediately
• Palpitations during or right after vigorous exercise that stop when you rest
• Occasional racing heart during anxiety or a panic episode
• Palpitations without any accompanying symptoms (no dizziness, no chest pain, no near-fainting)

If these are new, frequent, or worsening, a Gale primary care clinician can order a baseline ECG and review your medications and lifestyle for contributing factors 1Ref 1Marcus GM (2020).Evaluation and Management of Premature Ventricular Complexes.Benign prognosis of idiopathic PVCs in the absence of structural heart disease; evaluation with ECG, Holter, and echocardiogram; indications for referral based on PVC burden and symptoms.

Palpitations that need prompt evaluation — same day or soon

Contact a clinician the same day or within a few days if palpitations are:

• New and persistent — lasting more than 30 minutes without a clear trigger
• Accompanied by lightheadedness or near-fainting without actually losing consciousness
• Associated with shortness of breath that seems out of proportion
• Recurring frequently (multiple times per week) even if each episode resolves
• New in someone with known heart disease, structural heart problems, or a prior heart attack 1Ref 1Marcus GM (2020).Evaluation and Management of Premature Ventricular Complexes.Benign prognosis of idiopathic PVCs in the absence of structural heart disease; evaluation with ECG, Holter, and echocardiogram; indications for referral based on PVC burden and symptoms
• Occurring in someone with a family history of sudden cardiac death or inherited arrhythmia syndromes

These situations warrant an ECG, often a Holter monitor, and review of any medications or supplements 1Ref 1Marcus GM (2020).Evaluation and Management of Premature Ventricular Complexes.Benign prognosis of idiopathic PVCs in the absence of structural heart disease; evaluation with ECG, Holter, and echocardiogram; indications for referral based on PVC burden and symptoms.

Palpitations that are a medical emergency

Call 911 or go to the emergency department immediately if palpitations occur with:

• Chest pain, pressure, or tightness
• Fainting (loss of consciousness)
• Sudden, severe shortness of breath at rest
• Signs of stroke — facial drooping, arm weakness, speech difficulty
• Very rapid heart rate (over 150 beats per minute) that does not slow with rest

These combinations suggest a potentially dangerous arrhythmia or cardiac event requiring immediate evaluation.

What tests does a clinician use to evaluate palpitations?

The approach depends on how frequent and how worrying the symptoms are 1Ref 1Marcus GM (2020).Evaluation and Management of Premature Ventricular Complexes.Benign prognosis of idiopathic PVCs in the absence of structural heart disease; evaluation with ECG, Holter, and echocardiogram; indications for referral based on PVC burden and symptoms2Ref 2Joglar JA, Chung MK, Armbruster AL, et al. (2023).2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.AFib as a cause of palpitations requiring clinical evaluation; diagnostic approach including ECG, Holter monitoring, and echocardiography:

• ECG (electrocardiogram) — captures the rhythm at the moment of the test; may catch an arrhythmia or show a pattern that suggests one
• Holter monitor — worn for 24–48 hours to catch intermittent events
• Event monitor — worn for weeks; you activate it when you feel a palpitation
• Blood tests — thyroid function, complete blood count (to check for anemia), electrolytes
• Echocardiogram — ultrasound of the heart to assess structure if structural disease is suspected 1Ref 1Marcus GM (2020).Evaluation and Management of Premature Ventricular Complexes.Benign prognosis of idiopathic PVCs in the absence of structural heart disease; evaluation with ECG, Holter, and echocardiogram; indications for referral based on PVC burden and symptoms

For most people with occasional benign palpitations and a normal ECG, extensive testing is not needed.

What can I do to reduce palpitations at home?

For palpitations with a clear benign cause:

• Limit caffeine and alcohol
• Stay well-hydrated
• Manage anxiety and stress — regular moderate exercise supports cardiovascular health 3Ref 3Bull FC, Al-Ansari SS, Biddle S, et al. (2020).World Health Organization 2020 guidelines on physical activity and sedentary behaviour.Regular moderate physical activity as a cardiovascular health and anxiety-management strategy relevant to benign palpitations.
• Avoid energy drinks and stimulant supplements
• Review all medications with a clinician — some common drugs (decongestants, certain asthma medications) can trigger palpitations
• Get adequate sleep; sleep deprivation raises resting heart rate 4Ref 4Itani O, Jike M, Watanabe N, Kaneita Y (2017).Short Sleep Duration and Health Outcomes: A Systematic Review, Meta-analysis, and Meta-regression.Sleep deprivation and its adverse cardiovascular effects, including elevated heart rate.

If lifestyle changes help but symptoms persist, a Gale primary care clinician can guide next steps.