Palpitations, Missed or Skipped Beats

Palpitations are extremely common. There are many different causes of palpitations, and they are most commonly harmless. In some cases they can be the result of a heart condition, which might need investigation and treatment.

What are palpitations?

Palpitations are the sensation of feeling your own heart beating. They are often described as a fluttering, thumping, pounding, racing or strong beat in the chest. They can last for just a single beat, or a short run of beats. In some instances they can go on for several minutes, hours or days at a time. Some patients report that they can also feel a pulsing or throbbing sensation in the neck, throat, or that they can hear their heart beating in their ears.

What causes palpitations?

There are many different causes of palpitations. Some are caused by a heart condition, and others can be the symptom of a problem that is not directly in the heart itself. Some of the more common causes of palpitations are:

  • Arrhythmia – This is a when the heart is not beating in its normal rhythm. There are a number of different causes for this to happen, and broadly they can be caused by an arrhythmia that originates in the top chambers of the heart (atria) or in the lower chambers of the heart (ventricles). Some palpitations are caused by a small area in the atrium or ventricle that ‘fires off’ abnormally, and in other cases there may be additional electrical connections that you are born with that shouldn’t normally be there. Some arrhythmias can be very ‘organised’ and result in a regular heart beat that is usually fast, but not in the normal rhythm (sinus rhythm), while others can result in very ‘disorganised’ activity, making the heart beat irregularly.
  • Exercise
  • Alcohol
  • Caffeine
  • Smoking
  • Some medications (these can be either prescription medications or medications bought over the counter)
  • Recreational drugs
  • Stress, anxiety, nervousness or panic attacks
  • Hormone problems or changes (menopause, thyroid disease or pregnancy are common causes)

What are ectopic beats?

Ectopic beats are early, or extra heartbeats which can be a cause of palpitations. Although the are commonly referred to as ‘extra’ beats, many people describe them as feeling like a missing beat. Patients often describe the heart beating normally, followed by a strong beat, and a pause.

Ectopic beats are caused when an ‘impulse’ occurs from somewhere in the heart earlier than the normal beat that would occur during the normal heart rhythm (sinus rhythm). Ectopic heart beats are usually completely harmless but they can be quite uncomfortable and an unpleasant sensation, especially if they are occurring frequently. The two most common types of ectopic bet are:

  1. Atrial ectopics – These occur from the top chambers of the heart (atria)
  2. Ventricular ectopics – These occur from the lower chambers of the heart (ventricles)

Should I see a doctor about palpitations?

While palpitations are very common, they can be a cause of significant worry or concern for patients. At some stage in everyone’s life, they will experience palpitations. It is important to see a doctor about palpitations if they:

  • last a long time, don’t improve or get worse/more frequent
  • are associated with feeling dizzy, light headed, feeling like you might feint, or loosing consciousness
  • are associated with chest pains or chest tightness
  • there is a family history of heart problems, especially if there is a family history of sudden and unexpected death
  • cause you worry or concern

How are palpitations diagnosed?

Diagnosis of palpitations can sometimes be difficult, especially if they are infrequent. The challenge is to try and capture the symptoms of palpitations when you are having an electrocardiogram (ECG) or heart rhythm monitor. Heart rhythm monitors can be put on patients for anywhere between 24 hours to 2 weeks, depending on the type of monitor.

Heart rhythm monitors have variable numbers of electrode stickers that are placed on the skin, and attached to small wires which connect to a monitor recording box. This constantly records the heart rhythm, and if you experience palpitations while the monitor is on, you can make a note of the time and date that they occurred and the symptoms that you experienced. We can look at the recording at the time the symptoms were reported to see what was happening with the heart rhythm.

Other tests are sometimes required in addition to an ECG or heart rhythm monitor. These tests are usually to help identify the cause of the palpitations. These tests can sometimes include:

  • Blood tests
  • Echocardiogram (ultrasounds scan of the heart)
  • Blood pressure monitoring
  • Exercise treadmill tests (usually used if the palpitations are bought on by exertion)
  • Tests to look at the coronary arteries to see if there are any narrowing or blockages in the arteries that supply the heart muscle. This can be with a CT scan or sometimes a coronary angiogram
  • MRI scan of the heart

How are palpitations treated?

It often depends on the cause of the palpitations. Sometimes the palpitations are just the normal heart rhythm, which can occur during vigorous exercise. In this situation, there is nothing to treat, as the heart is doing exactly what it is supposed to do. Some palpitations do require treatment, and this may be directed at treating the underlying cause, such as an overactive thyroid gland, or trying to treat the symptoms themselves. Other treatments might involve avoiding the cause of the palpitations, such as avoiding caffeine or alcohol.

Treatments for arrhythmias that cause palpitations are varied, depending on the cause of the arrhythmia, and whether it is intermittent or constant. Medications to suppress the rhythm problem such as beta blockers or calcium channel blockers are commonly used. If the heart has gone out of its normal rhythm, such as in atrial fibrillation, some people undergo an electrical cardioversion. This is where a short general anaesthetic or sedation is given, before passing a specially timed electric shock through the chest to ‘reset’ the heart rhythm back to normal.

Some patients require other therapies to treat arrhythmias, such as a catheter ablation procedure. A catheter ablation procedure can be done under local anaesthetic or under general anaesthetic. There are benefits to using general or local anaesthetic depending on the arrhythmia being treated, and this should be discussed with you Cardiologist. Small tubes are inserted in to the blood vessels at the top of the leg. This allows specialised catheters to be inserted through the small tubes from the leg vessels to the heart. Once the catheters are inside the heart, specialised electrical maps can be made. Sometimes it is necessary to try to bring the arrhythmia on, by using some carefully timed electrical impulses to get the arrhythmia going. This helps to identify what type of arrhythmia is causing the palpitations, and can be used to diagnose the problem and direct the ablation treatment to the problem area.

Catheter ablations is where an energy source is used to intentionally damage the heart tissue that is causing the arrhythmia. The two energy sources that are used are radiofrequency (heating) energy, or cryoablation (freezing) energy.