Can COVID-19 Infection Cause Heart Palpitations?
Yes, COVID-19 infection can definitively cause heart palpitations, both during acute infection and as a persistent symptom lasting weeks to months afterward. This is well-established in major cardiology guidelines and occurs through multiple cardiac mechanisms 1, 2.
Mechanisms and Clinical Context
Palpitations occur in COVID-19 through several pathways:
- Acute phase arrhythmias: Both atrial and ventricular arrhythmias are documented complications during active infection, driven by inflammatory cascades, direct myocardial injury, and cytokine surge 1
- Myocarditis and myocardial involvement: Cardiac inflammation can manifest with palpitations as a cardinal symptom, alongside chest pain, dyspnea, and syncope 2
- Post-Acute Sequelae (Long COVID): Palpitations are explicitly recognized as a common long-term cardiovascular symptom in Post-Acute Sequelae of SARS-CoV-2 infection (PASC), persisting 4+ weeks after initial infection 1, 2
PASC-Cardiovascular Syndrome (PASC-CVS)
The 2022 ACC Expert Consensus specifically identifies palpitations as a common symptom in PASC-CVS, a condition where patients experience cardiovascular symptoms without objective evidence of structural heart disease on standard testing 2. This syndrome includes:
- Tachycardia and palpitations
- Exercise intolerance
- Postexertional malaise
- Chest pain
- Dyspnea
Research confirms that 28% of patients with mild initial COVID-19 reported palpitations at median 109 days post-infection, with 57% having persistent cardiac symptoms at nearly one year follow-up 3. The inflammatory cardiac involvement appears ongoing even in those with initially mild illness 3.
Risk Factors for Long-Term Palpitations
Specific risk factors predict who will develop persistent cardiovascular symptoms including palpitations 4:
- Anxiety and depression (OR 6.4)
- Elevated C-reactive protein (OR 1.009 per unit)
- Elevated D-dimer (OR 1.455)
- Elevated LDL-C (OR 1.78)
- Female gender 3
When to Evaluate Further
Cardiology consultation is recommended when palpitations occur with 2:
- Abnormal cardiac test results
- Known cardiovascular disease with new/worsening symptoms
- Documented cardiac complications during acute SARS-CoV-2 infection
- Persistent cardiopulmonary symptoms unexplained by other causes
Initial Testing Approach
For patients with palpitations and suspected PASC, the ACC recommends 2:
- Basic laboratory testing including cardiac troponin
- ECG
- Echocardiogram
- Ambulatory rhythm monitor (specifically for palpitations)
- Chest imaging (X-ray and/or CT)
- Pulmonary function tests
Management Strategies
For PASC-CVS patients with palpitations and tachycardia, the ACC provides specific treatment recommendations 2:
Non-pharmacological:
- Salt and fluid loading for symptomatic relief
- Recumbent/semi-recumbent exercise initially (rowing, swimming, cycling)
- Short duration exercise (5-10 minutes/day) with gradual increases
Pharmacological options (empiric use):
- Beta-blockers
- Nondihydropyridine calcium-channel blockers
- Ivabradine
- Fludrocortisone
- Midodrine
Critical Pitfalls to Avoid
Don't dismiss palpitations as anxiety alone: While anxiety is a risk factor, inflammatory cardiac involvement is documented even in asymptomatic patients 3
Don't assume normal troponin excludes cardiac involvement: PASC-CVS commonly presents with normal biomarkers but real symptoms 2
Consider arrhythmia monitoring: Palpitations may represent inappropriate sinus tachycardia, postural orthostatic tachycardia syndrome (POTS), or atrial arrhythmias—all documented PASC complications 1, 2
Screen for serious arrhythmias: While rare, ventricular tachycardia and high-degree AV block have been reported as COVID-19 cardiac manifestations 5, 6
The evidence is unequivocal: palpitations are a recognized acute and long-term cardiovascular complication of COVID-19, affecting patients across the severity spectrum from asymptomatic infection to severe disease 1, 3, 7.