Sensation of Feeling Heartbeat: Causes and Treatment
Palpitations (sensation of feeling your heartbeat) are most commonly benign and can be effectively managed by treating the underlying cause, with beta-blockers being the first-line treatment for symptomatic cases. 1
Definition and Clinical Presentation
Palpitations are defined as an unpleasant awareness of heartbeat, often described as:
- Heartbeat sensations that feel like pounding or racing
- Skipped beats or pauses
- Fluttering in the chest, throat, or neck
These sensations may be regular or irregular and can range from mild awareness to severely distressing symptoms.
Common Causes
Cardiac Causes
Arrhythmias:
- Sinus tachycardia (heart rate >100 bpm)
- Premature atrial or ventricular contractions (PACs/PVCs)
- Supraventricular tachycardia (SVT)
- Atrial fibrillation/flutter
- Ventricular tachycardia (less common but serious)
Structural Heart Disease:
- Valvular heart disease (particularly aortic stenosis or regurgitation)
- Cardiomyopathy
- Congenital heart defects
Non-Cardiac Causes
Physiological:
- Exercise or physical exertion
- Fever
- Anemia
- Dehydration
- Hyperthyroidism
- Hypoglycemia
Psychological:
- Anxiety or panic disorders
- Stress
- Enhanced cardioception (heightened awareness of normal heartbeat)
Stimulants and Medications:
- Caffeine
- Alcohol
- Nicotine
- Decongestants
- Beta-agonists (e.g., albuterol)
- Some antidepressants
- Illicit drugs (cocaine, amphetamines)
Diagnostic Approach
Initial Evaluation
- 12-lead ECG - Essential first test to identify baseline cardiac abnormalities 2
- Blood pressure measurement - To identify hypertension
- Basic laboratory tests - CBC, electrolytes, thyroid function tests
Further Testing Based on Symptoms
Ambulatory ECG monitoring:
- 24-48 hour Holter monitor for frequent symptoms
- Event recorder or loop recorder for infrequent symptoms (2 weeks)
- Implantable loop recorder for very infrequent but concerning symptoms
Echocardiography - Recommended to exclude structural heart disease, particularly in patients with sustained arrhythmias 1, 2
Treatment Approach
1. Treat Underlying Cause
- Correct reversible factors: Anemia, electrolyte abnormalities, thyroid dysfunction
- Discontinue or modify medications that may be causing palpitations
- Reduce or eliminate stimulants: Caffeine, alcohol, nicotine 2
2. Symptomatic Treatment
- Beta-blockers (e.g., metoprolol) - First-line treatment for symptomatic palpitations with a target heart rate of <100 bpm 1, 2
- Calcium channel blockers (diltiazem, verapamil) - Alternative for those who cannot tolerate beta-blockers 2
- Lifestyle modifications:
- Regular exercise
- Stress reduction techniques
- Adequate sleep
- Avoidance of triggers
3. Specific Treatments for Arrhythmias
- Sinus tachycardia: Treat underlying cause (fever, anemia, dehydration) 1
- SVT: Vagal maneuvers, adenosine, beta-blockers, calcium channel blockers; ablation for recurrent episodes 1
- Atrial fibrillation: Rate control, rhythm control, anticoagulation as appropriate
- Ventricular arrhythmias: Referral to cardiology/electrophysiology 1
When to Refer to Cardiology
- Palpitations with syncope or near-syncope
- Family history of sudden cardiac death
- Known structural heart disease
- ECG abnormalities
- Sustained arrhythmias
- Symptoms severely affecting quality of life despite initial management 2
Important Considerations
- Up to 16% of patients with palpitations may have no identifiable cause 3
- Palpitations are more common in individuals with lower body mass index, lower body fat percentage, and anxiety disorders 4
- The brain plays a significant role in the perception of heartbeats, with various areas activated during cardioception 4
- Palpitations without arrhythmias may respond to central alpha-2 agonists in some cases 4
Remember that while most palpitations are benign, they can occasionally signal serious underlying cardiac conditions that require prompt evaluation and treatment.