Palpitations: When to Seek Medical Assessment

Introduction

Palpitations are an unusual awareness of your heartbeat. They may feel like racing, pounding, fluttering or missed beats. They can occur during a normal rhythm, with extra beats or with an arrhythmia.

The sensation alone does not establish the diagnosis. Assessment aims to identify the rhythm during symptoms, look for underlying heart disease and determine whether urgent care is needed. [1]

When to seek emergency help

Seek emergency care if palpitations occur with chest pain, difficulty breathing, fainting or a feeling that you may faint.

In Qatar, call 999 for a medical emergency. Do not drive yourself or wait for a website enquiry to be answered. Do not delay seeking help to obtain a smartwatch recording.

If these warning symptoms have stopped, arrange urgent medical assessment. [8,9]

When to arrange prompt assessment

Recurrent or worsening episodes deserve medical review, particularly when they occur during exercise, affect daily activities or accompany known heart disease.

Tell your clinician about any family history of unexplained sudden death, inherited rhythm disorders or cardiomyopathy. Brief episodes are not automatically harmless; the clinical context matters more than duration alone. [1,4]

What can cause palpitations?

Possible causes include a normal but more noticeable heartbeat, premature atrial or ventricular beats, supraventricular tachycardia, atrial fibrillation or flutter, and less commonly ventricular arrhythmias.

Non-cardiac contributors include anaemia, thyroid disease, poor sleep, stress, alcohol, nicotine, stimulants and certain medicines. Symptoms should not automatically be attributed to anxiety without an appropriate assessment. [1]

What your clinician will ask

Useful details include:

• Whether episodes start and stop suddenly or gradually.

• Their frequency, duration and apparent regularity.

• Whether they occur at rest, with exertion or after a possible trigger.

• Associated chest discomfort, breathlessness, dizziness or fainting.

• Current medicines, supplements and stimulant use.

• Personal and family cardiac history.

An examination and a resting 12-lead ECG form part of the initial assessment. An ECG during an episode can be especially helpful. A normal ECG between episodes does not exclude an intermittent arrhythmia. [1,2]

Which additional tests may be needed?

Tests are selected according to the clinical findings; not everyone needs every investigation.

Blood tests may assess blood count, electrolytes, kidney function and thyroid function.

Echocardiography assesses cardiac structure and function when indicated, including suspected structural disease or an established arrhythmia requiring further evaluation.

Exercise testing may help when symptoms are exertional or an exercise-related arrhythmia or myocardial ischaemia is suspected.

Cardiac MRI, genetic assessment or an electrophysiology study are reserved for selected clinical situations rather than routine assessment of all palpitations. [1,3,4]

Choosing the right rhythm monitor

The aim is to correlate symptoms with an ECG recording.

• Daily symptoms: a 24–48-hour Holter may be appropriate.

• Less frequent symptoms: a longer continuous recording, patch monitor or external loop/event recorder may improve the chance of capturing an episode.

• Rare but concerning unexplained episodes: specialist assessment may include consideration of an implantable loop recorder, particularly when syncope is involved.

These are examples, not fixed rules. Device choice also depends on risk, episode duration and whether the person can activate a recorder.

Keep a symptom diary and use the event marker if instructed. A monitor that does not capture your usual symptoms may not settle the diagnosis. [2]

Can a smartwatch help?

A saved ECG recording from a compatible device can provide useful information for clinical review.

An optical pulse alert is not the same as an ECG diagnosis. Automated notifications can be incorrect, and a reassuring reading cannot exclude every important rhythm problem.

An initial diagnosis of atrial fibrillation requires clinician review of electrocardiographic evidence. Do not start anticoagulants or change heart medication based solely on a device notification. [5,6]

Palpitations during pregnancy

Pregnancy can increase awareness of the heartbeat, but persistent or recurrent palpitations should not simply be dismissed as normal.

Clinical assessment and ECG are important. The 2025 ESC pregnancy guideline supports a low threshold for longer-term rhythm monitoring when palpitations or syncope require investigation.

Symptoms accompanied by chest pain, breathlessness or fainting require urgent assessment. Medication decisions must account for pregnancy and breastfeeding. [7]

Related insight: Cardiovascular Disease in Pregnancy: Contemporary Cardio-Obstetric Assessment and Management.

How are palpitations treated?

Treatment follows the diagnosis rather than the sensation alone.

Some people need reassurance, management of contributing conditions and individualized advice about triggers. Others require rhythm-specific medication, catheter ablation or specialist follow-up.

If atrial fibrillation is confirmed, care also includes assessment of stroke risk and associated conditions. Anticoagulation is not a treatment for undiagnosed palpitations.

Do not stop prescribed medication or start an antiarrhythmic drug without medical advice. [1,3,4,5,6]

Preparing for your visit and follow-up

Bring your medication list, previous cardiac reports and any saved ECG recordings. Record the timing and circumstances of episodes.

Agree on how monitoring results will be communicated and what to do if symptoms recur. Seek reassessment if symptoms change or persist despite an initially reassuring evaluation. [1,2]