When to go to the emergency department for heart palpitations

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Most people barely notice their hearts beating. And that’s natural. But any noticeable change in the heartbeat should be concerning. Heart palpitations can be a sign of a serious condition, but some heart palpitations are totally normal.

I describe the feeling of heart palpitations as the heart-pounding sensation you get after running up a flight of stairs. But for people with heart palpitations, that feeling could just show up while they’re sitting on the couch.

What are heart palpitations?

A heart palpitation is the feeling of the heart racing or pounding. Heart palpitations may feel like the heart is:

  • Beating irregularly
  • Beating too quickly
  • Beating too strongly
  • Skipping beats

We see one or two patients per day who are complaining of these or similar symptoms. Patients sometimes tell me they can see their shirts move because their hearts are beating so hard.

Most heart palpitations aren’t dangerous. But they can be signs of several serious heart conditions. Get help if you feel heart palpitations that don’t go away quickly on their own. We’ll work to find what’s causing palpitations and refer you to additional care from a cardiologist if necessary.

"Get help if you feel heart #palpitations that don’t go away quickly on their own." via @MedStarWHC

What causes heart palpitations?

Older adults are more likely to have medical conditions that can increase their likelihood of having palpitations. But heart palpitations can show up in people of any age.

Some of the heart conditions that can cause heart palpitations include:

  • Cardiac arrhythmia (an irregular heartbeat), including atrial fibrillation (also known as A-fib) and atrial flutter
  • Supraventricular tachycardia (SVT)
  • Premature atrial complexes (PACs)
  • Premature ventricular complexes (PVCs)
  • Tachycardia

Other issues that can cause heart palpitations include: 

  • Being dehydrated
  • Caffeine, nicotine or alcohol
  • Certain medications, including decongestants or inhalers for asthma
  • Hormonal fluctuations in women who are menstruating, pregnant or about to enter menopause
  • Problems with electrolytes, including low potassium levels
  • Strong feelings of anxiety, fear or stress, including panic attacks

Overactive thyroid, also known as hyperthyroidism, can throw off the heart’s normal rhythm, causing palpitations. This type of thyroid disorder is treatable with medications to slow the heart rate and treat the overactive thyroid.

Heart palpitations and anxiety

Heart palpitations sometimes can be caused by extreme anxiety, rather than a heart condition. That might lead to a patient needing treatment for a possible anxiety disorder from a psychiatrist.

But we still have to make sure patients are checked out by a cardiologist for any possible heart problems first. We do have some patients who have been diagnosed before with anxiety and know that’s what’s happening. For the majority of patients, however, we don’t want to label their condition as an anxiety attack before knowing for sure that there isn’t a heart problem we need to address.

When to get help for heart palpitations

Most people’s hearts beat between 60 and 100 times per minute. If you’re sitting down and feeling calm, your heart shouldn’t beat more than about 100 times per minute. A heartbeat that’s faster than this, also called tachycardia, is a reason to come to the emergency department and get checked out. We often see patients whose hearts are beating 160 beats per minute or more. The body can’t sustain that for long periods of time.

You also should get checked out if you feel like your heart’s beating irregularly. The heart should beat steadily, like a metronome. If you feel like it’s pausing or skipping beats, that could be a sign of an abnormal heartbeat, which can increase the risk of a stroke.

"You should get checked out if you feel like your heart’s beating irregularly." via @MedStarWHC

If a patient comes into the emergency department while the palpitations are going on, we may be able to provide medications to slow the heart rate or convert an abnormal heart rhythm to a normal one. In extreme cases where medications aren’t enough, we may need to do a cardioversion. That’s when we shock the heart so it can reset itself to a normal rhythm. Patients are sedated during this procedure so they do not feel the electrical shock.  

Further testing for heart palpitations

In most cases, we see patients in the emergency department whose palpitations have either gone away or aren’t critical by the time they arrive. Like a car problem that clears up when you visit the mechanic, this can be frustrating for patients.  

We reassure them that just because we don’t see an abnormal heart rhythm now doesn’t mean that they didn’t have one before. We check for any signs of damage or injury, and we may monitor patients for a few hours at the emergency department to see if they have another episode of palpitions, but there may not be enough time to capture an abnormal heart rhythm that comes and goes.  

We often refer patients who have had heart palpitations to a cardiologist in the MedStar Heart & Vascular Institute. For example, we might diagnose an abnormal heart rhythm in the emergency department, but it’s not something that needs emergency treatment. Or we might not see evidence of an abnormal heart rhythm, but we think the patient could benefit from additional monitoring to rule out possible heart problems.  

A cardiologist can provide patients with special monitoring equipment to examine the heart’s rhythm. There are two main types of monitoring equipment. A Holter monitor will record the heart’s rhythm continuously for a defined time limit (often 24-48 hours), while an event recorder will only record briefly when a patient has symptoms of palpitations and presses a record button. If this testing shows evidence of a heart condition, our cardiologists work with patients to create an effective treatment plan.  

A normal heartbeat is easy to take for granted. So when we feel heart palpitations, it can be very scary. But with quick medical attention and advanced monitoring, your heart can beat steadily for a long time to come.

Chair, Department of Emergency Medicine, MedStar Washington Hospital Center

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