Heart Palpitations: When to See a Cardiologist

Heart palpitations are one of the most common reasons patients come to see me at Victoria Medical. That fluttering, racing, or thumping sensation in your chest can feel alarming — and in my experience, the anxiety it produces is often as distressing as the symptom itself. Most of the time, palpitations are benign. But some are not, and knowing the difference is exactly what a cardiologist is trained to do.

In over two decades of cardiology practice, I have assessed thousands of patients with palpitations. The majority leave reassured. A meaningful minority leave with a diagnosis that changes their management — and occasionally, their prognosis. This article explains what palpitations are, what causes them, and the specific symptoms that should prompt you to seek a specialist opinion rather than waiting to see whether they resolve on their own.

What Are Heart Palpitations?

A palpitation is an awareness of your own heartbeat. The heart beats approximately 100,000 times per day, and under normal circumstances you are entirely unaware of it. When something changes — the rate, the rhythm, or the force of contraction — the brain registers it as a sensation. Patients describe this variously as a flutter, a thud, a missed beat, a racing feeling, or a brief pause followed by a heavy thump.

The medical term covers a wide spectrum. A single ectopic beat — a premature contraction that briefly disrupts the normal rhythm — is the most common cause and is almost always harmless. At the other end of the spectrum, sustained ventricular tachycardia is a medical emergency. The clinical challenge is that both can feel identical to the patient experiencing them.

"The sensation of a palpitation tells you very little about its cause. That is why the clinical history, a 12-lead ECG, and often ambulatory monitoring are indispensable — not optional."

What Causes Palpitations?

The causes divide broadly into cardiac and non-cardiac. In a primary care setting, research shows that approximately 39% of patients investigated with Holter monitoring have a significant cardiac arrhythmia identified — meaning the majority have a non-cardiac explanation2. That is reassuring, but it also means that more than one in three patients with palpitations do have a rhythm problem that warrants specialist management.

Non-Cardiac Causes

Anxiety is the single most common non-cardiac cause. A 2025 cross-sectional study of 304 patients undergoing Holter monitoring found that anxiety was significantly associated with self-reported cardiac symptoms — with an odds ratio of 9.2 for severe anxiety — even in the absence of any underlying arrhythmia1. This does not mean the symptoms are imagined. The physiological link between the autonomic nervous system and cardiac rhythm is real: anxiety drives sympathetic activation, which raises heart rate and can trigger ectopic beats.

Other common non-cardiac triggers include: caffeine and stimulant intake, dehydration, anaemia, thyroid dysfunction (both hypo- and hyperthyroidism), fever, alcohol, and certain medications including decongestants, beta-agonist inhalers, and some antidepressants. In women, hormonal fluctuations around the menstrual cycle, pregnancy, and the perimenopause are well-recognised precipitants.

Cardiac Causes

When palpitations have a cardiac origin, the most common findings on ambulatory monitoring are supraventricular ectopics (SVEs), ventricular ectopics (PVCs), supraventricular tachycardia (SVT), and atrial fibrillation (AF). AF is particularly important: it is the most common sustained arrhythmia, its incidence is rising globally, and it carries a five-fold increased risk of stroke if untreated4. Structural heart disease — including hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy (ARVC), and dilated cardiomyopathy — can also present with palpitations, sometimes as the first and only symptom before a more serious event9.

Red-Flag Symptoms: When to Act Immediately

Before discussing when to book a routine cardiology appointment, I want to be direct about the symptoms that require emergency care. Exercise-induced syncope — blacking out during physical activity — is a genuine red flag6. It can be the first clinical manifestation of ARVC, hypertrophic cardiomyopathy, or a primary arrhythmic disease, all of which carry a risk of sudden cardiac death in young people. If you or someone near you loses consciousness during exercise, call 999.

When Should You See a Cardiologist (Rather Than Your GP)?

Your GP is an excellent first port of call for palpitations, and in many cases a normal ECG and basic blood tests will provide sufficient reassurance. However, there are specific situations where a direct referral to a cardiologist — or self-referral to a private cardiologist — is the more appropriate pathway.

I see patients who have been reassured by a normal resting ECG but continue to have symptoms. The critical limitation of a standard 12-lead ECG is that it captures only 10 seconds of cardiac activity. If your arrhythmia is paroxysmal — meaning it comes and goes — a normal resting ECG tells you very little. A 24-hour or 7-day Holter monitor, or an event recorder worn for up to 14 days, is far more likely to capture the rhythm during a symptomatic episode37.

What Happens at a Private Cardiology Assessment?

When a patient comes to see me at Victoria Medical with palpitations, the consultation follows a structured but unhurried pathway. The clinical history is the most important part. I want to know exactly what the sensation feels like, when it starts, how long it lasts, whether there are any triggers, and whether it is associated with any other symptoms. I also take a full cardiac risk factor history, a medication review, and a family history.

A 12-lead ECG is performed at the appointment. If the resting ECG is normal and the history suggests paroxysmal arrhythmia, I will arrange ambulatory monitoring. At Victoria Medical, our on-site laboratory means that blood tests — including thyroid function, full blood count, electrolytes, and ferritin — are processed the same day, with results typically available within hours rather than days.

If the ECG or history suggests a structural abnormality, I will arrange an echocardiogram. This is a painless ultrasound scan of the heart that assesses the chambers, valves, and overall function. It can identify hypertrophic cardiomyopathy, dilated cardiomyopathy, and valve disease — all of which can cause palpitations and carry implications for treatment and risk stratification5.

Atrial Fibrillation: The Palpitation You Cannot Afford to Miss

Of all the arrhythmias that present as palpitations, atrial fibrillation deserves particular attention. AF is the most common sustained cardiac arrhythmia, affecting an estimated 1.4 million people in the UK. Its prevalence increases sharply with age — from under 1% in those under 60 to over 10% in those over 80. The 2023 ACC/AHA guidelines emphasise that AF is associated with a substantially increased risk of stroke, heart failure, and all-cause mortality, and that early detection and rhythm control significantly improve outcomes4.

Paroxysmal AF — where the arrhythmia comes and goes — is particularly easy to miss on a standard ECG. A patient may have an entirely normal ECG at their GP appointment and then go into AF that evening. This is why ambulatory monitoring is so important in patients with palpitations who have risk factors for AF: age over 65, hypertension, diabetes, obesity, obstructive sleep apnoea, or a history of heart disease.

Opportunistic pulse palpation and ECG screening in primary care has been studied as a detection strategy. A large cluster-randomised trial found that while opportunistic screening increased awareness, it did not significantly increase the detection rate of new AF compared with usual care — suggesting that symptom-driven investigation in patients who report palpitations remains the most efficient pathway10.

Smartwatches and Wearable ECGs: Useful, But Not a Substitute

I am frequently asked about smartwatch ECGs. Devices such as the Apple Watch, Withings ScanWatch, and Kardia Mobile can record a single-lead ECG and have been shown to detect AF with reasonable accuracy. A 2025 qualitative study found that patients found smartwatch monitoring more user-friendly than traditional Holter monitors, though they reported anxiety triggered by automated algorithm outputs and uncertainty about when to initiate recordings3.

My view is that consumer wearables are a useful adjunct — particularly for capturing a symptomatic episode that might otherwise be missed — but they are not a substitute for a formal clinical assessment. A single-lead ECG cannot diagnose many important arrhythmias, cannot assess cardiac structure, and cannot provide the contextual clinical interpretation that a cardiologist brings. If your smartwatch has flagged an irregular rhythm, bring the recording to your appointment. It is valuable data. But it is the beginning of the investigation, not the end.

Lifestyle Factors That Trigger or Worsen Palpitations

Even when palpitations have a benign cause, there is usually something driving them. In my practice, the most common modifiable triggers I identify are: excessive caffeine intake (including energy drinks, which can contain 150–300mg per can), alcohol — particularly binge drinking, which is a well-recognised trigger for paroxysmal AF ("holiday heart syndrome"), poor sleep, dehydration, and high psychological stress. Addressing these factors often produces a dramatic reduction in symptom frequency, even before any pharmacological treatment.

Magnesium deficiency is an underappreciated contributor. Magnesium plays a key role in cardiac electrophysiology, and low levels — common in people with poor dietary intake, those taking diuretics, or those with gastrointestinal conditions — can increase ectopic beat frequency. A simple serum magnesium test is part of my standard palpitation workup.

Frequently Asked Questions

References

1. Giolo RL et al. Is self-perception of cardiac symptoms related to the psychological profile of patients? Einstein, 2025.
2. Chiang LK et al. Holter Monitoring Defined Cardiac Arrhythmia Among Patients Presented with Palpitation in Primary Care, 2017.
3. Karregat EP et al. Patient experiences with a smartwatch 1L-ECG versus traditional Holter monitoring. BMJ Open, 2025.
4. Joglar JA et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation, 2023.
5. Tfelt-Hansen J et al. Risk stratification of sudden cardiac death: a review. Europace, 2023.
6. Dores H. Exercise-induced syncope: a real red flag! Rev Port Cardiol, 2022.
7. Kułach A et al. 24h Holter Monitoring and 14-Day Intermittent Patient-Activated Heart Rhythm Recording After Severe COVID-19. J Clin Med, 2025.
8. Marston H et al. Mobile Self-Monitoring ECG Devices to Diagnose Arrhythmia that Coincide with Palpitations: A Scoping Review. Healthcare, 2019.
9. Agbaedeng T et al. Incidence and predictors of sudden cardiac death in arrhythmogenic right ventricular cardiomyopathy: a pooled analysis. Europace, 2022.
10. Uittenbogaart S et al. Opportunistic screening versus usual care for detection of atrial fibrillation in primary care. BMJ, 2020.