One of the most common reasons individuals seek advice from their physician is the sensation of awareness of their own heartbeat or palpitations. All of us will be aware of our heartbeat from time to time, most commonly after exercise, when nervous, or perhaps when unwell with an infection. Understandably, these symptoms are worrying but it is important to remember that they are not always a feature of heart disease.

The term palpitation covers a wide range of heart rhythms including an awareness of a normal heart rhythm which may feel more forceful or slightly faster than normal. Other common symptoms include an awareness of an irregular heartbeat – either missed, skipping, dropped or uneven beats.

Less commonly there may be a sensation of a very fast heartbeat – either ‘fluttering’ or a sensation of the heart ‘racing’. There are different causes for these presentations, however, here we will concentrate on those associated with atrial fibrillation.

Although the awareness of a change in heart rhythm is a major feature of atrial fibrillation, a significant proportion of individuals may not be aware of any change in their heart’s rhythm. Instead, individuals might be either asymptomatic or experience other symptoms such as breathlessness, fatigue, chest discomfort or dizziness.

In the modern era of smart-watches and fitness trackers (or when attending a gym), you may have been alerted to a potential abnormality in the heart rhythm of which you were unaware.

This often causes great anxiety and it should be noted that these devices are not always accurate and have a low threshold for reporting abnormalities.


Palpitations in atrial fibrillation

The key feature of atrial fibrillation is that the heartbeat is irregular – the pause between each beat varies in an unpredictable fashion giving rise to the term ‘irregularly irregular’. You may be aware of this from a fluttering sensation or a feeling that the beats are uneven – with a particular awareness of stronger beats which occur in an erratic fashion. This sensation may be more evident when exercising or when resting in bed at night.

You or your doctor may be able to detect this irregularity when feeling your pulse. However, there are other causes of this sensation. For example, extra or ectopic beats which often make it difficult to make a definitive diagnosis without a recording of the heart (also known as an electrocardiogram – ECG) when symptoms arise. This may also be the case when the heart rate is particularly fast and might be impossible for you or your doctor to determine whether the rhythm is irregular from examination of the pulse alone.

Palpitations due to atrial fibrillation may be ‘persistent’. This means palpitations continue either for seven days or longer (often until medical intervention, such as cardioversion, is performed in order to put the heart back into a normal rhythm), or ‘paroxysmal’ occurs, meaning palpitations continue for a period before the heart spontaneously reverts to a normal rhythm.

Episodes of atrial fibrillation, particularly when the heart rate is fast may be very troublesome and disabling either because of the awareness of the rhythm alone or the associated symptoms of breathlessness, dizziness, blackouts, or chest pain. Such episodes require prompt medical intervention.

Awareness of the heart’s irregularity in patients with longstanding atrial fibrillation and ‘permanent’ heart rhythm may diminish over a period of weeks to months spontaneously or with the help of treatment to control the heart rate.

Visiting your doctor

Before visiting your doctor, it is useful to keep a diary of your symptoms particularly recording any associated features such as chest pain or breathlessness, their duration, and any precipitating causes (for example exercise, alcohol or caffeine).

Where the sensation of palpitations is continuous, a diagnosis can often be made with a resting ECG recording in the clinic. However, where the symptoms are intermittent and absent when you see your doctor, it may not be possible to make a definitive diagnosis this way.

The key to identifying the cause of palpitations is a heart tracing taken when experiencing symptoms. Therefore, you might be fitted with or given a recording device to document the ECG when you are symptomatic.

Where the symptoms are more infrequent a small monitor implanted under the skin (known as an Implantable Loop Recorder – ILR) may be required to monitor the heart rate for several years or until the symptoms recur.

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