How do doctors test for heart palpitations?

Heart palpitations are abnormal fluttering or pounding in the chest that some people describe as feeling like their heart is skipping beats or beating too hard or too fast. There are many potential causes of palpitations, ranging from benign to serious conditions. Doctors use various tests to determine the cause and evaluate the severity of palpitations. Commonly used diagnostic tests include electrocardiograms (EKGs), Holter monitoring, echocardiograms, blood tests, exercise stress tests, and cardiac event monitors. The specific tests recommended depend on the individual’s symptoms, medical history, and examination findings. An accurate diagnosis is important to guide effective treatment.

Symptoms of Heart Palpitations

The main symptom of palpitations is an abnormal awareness of the heartbeat, described by patients as:

  • Fluttering in the chest
  • Racing or accelerated heart rate
  • Pounding sensation
  • Skipped beats or missed beats
  • Extra beats or doubled beats

Episodes of palpitations may last for a few seconds or much longer. They can occur infrequently or multiple times per day. Palpitations often start and stop suddenly. Many people experience them at night when lying down or during times of stress or exertion.

Palpitations are sometimes accompanied by other symptoms, including:

  • Chest discomfort or pain
  • Shortness of breath
  • Dizziness or lightheadedness
  • Fainting or near fainting
  • Anxiety

When palpitations are associated with symptoms like chest pain, fainting, or shortness of breath, prompt medical evaluation is recommended.

Causes of Heart Palpitations

There are many possible causes of palpitations, including:

Benign Causes

  • Caffeine, nicotine, alcohol, stimulant medications
  • Anxiety, stress, panic attacks
  • Fever, anemia, thyroid disorders, electrolyte imbalances
  • Pregnancy
  • Some prescription medications

For otherwise healthy people, benign causes are the most common reasons for palpitations. Avoiding triggers like caffeine, managing stress, staying hydrated, and regulating hormones or thyroid levels may alleviate palpitations.

Heart Rhythm Disorders

Abnormalities in the heart’s electrical system can cause various types of arrhythmias, which are the most common heart-related cause of palpitations. Examples include:

  • Premature ventricular contractions (PVCs)
  • Premature atrial contractions (PACs)
  • Supraventricular tachycardia (SVT)
  • Atrial fibrillation
  • Ventricular tachycardia

Certain arrhythmias like atrial fibrillation increase the risk of stroke and heart failure if left untreated. Antiarrhythmic medications or procedures like cardioversion or catheter ablation can often treat problematic rhythm disorders.

Structural Heart Problems

Structural abnormalities in the heart’s valves, chambers, or vessels can sometimes produce palpitations, for example:

  • Heart valve disorders like mitral valve prolapse
  • Congenital heart defects
  • Enlarged heart chambers (ventricles or atria)
  • Coronary artery disease

Structural problems may warrant medications, surgery, or device implantation to repair or replace damaged heart structures.

Other Serious Causes

More serious but rare causes of palpitations include:

  • Heart failure
  • Cardiomyopathy
  • Heart infection (myocarditis or endocarditis)
  • Certain medications or drugs

These conditions often produce other telling symptoms beyond just palpitations. Identifying and treating the underlying problem is critical.

Doctor Examination for Palpitations

The first step in evaluating palpitations is a detailed medical history and physical examination by a doctor. Important points they will assess include:

  • Description of the palpitation symptoms – duration, frequency, triggers, associated symptoms
  • Past medical history – especially heart conditions, thyroid disorders, anemia, diabetes, lung disease
  • Medication use – prescription, over-the-counter, supplements, illicit drugs
  • Lifestyle factors – caffeine, tobacco, alcohol, exercise, diet, stress, sleep
  • Family history of heart problems, sudden cardiac death
  • Physical examination findings – irregular pulse, heart murmur, lung congestion

The medical history provides key clues to help determine potential causes and guide which tests are most appropriate.

Electrocardiogram (EKG)

An EKG (also called ECG) is a simple, painless test that measures the heart’s electrical activity through electrodes placed on the skin of the chest, arms, and legs. It allows doctors to evaluate:

  • Heart rate and rhythm
  • Abnormal rhythms like atrial fibrillation, ventricular tachycardia
  • Ischemia or prior heart attack
  • Enlarged heart chambers
  • Abnormal conduction patterns like bundle branch block

EKG changes provide useful clues to help determine the type of palpitations and guide further testing. But because standard EKGs only record a few seconds of heart activity, they may miss intermittent rhythm problems.

Holter Monitor

If palpitations occur infrequently, doctors may order a Holter monitor to capture the heart’s electrical activity over an extended time – usually 24 to 72 hours. This portable battery-operated device records a continuous EKG. Patients wear electrodes on their chest that are connected to a small recorder. They keep a diary of any symptoms experienced. The recorded data helps identify:

  • Heart rate and rhythm during daily activities
  • Any abnormal rhythms and how often they occur
  • Correlation between symptoms and arrhythmias

Holter monitoring often detects arrhythmias not present during a standard EKG. The results determine if problematic rhythms are causing bothersome palpitations.


An echocardiogram is an ultrasound of the heart’s structure and function. It can identify various structural causes of palpitations, such as:

  • Heart valve abnormalities
  • Enlarged heart chambers
  • Impaired heart pumping function
  • Congenital defects
  • Cardiac masses or blood clots

Visualizing the heart’s valves, chambers, wall motion, and great vessels helps clarify whether structural heart disease is producing symptoms. Echocardiography is painless and does not expose patients to radiation.

Blood Tests

Doctors may order blood tests to look for potential causes of palpitations or rule out associated medical conditions, including:

  • Complete blood count (anemia)
  • Thyroid function tests
  • Electrolyte panel (sodium, potassium, calcium)
  • Cardiac enzymes like troponin (heart attack)
  • BNP levels (heart failure)
  • Drug screens

Blood tests can provide objective evidence of abnormalities that may relate to palpitations. Testing also establishes a baseline for comparison if new symptoms develop down the road.

Exercise Stress Test

An exercise stress test monitors the heart rhythm, blood pressure, and EKG changes while a patient walks briskly on a treadmill or pedals a stationary bike. It can assess:

  • Blood flow to the heart
  • Heart rate and rhythm with exertion
  • Abnormal heart rhythms provoked by activity
  • Ischemia or chest pain with exercise

Because many people experience palpitations with physical exertion, exercise stress testing often causes related EKG changes or arrhythmias while closely monitored. The results help customize treatment to prevent activity-related symptoms.

Cardiac Event Monitors

If symptoms are sporadic over weeks or months, doctors may prescribe an ambulatory cardiac event monitor. These portable devices continuously record heart rhythms for 1 to 4 weeks or longer. Available options include:

  • External memory loop recorder – Automatically saves EKG data when activated
  • Autodetecting recorders – Detect and capture abnormal heart rhythms without patient intervention
  • Implantable loop recorder – Inserted under the skin to monitor rhythms up to 3 years

Event monitors increase the chance of correlating infrequent, random palpitations with arrhythmias detected on EKG. This confirms the cause and determines appropriate treatment.

Tilt Table Test

If palpitations are associated with dizziness or fainting, doctors may recommend a tilt table test. Patients lie flat on an exam table that is tilted upright at different angles while heart rate and blood pressure are monitored. The test evaluates the body’s response to positional changes. The results can diagnose:

  • Vasovagal syncope – Heart rate and blood pressure drop in response to standing
  • Orthostatic hypotension – Drop in blood pressure when going from lying to standing
  • Postural orthostatic tachycardia – Increase in heart rate of more than 30 beats per minute upon standing

These conditions sometimes cause palpitations and lightheadedness when standing up. Medications, compression garments, or pacemakers can help prevent associated symptoms.


Doctors use a combination of medical history, physical examination, EKGs, ambulatory heart monitoring, imaging, blood tests, and exercise or tilt assessments to evaluate heart palpitations. The testing approach is tailored for each patient based on their specific symptoms and health status. The results reveal whether palpitations are due to benign causes like stress or caffeine or related to arrhythmias, structural heart abnormalities, or other cardiovascular conditions needing treatment. Proper diagnosis guides effective management to relieve troubling palpitations.

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