Ms. Tanmai (name changed), a 30-year-old teacher, visited my clinic with complaints of intermittent episodes of a racing heartbeat for the past 2 months. The incidents would occur and resolve spontaneously and last for 5 to 10 minutes each time. She was worried, as her mother had passed away from a heart attack at the age of 51. She wanted to know whether this raising of heartbeat has any relation to the heart attack of her mother.
Like this many times during my clinical practice, I come across mostly young individuals both sexes with a complaint of that they are able to feel loudly their heart beat “lubdub… lubdub…” Some say “gabhara” in the heart and unexplainable fear, anxiety, sweating, and nervousness. This phenomenon is medically called heart palpitations.
Heart palpitations are the sensation where the heart is skipping a beat, fluttering, pounding, racing, or beating too hard or loud, often felt in the chest, throat, or neck. While typically this is harmless and caused by stress or more coffee, tea (caffeine), it can indicate underlying cardiac issues if the frequency is more, or accompanied by symptoms like dizziness or fainting. They may feel like their heart is racing, beating too hard, and brief, they can also feel like a sudden flip-flop.
Recent studies in India indicate that palpitations are a frequently reported symptom, particularly in tertiary care cardiology settings, where they are often among the top reasons for consultation. While in many cases they are nonthreatening, a significant proportion are associated with underlying cardiac arrhythmias or psychological factors. For a general reader to understand that a cardiac arrhythmia is an abnormal, irregular, or faulty electrical heartbeat, causing the heart to beat too fast (tachycardia), more than a hundred beats per minute too slow (bradycardia), less than sixty beats per minute, or irregularly. These irregularities can result from damaged heart tissue or faulty electrical signals, manifesting as symptoms like palpitations, dizziness, or chest pain.
Prevalence
In clinical settings, palpitation is a common presenting complaint in cardiac clinics also in the clinics of general physicians. In some studies, it has been reported by over 55% of patients with cardiac rhythm disorders. A study on new-onset palpitations found that roughly 43.8% of cases were cardiac in origin (mostly arrhythmias), 35.4% were due to psychiatric causes (panic attacks/anxiety), and 20% were linked to other factors like anaemia or hyperthyroidism. A large 24-hour Holter monitoring study (2015-2023) in India found that 17.4% of patients (referred for symptoms like palpitations, giddiness, or syncope) were diagnosed with Atrial Fibrillation (AF).
Gen-Z group
Recent reports highlight a rise in arrhythmia-related palpitations among younger, urban populations (18-40 years) in India, linked to smoking, alcohol, and drug abuse, as well as the excessive drinking of coffee and tea, and also rising hypertension rates. Further psychiatric cause studies confirm that psychiatric factors, including panic disorders, play a major role in cases of benign palpitation, with some studies showing a high prevalence of mental distress in these patients.
According to the National Institutes of Health and recent trends and observations (2024-2026), a study of AF patients in central India identified palpitations as the most common presenting symptom, reported by 56% of patients. The 2024 study, a retrospective analysis of elderly Indian patients (65+ years) with puzzling symptoms, including palpitations, found a significant prevalence of arrhythmias, including atrial tachycardia. The underlying comorbidities, such as hypertension (50.8%), valvular heart disease (40.7%), and heart failure (25.9%) were frequently found in patients with symptomatic palpitations (specifically AF).
Causes of Palpitations in India
On a close analysis, cardiac causes, viz., arrhythmias (Atrial fibrillation, paroxysmal supraventricular tachycardia), rheumatic heart disease (RHD), and coronary artery disease (CAD) are major contributors. Coming to non-cardiac, particularly panic attacks, anxiety (35% in some studies), anaemia (6%), and hyperthyroidism (10%), as well as medication side effects. In some observational studies, fear of examinations, anxiety of failure or low marks in the examination are also causing considerable palpitations, though transient in some people.
Research in neighbouring countries
When we reviewed the studies in neighbouring countries, according to a publication in 2024 July in the Singapore Med Journal, palpitation is one of the most common symptoms in primary care, accounting for about 16% of the presenting complaints in general practice. In a cardiologist’s clinic, it is the second most common complaint after chest pain. A prospective cohort study by Weber and Kapoor identified underlying aetiologies in 84% of the 190 patients presenting with palpitations to a university medical centre’s emergency department, inpatient service or outpatient clinic, of which 43% were attributed to cardiac causes, 31% to anxiety or panic attack disorder, 6% to illicit drugs, prescription or over-the-counter medications, and the remaining 4% to non-cardiac medical causes.
Palpitations, while being relatively common, may sometimes be a cause of concern, as they can be a manifestation of life-threatening cardiac or noncardiac pathologies. Many patients who present with palpitations are concerned about an underlying cardiac cause. While certain diagnoses might be straightforward, some may prove challenging due to a myriad or paucity of accompanying symptoms. Nevertheless, studies have found palpitations to be associated with low mortality and cardiac morbidity in the outpatient setting. However, patients with persistent symptoms have higher psychological symptoms, role impairment, and healthcare utilisation. Therefore, the role of general practitioners and general physicians is to evaluate palpitations in a cost-effective and evidence-based manner, tease out potential serious and life-threatening causes to ensure the right siting of care, and control symptoms with appropriate therapy to reduce psychological burden and impairment of activities in patients.
Other conditions
As palpitations can be caused by a variety of conditions, it is critical to approach the symptom systematically. This section will outline the important diagnostic considerations in evaluating palpitations and key points in the clinical assessment. An indispensable component of the evaluation of palpitations is looking for a cardiac cause, which can arise from ischemia or an electrical conduction defect, which gives rise to dysrhythmias or structural abnormality. Dysrhythmias or abnormal rhythms could be either fast (tachydysrhythmias) or slow (bradydysrhythmias), which can either be regular or irregular, and can be better characterised with electrocardiography. The second important cause of palpitations is drugs and substances. Use of caffeine, tobacco, alcohol, or sympathomimetics is known to cause palpitations. Cessation of a sympatholytic, such as beta-blockers, can likewise cause palpitations.
The third group includes conditions that contribute to systemic stress, such as hypovolaemic state, pregnancy, anaemia, fever, sepsis, pulmonary embolism, electrolyte disturbances, and endocrinopathies. Important endocrine conditions include hypoglycaemia, hyperthyroidism, and neurological abnormalities that affect the autonomic nervous system may give rise to palpitations, such as vasovagal syndrome and postural orthostatic tachycardia syndrome (POTS). Lastly, psychological conditions, such as anxiety and panic attack disorders, are another common group of conditions accounting for palpitations in the general practice. Take away message to the readers is that if palpitations frequently and consistently transpire in any individual, they should consult a cardiologist for a systemic evaluation and to rule out hidden life-threatening illnesses.
