What Should You Do When You Feel Heart Palpitations?
Stay calm and sit or lie down. Try vagal maneuvers such as bearing down, splashing cold water on your face, or coughing forcefully. If palpitations are brief and occur in isolation without other symptoms, they are usually benign. Seek emergency care if palpitations last more than a few minutes with chest pain, dizziness, or fainting.
Vagal maneuvers stimulate the vagus nerve, which can slow the heart rate and terminate certain types of supraventricular tachycardia. The Valsalva maneuver — bearing down as if having a bowel movement for 10-15 seconds — is the most studied technique and can terminate SVT in up to 20-25% of cases. The modified Valsalva maneuver, where patients are laid supine with legs elevated immediately after straining, increases success rates to approximately 43% according to the REVERT trial published in The Lancet.
Document your palpitation episodes by noting when they occur, what you were doing, how long they last, and any associated symptoms. This information is invaluable for your doctor when determining whether further evaluation is needed. Many smartwatches and smartphone apps can now record a single-lead ECG during episodes, providing objective data about the heart rhythm that can guide clinical decision-making.
The modified Valsalva maneuver increases SVT termination success rates to approximately 43% according to the REVERT trial
What Causes Heart Palpitations?
The most common causes are premature ventricular contractions (PVCs) and premature atrial contractions (PACs), which occur in virtually all adults. Other causes include supraventricular tachycardia (SVT), atrial fibrillation, anxiety and panic attacks, thyroid disorders, anemia, caffeine, alcohol, and certain medications.
PVCs are extra heartbeats originating from the ventricles. They are extremely common — 24-hour Holter monitoring detects PVCs in up to 75% of healthy adults. Most people experience fewer than 1% PVC burden (percentage of total heartbeats), which is considered benign. However, PVC burdens exceeding 15-20% may lead to PVC-induced cardiomyopathy, a reversible form of heart failure. Catheter ablation of the PVC focus can cure this condition with success rates exceeding 80%.
Supraventricular tachycardia (SVT) refers to rapid heart rhythms originating above the ventricles, including AV nodal reentrant tachycardia (AVNRT), AV reentrant tachycardia (AVRT), and atrial tachycardia. SVT typically presents as sudden-onset rapid regular palpitations at rates of 150-250 bpm that end abruptly. AVNRT is the most common type, predominantly affecting young women. Catheter ablation is highly effective for SVT, with cure rates exceeding 95% and low complication rates.
How Are Heart Palpitations Treated?
Treatment depends on the underlying cause and severity. Benign palpitations from PVCs typically need only reassurance and trigger avoidance. SVT may be treated with vagal maneuvers, medications like adenosine or beta-blockers, or curative catheter ablation. Atrial fibrillation requires anticoagulation and rate or rhythm control.
For benign PVCs, the most important intervention is reassurance. Studies show that simply knowing PVCs are harmless significantly reduces symptom burden and anxiety. When treatment is needed for bothersome PVCs, beta-blockers (metoprolol, atenolol) and calcium channel blockers (diltiazem, verapamil) are first-line medications. For PVCs refractory to medication or with high burden (>15%), catheter ablation offers a curative option with success rates of 80-95% depending on the PVC origin.
For SVT, catheter ablation is often recommended as first-line therapy given its high cure rate (>95%) and low risk profile. Medications including beta-blockers, calcium channel blockers, and flecainide are alternatives for patients who prefer medical management or are not candidates for ablation. Acute SVT episodes can often be terminated with vagal maneuvers or intravenous adenosine in the emergency department.
What Lifestyle Changes Help Reduce Heart Palpitations?
Reduce caffeine and alcohol consumption, stay well-hydrated, manage stress through relaxation techniques, get 7-9 hours of sleep, exercise regularly at moderate intensity, and avoid known triggers. These lifestyle modifications can significantly reduce palpitation frequency in many patients.
Stress management is particularly important since anxiety and stress are among the most common palpitation triggers. Techniques including diaphragmatic breathing, progressive muscle relaxation, mindfulness meditation, and cognitive behavioral therapy have demonstrated effectiveness. Regular aerobic exercise at moderate intensity paradoxically reduces palpitation frequency by improving cardiac autonomic tone and reducing resting sympathetic activation. However, some individuals experience palpitations during intense exercise, and this pattern should be evaluated by a cardiologist.
Adequate hydration is often overlooked but important. Dehydration reduces blood volume, causing the heart to compensate with faster or irregular beats. Electrolyte imbalances, particularly low magnesium and potassium, can also trigger arrhythmias. Ensuring adequate intake of magnesium-rich foods (dark leafy greens, nuts, seeds) and potassium-rich foods (bananas, avocados, sweet potatoes) supports normal cardiac electrical function.
