Restless Leg Syndrome
Palpitations — a racing, fluttering, or irregular heartbeat sensation — are a common presentation with causes ranging from benign lifestyle triggers to significant arrhythmias. Specialist evaluation identifies the underlying cause and determines whether treatment is required.
Leg pain or heaviness can be an early sign of venous or circulation problems
Palpitations are the subjective awareness of the heartbeat — described as racing, fluttering, pounding, skipping, or irregular sensations in the chest, throat, or neck. They are one of the most common reasons for cardiology referral. While many palpitations are benign and related to lifestyle triggers, a significant proportion reflect underlying cardiac arrhythmias requiring investigation and treatment. Accurate clinical evaluation determines which patients need further workup and which can be safely reassured.
Causes
Palpitations arise from a broad spectrum of causes. Physiological triggers include caffeine, alcohol, nicotine, strenuous exercise, dehydration, and anxiety — all of which transiently increase sympathetic tone or alter cardiac conduction. Medical causes include cardiac arrhythmias — atrial fibrillation, SVT, ventricular ectopics, and ventricular tachycardia — as well as hyperthyroidism, anaemia, hypoglycaemia, and electrolyte disturbances. Certain medications — including beta-agonist inhalers, decongestants containing pseudoephedrine, and digoxin toxicity — can also provoke palpitations. Structural heart disease, including cardiomyopathy and valve disease, predisposes to arrhythmias that present as palpitations.
Features That Guide Diagnosis
The clinical character of palpitations provides important diagnostic information. Sudden-onset, regular rapid palpitations that start and stop abruptly suggest SVT. An irregular, sustained rapid rhythm is characteristic of atrial fibrillation. Isolated "skipped beats" or a brief thump followed by a pause are typical of premature atrial or ventricular contractions. Palpitations triggered by exertion raise concern for ventricular arrhythmias in structural heart disease. Palpitations associated with presyncope, syncope, or chest pain require urgent evaluation regardless of perceived severity.
When to Seek Urgent Assessment
Seek immediate emergency care — call 995 — if palpitations are accompanied by syncope (loss of consciousness), severe chest pain, breathlessness at rest, or haemodynamic instability. These features may indicate ventricular tachycardia, ventricular fibrillation, or a high-degree heart block. Urgent but non-emergency cardiology assessment is appropriate for new, frequent, or symptomatic palpitations — particularly in patients with known structural heart disease, a family history of sudden cardiac death, or prior arrhythmia.
Diagnosis
Evaluation begins with a detailed history characterising onset, duration, frequency, triggers, associated symptoms, and medication review. A resting 12-lead ECG captures arrhythmias present at the time of recording and may reveal pre-excitation (Wolff-Parkinson-White pattern), QT prolongation, or structural changes. For intermittent palpitations, ambulatory monitoring is essential: a 24–48 hour Holter monitor for frequent symptoms, a prolonged event recorder for weekly or less frequent episodes, and an implantable loop recorder (ILR) for rare or infrequent palpitations requiring months to years of monitoring. Echocardiography assesses for structural heart disease. Thyroid function, full blood count, and electrolytes exclude reversible metabolic causes.
Treatment
Treatment is directed at the underlying cause. Lifestyle modification — reducing caffeine and alcohol, managing stress, maintaining hydration, and correcting nutritional deficiencies — resolves palpitations in many patients with benign triggers. Cardiac arrhythmias are treated according to type and clinical significance: antiarrhythmic medications for rate or rhythm control, catheter ablation for SVT and selected ventricular arrhythmias, and ICD implantation for life-threatening ventricular arrhythmias. Vagal manoeuvres — including the Valsalva manoeuvre and carotid sinus massage — can terminate SVT acutely and are taught to selected patients for self-management of recurrent episodes. Metabolic and endocrine causes are corrected with targeted medical therapy.
Experiencing frequent or concerning palpitations in Singapore? Dr. Peter Chang consults at Paragon Medical Centre, Orchard Road. Book a specialist assessment today.