Palpitations and Skipped Beats: The Gentle Touch That Worries So Many

I see it in their faces in my office.  Concern, worry, even distress.  When they roll on their left side in bed, or when they are sitting quietly reading, or perhaps before a business presentation, they can feel their heart beat stronger, or faster, or with an irregularity or thud that startles them.  We need a diagnosis in medicine to provide the insurance carrier so we call these events palpitations. 


The Latin root is palpare or a gentle tap but in real life it may not be so gentle.  As palpitations cause a considerable amount of concern and lead to many office visits, a brief dive into heart beats is worthwhile.

How Does the Heart Beat?

In its optimal state, the top of the heart (atria) and the bottom of the heart (ventricles) beat in perfect synchrony about 50-90 times a minute at rest.  This organization is called sinus rhythm and provides optimal efficiency of pumping as the timing provides the maximal amount of blood ejected per heart beat.  This all starts at the top of the heart in the sinus node, travels to the middle of the heart, or the AV node, then the electrical wave-front moves on to cause the forceful contraction that ejects blood to the whole body. There are many ways that this ballet is altered.  The top of the heart can fire early causing a premature atrial contraction (PAC).  The bottom of the heart can also feel neglected and fire early creating a premature ventricular contraction (PVC).  These can occur in a single form and cause a thud in the chest but can also occur in multiples or runs, called atrial or ventricular tachycardia, the latter of which is often a marker of some serious underlying problem.  The last common problem I see is when the heart loses all organization of rhythm and quivers, or fibrillates like a bag of worms, creating atrial fibrillation or AFIB as heart doctors call it.  This is so common that it dominates my hospital and office practice.

Why are do Skipped Beats Occur?

            All of us have some premature beats at times.  Prolonged heart monitors placed on military recruits or medical students will identify a small number of skipped beats in the average person.  Sometimes apparently healthy persons even have every other beat as a skip, something called bigeminy, which can make the pulse heart to measure and cause worry that the heart rate is 30 when it is actually 60.  Although reassurance is all that is needed in many cases, a search for root causes is often worthwhile, particularly in people with medical issues, athletes, older individuals, and person with additional symptoms like dizziness, near blackouts, and shortness of breath. A simple list of considerations is whether there is high blood pressure, an overactive thyroid, lung disease such as emphysema, an electrolyte imbalance like a low potassium or magnesium level, poor sleep or sleep apnea, a valve disorder, or even silent heart damage.  Additional factors are anxiety and stress, excess alcohol or caffeine, and medications like inhalers for asthma and cold medications.  Of course, illicit drug use may be a factor.  A diet low in plants and vegetables is worthy of reviewing along with patterns of exercise such as ultra-exercise which is associated with a five-fold increased risk of AFIB.  Routine studies that may be needed include an electrocardiogram, blood work, extended heart monitoring often called Holter monitors, an echocardiogram ultrasound evaluation, and treadmill exercise testing.  In some cases, prescription medication, electrical therapies, and a procedure called ablation may manage or cure the more serious causes of palpitations.

When to See a Doctor?

You should see a doctor if you have known heart disease like a prior heart attack, have associated chest pain, shortness of breath, dizziness, blackouts, or the rare family that has young members that have died suddenly. 

Natural Approaches to Palpitations

In most others a brief period of natural healing is worthwhile. Avoiding offending medications and stimulants, improving sleep patterns, and managing stress with yoga, meditation or tai-chi are helpful.  The most helpful measure I offer patients after those approaches is to add magnesium as a supplement. The Western diet is shamefully low in magnesium due to a low intake of fruits, vegetables, nuts and seeds and the deterioration of soil quality with low magnesium content in many produce choices.  In fact, a red apple today has on average 80% less magnesium than an apple 80 years ago because of low soil content of magnesium and other minerals.  Consistently, organic produce grown by farmers more concerned with the environment have 4-5 times the amount of magnesium and other nutrients.

Be cautious taking extra magnesium if you have kidney disease but for most persons 250-500 mg a day of extra magnesium is very safe.  Most drug stores carry magnesium oxide which may work great if you are constipated but is poorly absorbed.  I tell patients to buy magnesium taurate, malate, glycinate or citrate which may require a search at a dedicated vitamin shop.  Magnesium taurate works particularly well taken at night as it may stop palpitations, improve bowel regularity, relieve migraines, help PMS, and provide a restful nights’ sleep.  Coenzyme Q10, also called coQ10, is another helpful natural supplement that is effective alone or combined with magnesium. 

Correct the Root Cause of Palpitations

There is nothing new about palpitations and even the ancient Song of Songs reflects that “you have made my heart beat faster with a single glance of your eyes”.   You do not need to see a doctor for love related racings!  However, in other settings, take a breath, take your pulse, and consider if you have an easily correctable cause of heart racing.  An Apple Watch or a Kardia heart monitor can help define the cause of the palpitations. A 48 hour or 2 week heart monitor (offered at the Kahn Center) can define the cause of the symptoms. A sleep study may identify disordered sleep that can be treated and resolve the palpitations. Excess alcohol and caffeine are considerations. An echocardiogram to examine heart structure is often a good idea.


Dr. Joel Kahn

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