What a Skipped Heartbeat Really Means
The feeling of a skipped heartbeat is rarely the sign of a serious illness. But some features of it need looking into. Which ones, and how the decision is reached.
A moment of emptiness in your chest, then one single forceful beat. The sensation people describe as a skipped heartbeat is one of the commonest reasons for a cardiology appointment. Most of the time it is not the sign of a serious illness. But some features of it do need looking into. This article explains which is which, and how the decision is reached.
What Is Actually Happening?
The heart normally works to a regular signal from its own internal clock, the sinus node. This is called sinus rhythm.
Sometimes a signal arrives out of turn from somewhere else in the heart, and the heart beats earlier than expected. That early beat is weak, because the chambers have not filled completely, and you usually do not feel it at all.
What you feel comes afterwards. Following the early beat the heart takes a short pause to gather itself; during that pause the chambers fill more than usual, and the next beat is stronger than you are used to.
So the sensation has two parts: a gap, then a thump. This is exactly what patients mean when they say “my heart stopped and started again” or “something fluttered in my chest”. The heart does not stop; its turn slips.
Ectopic Beats: The Medical Name for It
Ectopic beats — also written as premature or early beats, and as extrasystoles — are the name for these out-of-turn beats. The words all describe the same thing.
Everyone has them. Healthy people with no symptoms at all can have hundreds of early beats in a day, and that is expected. The difference lies in whether a person notices them; noticing them does not mean they are more dangerous.
There are two kinds, depending on where they start
Which abbreviation appears in your report matters, because the two are not the same thing:
Atrial (supraventricular) ectopic beats: The signal starts in the upper chambers, the atria. Reports write these as APB, APC or SVE. They are generally the more benign of the two.
Ventricular ectopic beats: The signal starts in the lower chambers, the ventricles. Reports write these as VPB, VPC or VE. The sensation people feel usually comes from these, because the pause that follows is longer.
Neither of them, on its own, means there is a disease. What matters is how often they come, where they start, and whether the structure of the heart is normal.
Is a Skipped Heartbeat Dangerous?
In most cases it is not. In people whose heart structure is normal and whose symptoms are infrequent and mild, ectopic beats are considered benign and need no treatment. Simply knowing this often reduces the symptom, because the anxiety a skipped beat creates makes the beats easier to notice.
Some features, however, do call for assessment.
When to see a doctor without delay
If fainting, or nearly fainting, goes with it. This finding should be assessed without delay.
If it comes with chest pain or breathlessness.
If instead of single skipped beats there is a sustained fast heartbeat. Episodes that start and stop abruptly and take the rate above 150 a minute at rest suggest something different.
If the episodes are becoming more frequent or lasting longer.
If you have a known heart condition. Where there has been a heart attack, heart failure or valve disease, ectopic beats are not viewed in the same way.
If anyone in your family died suddenly at a young age.
If exercise increases the beats rather than reducing them. Benign ectopic beats usually become less frequent with exertion.
If one of these applies to you, the sensation should not be waved away as something everybody has.
Everyday Things That Bring It On
How often ectopic beats come varies through the day, and most of the triggers have nothing to do with the heart itself:
Caffeine, nicotine and alcohol. Coffee, energy drinks and cigarettes are the three most often reported. Alcohol can still be having an effect the following day.
Poor sleep and tiredness. A few disturbed nights can increase the beats noticeably.
Anxiety and stress. Anxiety both increases the number of beats and makes the ones already there easier to notice.
Electrolyte disturbance. A low blood potassium or magnesium can increase ectopic beats. It is worth thinking of in people taking diuretics, and after prolonged diarrhoea or vomiting.
Thyroid disorder and anaemia. An overactive thyroid and a low blood count both speed the heart up and cause palpitations and skipped beats. Both show on a simple blood test and both are correctable causes.
Some medicines. Asthma inhalers, decongestant sprays and thyroid tablets can increase ectopic beats. This is why bringing a list of what you take to the appointment matters.
A large or late meal, and reflux. The number of patients who report that a full stomach sets the beats off is not a small one.
Noting for a week what time the beats come and what preceded them answers half the questions you will be asked at the appointment.
Recording the Beats: ECG and Rhythm Holter
The whole assessment rests on one thing: getting the beat on a recording. The description alone does not establish a diagnosis, because the same sensation can come from different sources.
An ECG (electrocardiogram) records the heart’s electrical activity over a few seconds. If an early beat happens to fall in those seconds, where it started can be seen.
A rhythm Holter is a portable device that makes the same recording continuously for 24 or 48 hours. Where episodes are infrequent, longer recorders or wearable rhythm monitors are used. While the device is on you are given a diary and asked to write down the time you felt the beats, because whoever reads the report will look at that time and match your sensation to the recording.
What if the ECG was normal?
A normal ECG does not rule out a rhythm disturbance. This is the point patients most often misunderstand.
An ECG shows only the few seconds during which it was recorded. Ectopic beats fluctuate through the day; there may be none in the morning and many in the evening. If no beat occurred during the recording, it looks entirely normal.
So if your symptoms are continuing, a normal ECG is not the end of the assessment but the beginning of it. The next step is a longer recording.
What does the number in your Holter report mean?
The report gives you two things: how many ectopic beats there were, and their proportion of the day’s total beats. That proportion is called the ectopic burden.
There is a reason the proportion is given. A heart beats on average around a hundred thousand times a day. The number in the report is a share of that total; read on its own, “2,000 ectopic beats” and “20,000 ectopic beats” both sound like “a lot”, and they are not the same thing.
The report also shows whether the beats start in the atria or the ventricles, whether they come singly or in runs, and how they are spread through the day.
At what level that proportion calls for a procedure is not decided by looking at a single number. The severity of your symptoms, where the beats start, the structure of your heart and its pump function are assessed together.
Why the Heart’s Pump Function Is Measured
This is the part most sources leave out, and it is the real reason ectopic beats are followed up.
An echocardiogram is an ultrasound picture of the heart. It shows the size of the chambers, the state of the valves and the strength of the heart’s contraction. In someone with ectopic beats it answers two questions: is there anything in the structure of the heart that explains them, and is the pump function normal?
The second question matters because of this: if ectopic beats continue at a very high proportion over a long period, the coordination of the heart’s contraction can be disturbed and the pump function can weaken over time. This is called arrhythmia-induced cardiomyopathy. It is uncommon, but what makes it important is that it can be reversible: when the ectopic beats are brought under control the pump function can recover.
For this reason the echocardiogram is repeated at intervals in people with frequent ectopic beats. The point of the follow-up is not the sensation itself but how the heart is carrying the load.
If Treatment Is Needed, What Are the Options?
Most ectopic beats need no treatment. When they do, the order is as follows.
Observation and daily routine
The first step is removing the correctable causes: cutting down caffeine and cigarettes, settling the sleep routine, correcting thyroid and blood results, replacing an electrolyte deficiency. Where the structure of the heart is normal and the burden is low, that is often all the treatment there is.
To be honest about it, these steps do not always remove the sensation completely. The aim is to bring the symptom down to a level you can live with and to avoid medicines you do not need.
Medicines
If the symptom is affecting daily life, beta blockers can be used. These medicines reduce the heart’s response to the signals; rather than abolishing the ectopic beats, they make them less frequent and less noticeable.
Stronger rhythm medicines are considered only in particular situations and with their side effects in mind. Which medicine suits you is decided by assessing your recordings and your other conditions.
When Does Ablation of Ectopic Beats Come Up?
Ablation of ectopic beats means finding the point in the heart the early beats come from and rendering it inactive with energy. It is not considered for every skipped beat; it comes up in these situations:
The beats are frequent and causing symptoms, and medicines are not giving an adequate response
Rhythm medicines cannot be used because of their side effects
Frequent ectopic beats have begun to affect the heart’s pump function
Recordings have shown that the beats come from a single focus
How well the procedure works depends on the focus being located correctly, and this is where three-dimensional mapping comes in: the point the early beat starts from is marked on a computer-generated map of the heart, and the catheter is guided to it. The detail of the method, how it is carried out and its risks are set out on that treatment page.
Where instead of single skipped beats there is a sustained irregular fast heartbeat, the assessment goes in a different direction and atrial fibrillation is looked for. The other methods are on the rhythm disorders and ablation page.
Skipped Beats, or a Panic Attack?
The two resemble each other and are often confused. The points that help tell them apart:
How it starts: An ectopic beat is a single beat; it happens and is over in an instant. In a panic attack the palpitation builds over minutes and carries on for a while.
What goes with it: In a panic attack there is sweating, trembling, tingling in the hands, a feeling of suffocation and intense fear alongside it.
The pattern: With an ectopic beat there is a stumble in the rhythm and a sense of a gap. In a panic attack the heart is fast but beating regularly.
Making this distinction from the description alone is not safe. The two can also be present in the same person, and it is right to see a rhythm recording before starting treatment for anxiety. The recording is made to rule out the heart, not to rule out anxiety.
Assessment of Skipped Beats and Rhythm in Antalya
Prof. Dr. Umuttan Doğan is a cardiologist working in interventional cardiology and electrophysiology. Assessment of rhythm disturbances and ablation procedures are carried out in the catheter laboratory at Antalya American Hospital.
If the sensation is continuing, you can be seen at the clinic in Konyaaltı with any ECG and Holter recordings you have, a list of the medicines you take and your blood results. You will find his background and contact details on their own pages.
Frequently Asked Questions
Is the feeling of a skipped heartbeat dangerous?
In people whose heart structure is normal and whose symptoms are mild, ectopic beats are usually benign and need no treatment. If fainting, chest pain or breathlessness goes with them, if you have a known heart condition, or if anyone in your family died suddenly at a young age, the assessment should be made without delay.
How many skipped beats a day is too many?
There is no single number. The Holter report gives the count of ectopic beats and their proportion of the day’s total beats; the decision is made by looking at that proportion together with the severity of your symptoms, where the beats start and your heart’s pump function. The same count may mean observation in someone with a normal heart and treatment in someone whose pump function is affected.
I have skipped beats but my ECG was normal — what should I do?
A normal ECG does not rule out a rhythm disturbance; it shows only the few seconds during which it was recorded. If your symptoms are continuing, the next step is a 24 to 48 hour rhythm Holter, or a longer recording where the episodes are infrequent. Noting the times you feel the beats while the device is on makes the recording easier to interpret.
Will the beats stop if I give up coffee and stress?
They may become less frequent, but it cannot be said that they will stop altogether. Caffeine, nicotine, alcohol, poor sleep and anxiety are triggers that increase ectopic beats, and correcting them eases the symptom in most people. Correctable causes such as thyroid disorder, anaemia and a low electrolyte level need looking for as well.
Should I take medicines for my skipped beats, or will I need ablation?
The order is usually this: removing the correctable causes, then beta blockers if needed, then ablation where there is no response or where medicines cannot be used. Ablation also comes up where frequent ectopic beats have begun to affect the heart’s pump function. Which of these suits you is decided by assessing your recordings and your symptoms.
The information on this page is for general guidance and does not replace a consultation. Decisions about diagnosis and treatment are made by your doctor after assessing your own situation.