The medical term for the sensation of a fast or irregular heartbeat is “palpitations.” If you get palpitations and aren’t about to pass out, take your pulse (heart rate). First, get a timer or a clock with a second hand. Next, place your right index and middle fingers on the palm side of your left wrist, about an inch below the base of your thumb. (If you prefer, you can switch hands.) Then, count the number of beats in fifteen seconds, and multiply that number by four. That’s your pulse, in beats per minute.
A normal resting heart rate is between 60 and 100 beats per minute, though if you’re young and fit, it may be in the 50s. (If you’re a trained endurance athlete, it may be in the 40s or even 30s.) In response to exercise or a strong emotional reaction (like terror—boo!), your heart rate shouldn’t go above 220 minus your age. Under all circumstances, your heartbeat should be regular, though an extra or skipped beat every now and then is okay.
So is that pitter-patter in your chest a sign that you’re in love? That you’re a nervous wreck? Or that your ticker is crying out for emergency help?
Take a Chill Pill
You brought four venti coffees to work—but not to share. Caffeine stimulates the heart’s rhythm center, increasing the heart rate and the likelihood of extra beats. If extra caffeine wakes you up but also causes five-hour agony, try another solution for fatigue . . . like, uh, sleeping more! (See here for some tips.)
You’ve been taking Adderall to focus at work or school. Amphetamines like Adderall or Ritalin can increase focus and attention, but they also stimulate the heart’s rhythm center. Illegal amphetamines like crystal methamphetamine and MDMA (better known as ecstasy), as well as other stimulants like cocaine, have the same effect. If you’re using amphetamines prescribed by a doctor for an attention disorder but you get frequent and bothersome palpitations, ask about switching medications. If you’re getting these drugs from a less reputable source, like your college roommate, then the solution is pretty obvious. If you need help tapering off drugs, just speak to your doctor. As long as you do not pose an immediate risk to the welfare of others, or to your own life, a doctor is oath-bound to keep your problem private.
Your body contains two hearts. It’s normal to feel an increased heart rate during pregnancy. Although your baby obviously has his or her own heart, yours is doing all the heavy lifting. During pregnancy, your heart has to pump blood to the placenta, which provides food, water, and oxygen to your growing child. (Nowadays, this state of absolute dependency often continues well beyond the child’s thirtieth birthday.) To support both you and your junior passenger, your heart dilates and beats faster and harder. If you’re feeling frequent skipped or extra beats, however, or your heart is consistently racing above 100 beats per minute, see your obstetrician.
You used to take a beta blocker (like metoprolol/Toprol or atenolol/Tenormin), but your doctor just stopped it. Beta blockers slow down the heart rate by blocking receptors in the heart’s rhythm center. Over time, the cells grow new receptors to reduce the effects of the drug, sometimes necessitating a dose increase. After you pull the plug on the medication, those extra receptors leave the heart really sensitive to stimulation. It’s a better idea to gradually lower the dose of a beta blocker before stopping it, giving your heart time to adjust.
You’re taking cold or flu medicine. Many common over-the-counter cold and flu preparations contain stimulants, like pseudoephedrine or phenylephrine, which constrict the blood vessels in the nose to reduce mucous production. Unfortunately, they can also stimulate your heart, leading to palpitations, and raise your blood pressure. The effects stop as soon as you discontinue the medication. As an aside, pseudoephedrine is also famous because it is used to cook crystal methamphetamine. As a result, many states require proof of ID such as a driver’s license whenever you purchase cold or flu medications because sales of pseudoephedrine are limited. (Walter White ruined it for all of us . . . )
You’re a wheezer. Many of the inhalers for asthma and chronic obstructive pulmonary disease (COPD) contain a chemical known as a beta agonist, which stimulates the heart and can produce palpitations. If the symptoms are really bothersome, ask your doctor about switching to a different inhaler.
Make an Appointment
You feel frequent skipped or extra beats. Most of the time, extra beats (even frequent ones) are not a problem. If you get them only once or twice per day, there’s no cause for alarm.
If you get palpitations throughout the day, you’re probably still fine but should see your doctor for some tests. First, you’ll need an electrocardiogram (also known as an ECG or EKG), in which stickers are applied to your chest to capture the heart’s electrical signals. Next, you’ll need an ultrasound (a.k.a. an echocardiogram) to make sure your heart’s structure and function are normal. Finally, you’ll need blood tests to check for abnormal levels of electrolytes like calcium and magnesium.
If those tests all come back normal, you probably have nothing to worry about. If your palpitations continue to occur frequently, however, your doctor may order a Holter monitor (basically an ECG that you wear for twenty-four hours or more). If this shows that your extra beats are really, really frequent (tens of thousands per day), you’ll need a procedure known as an ablation to eliminate the source of the extra beats.
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Quick Consult
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Slow Heartbeat
As described earlier in this section, a normal heart rate is between 60 and 100 beats per minute, but athletes may have resting rates in the 40s or even 30s. If you have a slow heart rate, you’re probably okay as long as you feel fine and your blood pressure is normal.
If, on the other hand, your pulse is on the slow side (less than 50) and you feel lightheaded, like you’re about to pass out, the low heart rate is likely dropping your blood pressure. Lie down before you hurt yourself, then call an ambulance. If you don’t feel lightheaded right now but do have a low heart rate and a history of passing out (or feeling like you’re about to pass out), your pulse could be responsible. See your doctor, who will likely recommend a heart monitor.
The common fixable causes of slow heart rate include medication side effects, Lyme disease, sarcoidosis (an autoimmune disease), abnormal blood potassium levels, and brain disease. The medicines that cause low heart rate include beta blockers (metoprolol/Toprol, atenolol, carvedilol/Coreg) and calcium channel blockers (verapamil, diltiazem/Cardizem); if you take these and feel woozy, your dose is probably too high (or you took an extra pill by mistake).
If your doctors can’t find a fixable problem, they’ll likely recommend a pacemaker. This device monitors your heart rate and turns on whenever it drops below a certain level. By sending short, stimulating electrical jolts to the heart at regular intervals, the pacemaker ensures your pulse never drops below a certain level. It’s about the size of a silver dollar and sits just under the skin below your collarbone.
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The only other situation in which extra beats require treatment is when they are painful or bothersome. Sometimes, all you need to do is sleep more, cut out caffeine, and stop sweating the small stuff (and, as you know, it’s all small stuff). If you still get bothersome palpitations, your doctor may prescribe a beta blocker to help slow your heart.
You get frequent episodes of rapid heartbeat lasting for more than a few seconds. You need to get checked out. The first tests are usually an ECG, to check your heart’s resting rhythm; an echocardiogram, to check your heart’s structure and function; and blood tests, to ensure your electrolytes aren’t out of whack. You may also get a Holter monitor to capture and identify the heart rhythm causing your palpitations. (See the previous section for descriptions of these tests.) Based on the findings, your doctor may prescribe medications to prevent the abnormal rhythm or recommend an ablation procedure to burn (and therefore eliminate) the heart cells responsible for it.
You’ve been drinking a lot of booze. Every year around Christmas, we see people who hit the eggnog a bit too hard and
develop palpitations. The association is so common it was dubbed holiday heart. (Shockingly, this is not also the name of a Mariah Carey album.) You’ll need to see your doctor to check your heart rhythm and search for other causes of palpitations. Usually, your rhythm returns to normal once you’re back on the wagon. Of note, heavy alcohol drinking can also cause a more serious condition known as cardiomyopathy, in which the heart muscle becomes weakened. It’s okay to drink in moderation, but limit yourself to no more than one or two servings per day.
You constantly feel hot, have been losing weight, and feel shaky. Although you might not mind the weight loss, you should get checked for an overactive thyroid. The thyroid gland, a squishy organ on the front of your neck, helps regulate your metabolism. If it gets cranked up too high, you may develop tremor, diarrhea, weight loss, and heat intolerance (you’re always opening the window or turning on the air-conditioning). Your heart also gets overexcited and may go into an abnormal rhythm. Your doctor will need to figure out why your thyroid is overactive; usually, this consists of a few blood tests and an ultrasound. If you’re taking thyroid supplements, your dose is probably too high.
You have a history of stroke. If you get palpitations and have had a stroke, you may have a heart rhythm known as atrial fibrillation. This rhythm actually causes strokes, and may cause you to have another one if you ignore it. In atrial fibrillation, the top chambers of the heart (the atria, which collect blood), go into such a fast, disorganized rhythm that they no longer beat in sync with the bottom parts (the ventricles, which pump blood). Although blood still gets forced into the ventricles—which is good, since you’d otherwise die instantly—some blood may hang in the atria for a bit too long and coalesce into a clot. If that clot drops down to the left-sided ventricle, it can get pumped straight to the brain, block normal blood flow, and cause a stroke. As a result, most patients with atrial fibrillation need medications to thin their blood and reduce the likelihood of clots. Additional medications—known as beta blockers and calcium channel blockers—can also help slow down your heart rate.
You have a terrified feeling, like the world’s closing in. You’re probably suffering from panic attacks, which cause palpitations and an impending sense of doom. If these attacks occur often, you may have full-blown panic disorder. Your doctor can refer you to a psychiatrist to explore therapeutic and medical options.
You have a pacemaker. If you have a pacemaker, your heart is by definition abnormal, and your palpitations may be arising from whatever condition earned you the pacemaker in the first place. If, however, you get frequent extra beats associated with a full sensation in your neck, the pacemaker itself may be responsible. Ask your cardiologist to check it.
You get palpitations and/or chest pain when you exert yourself. You likely have blockages in your coronary arteries, which supply the heart muscle with blood. These blockages become most problematic when you exert yourself, since that’s when the heart muscle needs the most blood. The parts of the heart that aren’t getting enough blood generate pain and may start acting abnormally, triggering extra beats or abnormal rhythms. You should see your doctor pronto for a stress test (to check your heart’s function while you exercise). If you get chest pain often or while you’re not exerting yourself, head to the emergency room.
Get to the E.R.
You have palpitations and feel lightheaded, or you pass out. For the heart to pump blood to the rest of your organs, it needs enough time to fill up and generate a good squeeze. If your heart starts going really, really fast, it may not have enough time to complete this cycle, leading to a significant reduction in its output. If the heart’s output falls so much that your blood pressure drops, you’ll feel lightheaded and may even pass out. Low blood pressure can cause permanent organ damage. Call an ambulance. You may need an electrical shock to restart your heart’s rhythm and bring your blood pressure back to normal.
Your palpitations cause chest pain. As we mentioned previously, blockages in the coronary arteries can deprive parts of the heart of blood, causing pain and triggering abnormal heart rhythms. Unfortunately, those rhythms can get so fast and disruptive that they impair your heart’s pumping function. At this point, you enter a vicious cycle, because even less blood gets pumped to the coronary arteries, further depriving your heart of blood, and causing more abnormal heart rhythms. If you don’t get help fast, your heart may just throw in the towel and stop altogether.
Shortness of Breath
First of all, if you’re gasping for breath, put down this book and call an ambulance right now. (If you’re browsing at a bookstore, first buy this book and then call an ambulance. Just kidding.) If you don’t feel like death is imminent but have been feeling short of breath for a few days or weeks, read on.
As you likely know, air is important. Unless you’re a trained diver or David Blaine, your body can’t go for more than a minute or two without oxygen. (The world record for breath-holding is twenty-four minutes, but we strongly recommend a different hobby.)
When you take a breath, your lungs fill with oxygen. Blood picks up that oxygen as it passes through the lungs. The heart then pumps that oxygen-rich blood to every nook and cranny of your body.
Shortness of breath occurs when any part of this process breaks down: air doesn’t get into your lungs, your lungs don’t transfer oxygen to blood cells, your body doesn’t have enough blood cells to carry oxygen, or your heart doesn’t pump blood effectively.
If you experience new, sudden-onset shortness of breath, see a doctor right away. If you’ve slowly been getting more winded, you might wonder if you’re out of shape, getting older, or have an actual medical problem. Should you sit in front of a fan so you have more air to breathe? Pony up for a gym membership? Borrow your nephew’s inhaler? (Please don’t.) Or get checked out?
Take a Chill Pill
You recently started exercising and feel more winded than expected. Hit your breaking point on the elliptical before your friends even break a sweat? If you were previously a couch potato, working out may be harder than you thought. We applaud your efforts to become active, but you’re probably “deconditioned.” (That’s a medical term for “out of shape,” and it sounds a lot better when explaining your slowness to others.) As long as your breathing hasn’t been getting worse, and you don’t have any of the symptoms listed in the next section, just keep pushing yourself more each day. Before long you’ll have a six-pack under your shirt, rather than just in your fridge.
Make an Appointment
You get easily winded climbing stairs or walking uphill, but you feel fine at rest. The most common reason for shortness of breath with exertion is a low red blood cell count, a condition known as anemia. When your body is short on red blood cells, your heart struggles to deliver adequate oxygen to your muscles and organs. Anemia usually results from bleeding, though sometimes your body fails to make enough blood or destroys blood cells by mistake. In women, the most common cause of anemia is a few months of heavy periods (see here). In older adults, a dreaded possibility is colon cancer. A tumor can slowly bleed for weeks or even months without changing the appearance of your stool. Most adults with unexplained anemia have earned themselves a colonoscopy, a procedure in which a camera is snaked through the colon in search of tumors or other bleeding sources. Other causes of worsening shortness of breath with exertion include lung disease and heart disease. Your doctor can check for these conditions with an X-ray of your chest, an ultrasound of your heart, and possibly a stress test.
You have a fever and a cough. You may have pneumonia, a lung infection that jams up part of one or both lungs with mucus and pus, preventing blood from picking up oxygen. Some people also experience sharp pain with deep breathing. Your doctor can confirm the diagnosis with blood tests and a chest X-ray. If you can’t get a same-day appointment or feel really weak and lightheaded, just go to the emergency room. If you have pneumonia, you’ll need a week of antibiotics.
Your legs have gotten extra thick and squishy. If yo
ur legs seem swollen and easily indented by your socks, your body may be overloaded with extra fluid. This fluid can also flood the lungs and prevent the normal transfer of oxygen from air to blood. The major causes are heart failure (not pumping blood effectively, so fluid backs up everywhere) and kidney disease (can’t get rid of extra fluid in urine). Your doctor will order blood tests and an ultrasound of your heart. See also here.
You feel really short of breath when lying down, so you sleep with extra pillows to prop yourself up. Or you find yourself falling asleep in your armchair because you can’t get comfortable flat on your back. In either case, you may have heart failure. The heart can’t generate enough force to push blood forward, and when you lie down a sudden rush of blood toward the heart overwhelms it. The blood backs up in your lungs, causing shortness of breath. See your doctor for an urgent assessment, including an ultrasound of your heart. If your breathing is really labored, just go to the E.R.
You sometimes sound like you’re breathing through a dog whistle. If you occasionally notice yourself wheezing, you may have asthma or COPD. In both diseases, the airways between your mouth and lungs partially collapse, making it hard to get air in and out. As air rushes through the narrowed airways, it makes a high-pitched wheezing sound. The usual treatment is inhaled medication to open up the airways. If you’re wheezing for more than fifteen minutes and can’t catch your breath, get to an E.R.
You have been coughing for several weeks. A common cause of shortness of breath and long-standing cough is COPD. This condition frequently affects long-time smokers. As described above, it may also cause wheezing. Other potential explanations include simmering infections, like tuberculosis, which can cause several weeks of progressive symptoms; asthma, which is like COPD but is more common in young adults and people without a history of smoking; and lung cancer, which can irritate airways and partially block airflow. Your doctor will likely order an X-ray and/or CT scan of your lungs.
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