Palpitations and Chest Pain: When It's the Heart and When It's Not
Your heart is pounding out of your chest. There's pain behind your sternum when you take a deep breath. It feels like your heart "skipped a beat." These symptoms are frightening — and rightly so, they deserve attention. But in most cases they are not caused by a dangerous heart condition. Let's look at when you can relax and when you need to act immediately.
Palpitations: When They're Normal and When They're Not
Palpitations are the sensation of your own heartbeat. Normally we don't notice it. When we start to notice it — that's a symptom worth evaluating.
When a fast heartbeat is normal:
- Physical exertion — the heart speeds up to deliver more oxygen to muscles
- Stress, fright, anxiety — adrenaline release accelerates the rhythm
- Caffeine, energy drinks, alcohol
- Elevated body temperature — each degree above normal increases heart rate by about 10 bpm
- Pregnancy — blood volume increases, the heart works harder
- Dehydration
When palpitations need evaluation:
- Occur at rest without an obvious trigger
- Accompanied by dizziness, near-fainting, or loss of consciousness
- Start and stop suddenly ("like a switch being flipped")
- Resting heart rate is consistently above 100 bpm
- Accompanied by chest pain or shortness of breath
Ectopic beats (extrasystoles) — extra heartbeats outside the normal rhythm — feel like a "skip," "flutter," "thud," or "flip" in the chest. Occasional ectopic beats in healthy people are normal and present in most individuals. If they are frequent, accompanied by other symptoms, or causing anxiety — an ECG and Holter monitor are worth doing.
Chest Pain: Heart, Lungs, Muscles, or Stress
Chest pain is the symptom that causes the most fear. Rightly so — it deserves evaluation. But it's important to understand that most chest pain is not cardiac in origin.
Features that suggest cardiac pain:
- Pressure, squeezing, or heaviness — "like a weight on the chest"
- Radiates to the left arm, shoulder, jaw, neck, or back
- Comes on with physical exertion and goes away with rest
- Lasts more than 15–20 minutes
- Accompanied by shortness of breath, sweating, nausea
Features that suggest non-cardiac pain:
- Pain with breathing or in a specific body position — more likely lungs or muscles
- Pain when pressing on the chest wall — muscular or costochondral (rib cartilage inflammation)
- Pain after eating, with heartburn — GERD (acid reflux)
- Sharp, stabbing, brief pain (seconds) — usually not cardiac
- Pain in a young person without risk factors, in a state of anxiety
Other causes of chest pain:
- Pleuritis — inflammation of the lung lining; pain worsens with breathing and coughing
- Pneumothorax — air in the pleural space; sudden sharp pain with shortness of breath — emergency
- Pulmonary embolism — chest pain with shortness of breath and rapid heartbeat — emergency
- Shingles — burning pain along a nerve path, followed by a rash
- Panic attack — chest pain with palpitations and fear of dying
Angina: Symptoms and How It Differs from a Heart Attack
Angina (angina pectoris) is chest pain caused by insufficient blood supply to the heart muscle. The cause is narrowing of the coronary arteries (the vessels that feed the heart) by atherosclerotic plaques.
Stable angina: pain occurs predictably — with a certain level of physical exertion or stress, lasts 5–15 minutes, and resolves with rest or nitroglycerin. This is a chronic condition requiring treatment, but not an emergency.
Unstable angina and heart attack:
- Pain occurs at rest or with minimal exertion
- Pain intensifies and does not resolve with nitroglycerin or rest
- Lasts more than 20–30 minutes
- Accompanied by sweating, nausea, shortness of breath, sense of impending doom
Unstable angina and heart attack are emergencies. Call emergency services immediately. Every minute of delay increases the area of heart muscle damage.
Important: in women, older adults, and people with diabetes, a heart attack may present atypically — without classic chest pain. Instead: weakness, nausea, abdominal pain, shortness of breath.
Panic Attack vs. Heart Attack
Panic attacks and heart attacks share very similar symptoms — which is why people having panic attacks often call emergency services. This is the right call: on a first episode, ruling out a cardiac cause is the correct approach.
Similarities: chest pain, rapid heartbeat, shortness of breath, sweating, fear of dying.
Features of a panic attack:
- Triggered by stress or occurs without an obvious cause, often in younger people
- Chest pain is sharp and stabbing, not pressing or crushing
- Intense fear, sense of unreality, numbness or tingling in the extremities
- Resolves on its own within 10–30 minutes
- ECG during the episode — normal or sinus tachycardia
Features of a heart attack:
- Crushing pressure radiating to the arm, jaw, or back
- Intensifies, does not resolve on its own
- More common in people over 40–50 with risk factors (smoking, hypertension, diabetes, high cholesterol)
If you're unsure — call emergency services. A false alarm is better than a delayed response to a heart attack.
If you're concerned about cardiac symptoms, Symptomatica can help you evaluate them and understand how urgently you need care.
When to Call Emergency Services Immediately
Don't wait — call emergency services for:
- Crushing or squeezing chest pain, especially radiating to the arm, jaw, or back
- Chest pain with shortness of breath, sweating, or nausea
- Sudden severe shortness of breath at rest
- Loss of consciousness or near-fainting with chest pain
- Very rapid pulse (over 150 bpm) with dizziness
- Chest pain in someone with known heart disease
Frequently Asked Questions
My heart "skipped a beat" — what is that?
The sensation of a "skipped beat" is almost always an ectopic beat (extrasystole). After the extra beat comes a compensatory pause, which feels like a "drop." Then the heart contracts more forcefully — felt as a "thud." Occasional ectopic beats in healthy people are completely normal. If they are frequent, accompanied by dizziness or shortness of breath — get an ECG.
Chest pain when breathing in — is that the heart?
Pain that worsens with a deep breath is usually not cardiac. Cardiac pain typically does not change with breathing. Pain on inhalation more often points to pleuritis (lung lining inflammation), costochondritis (rib cartilage inflammation), muscle pain, or — less commonly — pulmonary embolism. If breathing-related chest pain comes with shortness of breath and a rapid heartbeat, seek urgent care.
Why does my heart race after eating?
A mild increase in heart rate after eating is a normal response. After a meal, blood is redirected to the digestive organs and the heart compensates by beating faster. This is usually insignificant. Pronounced tachycardia after eating can occur with postural tachycardia syndrome (POTS), dumping syndrome after stomach surgery, or hypoglycemia. If it happens regularly, see a doctor.
Can I exercise with ectopic beats?
It depends on the type of ectopic beats and whether there are structural heart changes. Isolated supraventricular ectopic beats in a structurally normal heart are generally safe to exercise with. For ventricular ectopic beats — especially if they increase with exertion — a cardiologist consultation and an exercise stress test (treadmill or cycle ergometer) are recommended before resuming intense training.
Is angina already a pre-heart-attack condition?
Stable angina is a chronic coronary artery disease, not a pre-heart-attack state. With proper treatment (medications, lifestyle changes, sometimes stenting), people with angina live long lives. Unstable angina — when pain occurs at rest or is escalating — is an acute coronary syndrome requiring emergency care.
I developed palpitations after COVID-19 — what should I do?
Post-COVID syndrome frequently includes tachycardia and palpitations. One cause is postural tachycardia syndrome (POTS): the heart rate surges sharply when standing up. Another is myocarditis (inflammation of the heart muscle). For palpitations after COVID-19, see a cardiologist: get an ECG, Holter monitor, echocardiogram, and a troponin blood test.
Symptomatica is an informational reference service. Not a medical service; does not diagnose or prescribe treatment. For any symptoms, please consult a doctor.