Palpitations with anxiety: what they are, and what has to be excluded first

    A thud, then a pause, then a harder thud. Or a run of fast beats that arrive out of nowhere while you are sitting still. You have felt your own pulse more in the last month than in the previous decade.

    Do this now

    After the thump, two minutes

    2 minutes

    1. Sit down and take your hand off your pulse. Monitoring it makes the next few minutes longer.
    2. Mouth closed. Breathe in through the nose for four, out through the nose for eight.
    3. Two minutes, small and quiet. The long exhale is what slows the heart; a big inhale does not.
    4. Let the beats be there without counting them. Name three objects in the room instead.
    5. If it settles, carry on with what you were doing rather than sitting down for the afternoon.
    Run it with a timer

    What you are usually feeling

    Most benign palpitations are ectopic beats — an early beat from the atria or ventricles, followed by a compensatory pause, then a beat that feels unusually forceful because the ventricle had extra time to fill. So the classic "skipped beat then a thump" is one event, not two, and it is common in healthy hearts. Anxiety increases both their frequency and, much more, how much you notice them.

    The awareness half

    Anxiety raises adrenaline, which makes the heart beat harder as well as faster, and it sharply increases interoceptive attention — how much of your own internal state reaches consciousness. That combination means the same number of ectopics can go from unnoticed to dominating your day. Checking the pulse repeatedly strengthens the loop, which is why the practice above starts by taking your hand away.

    Why this page insists on being checked

    Because palpitations are one symptom where the breathing explanation must come second. Atrial fibrillation, supraventricular tachycardia, thyroid overactivity, anaemia and several medications all produce them, and some need treating. An ECG, bloods and — if episodes are brief — a wearable monitor settle the question. Breathing work is the right thing to do after that conversation, not instead of it.

    What changes it, over a week

    • This week

      Get an ECG and basic bloods if you have not. Everything else on this page assumes that has happened.

    • All day

      Mouth closed, breathing quiet. Over-breathing raises ectopic frequency and awareness both.

    • Twice a day, ten minutes

      Slow nasal breathing at in-four, out-eight. Lower arousal means fewer noticed beats.

    • Test the obvious

      Two weeks with less caffeine, less alcohol and more sleep, and keep a simple diary. Those three explain a large share of benign palpitations.

    When this is not a breathing pattern

    See a clinician — promptly, and before assuming any of this applies to you — if any of these describe you:

    • Palpitations with chest pain, breathlessness, fainting or near-fainting — seek urgent assessment
    • A sustained fast or irregular pulse rather than isolated beats, especially over 120 at rest
    • Palpitations during exertion rather than at rest
    • A family history of sudden cardiac death, cardiomyopathy or inherited heart rhythm conditions
    • Palpitations with weight loss, tremor or heat intolerance — ask about thyroid function

    This page is education, not medical advice, and no part of it is a diagnosis. Full disclaimer.

    Questions people ask

    Are palpitations from anxiety dangerous?
    Benign ectopic beats in a structurally normal heart are not, and they are very common. That sentence only applies once someone has established that the heart is structurally normal, which is why the first item in the week above is an ECG.
    Why do I notice them most at night?
    Lying still and quiet removes every competing sensation, and your pulse is suddenly the loudest thing in the room. Ectopics are also slightly more common at low heart rates, which is when you are resting.
    Does caffeine cause them?
    In many people, yes — along with alcohol, nicotine, dehydration and short sleep. A two-week test with a diary tells you far more about your own heart than any general answer.

    What this page is built on

    • — Raviele et al., 2011, Europace — EHRA position paper on the management of patients with palpitations
    • — Barsky et al., 1994, Archives of Internal Medicine — palpitations, anxiety and cardiac awareness
    • — Zaccaro et al., 2018, Frontiers in Human Neuroscience — respiratory modulation of heart rate and the exhale

    Named by author and year. The DOIs live in the journal.

    Put a number on it

    Most of what is on this page tracks one measurement: the Control Pause. It takes sixty seconds, needs no account, and it is the thing that tells you whether any of this is working.

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    Go deeper

    From the journal

    What the body is doing

    Chest, throat, gut, jaw, hands, head — the physical side of stress. All topics