Heart palpitations from anxiety are the conscious awareness of the heartbeat, usually produced by increased force of contraction during the stress response and amplified by the brain monitoring the body for signs of trouble. Most are benign. The first time anyone has unexplained palpitations, a clinical evaluation is the appropriate step. Once cardiac causes are ruled out, the patterns described below typically apply.
Heart palpitations are one of the most alarming physical symptoms of anxiety, in part because they're difficult to ignore and in part because the heart is, by reputation, the organ no one wants to second-guess. Most palpitations associated with anxiety aren't dangerous in otherwise healthy people whose cardiac evaluation has been normal. A first episode of unexplained palpitations always warrants medical evaluation. The patterns described in this article apply once that evaluation is complete and reassuring. The first time they happen, a clinical workup is still the right step.
What palpitations are
A palpitation is the awareness of the heartbeat. Most of the time, the heart contracts without conscious notice. A palpitation can mean the heart skipped, fluttered, paused, pounded harder than usual, or simply became audible in a way it wasn't a moment earlier. The sensation doesn't necessarily correspond to anything unusual happening electrically. Often the rhythm is normal and the perception has changed.
A small percentage of palpitations represent benign extra beats: premature atrial or premature ventricular contractions. These are present in most adults at low frequency. Caffeine, alcohol, short sleep, dehydration, and anxiety all increase their rate. They aren't the same as an arrhythmia of clinical concern, and most aren't treated.
The different things palpitations actually feel like
Patients describe palpitations in several distinct ways, and the description matters because different sensations have different implications.
A pounding heartbeat that's hard to ignore. The heart feels louder than usual, sometimes audible through the chest wall, often more noticeable when lying down at night. This is usually increased force of contraction during sympathetic activation. It's the most common pattern in anxiety.
A skipped or flipped beat. A momentary pause followed by a more forceful beat. This is usually a premature atrial contraction (PAC) or premature ventricular contraction (PVC), extra beats that briefly disrupt the regular rhythm. Most adults have a small number of these every day without noticing. Caffeine, alcohol, short sleep, dehydration, and anxiety all increase the rate.
A run of fast, regular beats that starts and stops abruptly. This pattern can suggest a supraventricular tachycardia, which is benign in most cases but worth a cardiac workup if it recurs.
A racing, irregular beat. An irregular fast rhythm in someone over 40, or in someone with cardiac risk factors, should be evaluated for atrial fibrillation. This isn't in the typical pattern of anxiety palpitations.
Knowing which of these is happening is part of what a clinical evaluation is for. The single best tool is a workup that includes an EKG and, in some cases, an event monitor (a small wearable device that captures the heart rhythm during a symptomatic episode). These are common, fast, and well-covered by most insurance.
Why caffeine matters more than people expect
Caffeine is the most underrated driver of palpitations in adults who present with anxiety. Two specific reasons.
First, caffeine sensitivity varies widely by genetics. The CYP1A2 enzyme that metabolizes caffeine has fast and slow variants; a slow metabolizer who drinks the same amount as a friend will have substantially higher and longer-lasting circulating caffeine. Slow metabolizers often present with palpitations they have attributed entirely to anxiety.
Second, the cumulative dose matters. A morning coffee, a mid-morning second cup, a soda at lunch, a pre-workout supplement, and a late-afternoon tea can easily add up to 600 to 800 mg of caffeine, far above the 400 mg threshold most adults tolerate without effects.
A simple two-week experiment usually clarifies the role: reduce caffeine to under 200 mg daily (one small coffee) and track palpitation frequency. For many patients, the reduction alone halves the symptom.
The role of dehydration and sleep
Two other commonly missed contributors.
Dehydration concentrates blood volume and increases heart rate to maintain perfusion. Adults who present with palpitations often turn out to be drinking far less water than they think. A reasonable target is approximately 2 liters per day, more in heat or with exercise.
Short sleep reliably increases ectopic beats. The night after four hours of sleep, the next day's PAC rate climbs measurably. Combined with caffeine to compensate for fatigue, the effect compounds. Protecting sleep is one of the most effective non-medication interventions for recurring palpitations.
Why anxiety produces them
Sympathetic nervous system activation increases the force and rate of cardiac contraction. The heart beats harder, sometimes a little faster, and the chest wall becomes more sensitive to its own movement. The combination makes the heartbeat audible and felt in a way it normally isn't.
Once the heartbeat is noticeable, the anxious brain tends to monitor it. Monitoring keeps the activation going, which keeps the palpitations present. This is the same loop that maintains chest tightness and panic. The trigger may have been small, but the monitoring extends the symptom by hours.
When to get evaluated
A short version: the first time anyone has unexplained palpitations, an evaluation is the appropriate step. A primary care visit with an EKG is fast and usually reassuring either way. Pursue evaluation more urgently if palpitations occur with chest pain, shortness of breath at rest, fainting, or a family history of early cardiac events. These don't rule out anxiety, but they can't be assumed away.
Once a clinician has done a basic workup and found no structural heart disease, the patterns described here are usually the framework that fits.
What tends to help
Reduce the inputs that increase ectopic beats. For most people that means cutting caffeine intake meaningfully, protecting sleep, addressing alcohol use, and rehydrating. These changes alone often reduce palpitation frequency by half.
In the moment, the same approaches that help chest tightness work for palpitations: a long exhale, light movement, and a deliberate decision to stop checking the pulse. Checking the pulse is the most reliable way to extend the symptom.
If anxiety is the underlying driver, addressing the anxiety usually reduces the palpitations. CBT with an interoceptive exposure component is particularly well-suited to symptoms that get worse when the person notices them. SSRIs work over weeks and reduce the underlying reactivity that the loop runs on.
For a wider look at how anxiety shows up in the body and the mind, see the physical and mental anxiety symptoms most people miss on shrinkMD. (shrinkMD is part of The Shrink Network, founded by Shariq Refai, MD, MBA.)
Related: Chest tightness from anxiety · Why panic attacks end the way they do · Adrenaline