Ectopic heartbeats are early or extra beats that interrupt your heart’s normal rhythm. They usually feel like a skipped beat, a flutter, or a single heavy thump in the chest, often followed by a brief pause. They are very common, most people have them at some point, and in the large majority of cases they are harmless and do not damage the heart.

They are worth getting checked when they are frequent, when they come in runs, or when they appear alongside other symptoms such as dizziness, fainting, chest pain or breathlessness. A cardiologist can usually tell you within a few tests whether your heart is structurally healthy, which is the key question, and in most cases that answer brings real peace of mind.

What happens during an ectopic beat

Every normal heartbeat starts with an electrical signal from the sinus node, the heart’s natural pacemaker, in the right upper chamber. The signal travels in an orderly way through the atria and down into the ventricles, which then contract and pump blood around the body.

An ectopic beat happens when a signal fires early from somewhere else in the heart. If it starts in the upper chambers it is called an atrial ectopic, or premature atrial contraction. If it starts in the lower chambers it is a ventricular ectopic, or premature ventricular contraction.

The early beat often pumps very little blood, so you may not feel it at all. What many people notice is the next beat. After an ectopic, the heart often pauses briefly to reset, then delivers a stronger contraction because the chamber has had extra time to fill. That is the thump people describe. It is the reason ectopics so often feel as though the heart has stopped for a moment and then restarted.

What causes ectopic beats

In most people there is no underlying heart disease. Ectopics are simply more likely when the heart is more electrically irritable, and common triggers include the following.

• Caffeine from coffee, tea, energy drinks and some soft drinks
• Alcohol, particularly the morning after a heavy evening
• Smoking and nicotine products
• Stress, anxiety and adrenaline
• Lack of sleep and tiredness
• Strenuous exercise
• Hormonal changes, including pregnancy and the menopause
• Some medicines, including certain decongestants and asthma inhalers

Less commonly, frequent ectopics can be linked to an underlying problem such as a weakened heart muscle, a valve problem, a previous heart attack, an overactive thyroid or low potassium or magnesium levels. Finding or ruling out these causes is the main purpose of an assessment.

Why ectopics often feel worse at night

Many people notice ectopic beats most when they are lying still in bed or sitting quietly in the evening. There are two reasons. When the heart rate slows at rest, there is more time for an early beat to slip in between normal beats. And when there are fewer distractions, you are simply more aware of your heartbeat, particularly lying on your left side, where the heart sits closer to the chest wall.

We’ve found that this is one of the most reassuring things to explain to patients. Ectopics that appear at rest and fade during exercise are generally the benign type, because a faster heart rate tends to override them.

When ectopic beats need investigating

The NHS advises seeing your GP if palpitations keep coming back, are getting more frequent, last more than a few minutes, or if you have a heart condition or a family history of heart problems. A cardiology assessment is particularly worthwhile if any of the following apply.

• Your ectopics are very frequent, or come in pairs or runs of several beats in a row
• They increase during exercise rather than settling
• You feel dizzy, light-headed or faint with them
• You have chest pain or unexplained breathlessness
• There is a family history of sudden death at a young age or an inherited heart condition

Call 999 if palpitations come with chest pain, severe breathlessness, fainting, or if they do not stop.

How ectopic beats are diagnosed

Because ectopics come and go, a single ECG in clinic can easily miss them. The aim of testing is to capture them, count them, and check that the heart’s structure and function are normal.

• An ECG records the rhythm over a few seconds and can show ectopics if they happen during the recording, as well as other clues about the heart’s electrical system.
• A 24 hour ECG, often called a Holter monitor, records every heartbeat over a day and night. It shows how many ectopics you have, where they come from and whether they occur singly or in runs.
• A 7-day cardiac event recorder is useful when symptoms are less frequent, as it gives a longer window to match what you feel with what the heart is doing.
• An echocardiogram checks that the heart muscle and valves are healthy.
• An exercise stress test shows whether ectopics settle or increase with exertion.
• Blood tests check thyroid function and potassium and magnesium levels.

In our experience, a 24 hour ECG combined with an echocardiogram works better than a resting ECG alone for assessing ectopics because it shows both how often they happen and whether the heart itself is healthy. Those two answers together are what decide whether any treatment is needed. From working with patients over many years, we’ve found that a normal echocardiogram is the result that changes how people feel about their symptoms most of all.

How ectopic beats are treated

Most people with ectopic beats and a structurally normal heart do not need any treatment. Understanding what the sensation is, and knowing the heart is healthy, is often enough to make the beats far less troubling.

When treatment does help, it usually starts with the triggers.

• Cutting down or stopping caffeine for a few weeks to see if it makes a difference
• Reducing alcohol, particularly binge drinking
• Stopping smoking
• Improving sleep and managing stress
• Correcting low potassium, magnesium or thyroid problems if they are found

If ectopics remain frequent and troublesome, a cardiologist may suggest a beta blocker or another medicine to calm the heart’s electrical activity. For a small number of people with very frequent ventricular ectopics, particularly if they start to affect how well the heart pumps, catheter ablation can be used to target the area of heart muscle where the early beats begin.

Ectopic beats and anxiety

Ectopics and anxiety often feed each other, and many people first notice their heart palpitations during a stressful period. A skipped beat causes a jolt of worry, adrenaline rises, and the extra adrenaline makes more ectopics likely. Many people find themselves checking their pulse repeatedly, which keeps the cycle going.

From working with patients at our practice, we’ve found that a clear explanation and a set of normal results breaks this cycle more effectively than anything else. Once people know what they are feeling and that their heart is healthy, the beats often become less noticeable, even when the number of ectopics on a monitor has not changed much.

Getting your heart checked in Tunbridge Wells

At our Warwick Park practice, most of the tests used to investigate ectopic beats, including ECGs, 24 hour monitoring and echocardiograms, are carried out on site. Our consultant cardiologists have each worked in the Tunbridge Wells area for more than ten years and hold NHS posts locally and at King’s College Hospital, so the person reviewing your results is the same specialist who manages heart rhythm problems in the local NHS service.

Conclusion

Ectopic heartbeats are early or extra beats that feel like a skip, flutter or thump. They are very common and usually harmless, and they are often triggered by caffeine, alcohol, stress, tiredness or hormonal changes. They are worth investigating if they are frequent, come in runs, increase with exercise, or appear alongside dizziness, chest pain or breathlessness.

If ectopic beats are worrying you, West Kent Cardiology Partnership can arrange the right monitoring and a clear explanation of your results. Contact us or call 01892 526726 to book an appointment.