Heart palpitations, the sensation of a fluttering, racing, or skipped heartbeat, are a widely reported symptom following an infection with SARS-CoV-2, the virus that causes COVID-19. This experience can occur during the acute illness or emerge weeks and months later as part of post-acute COVID-19 syndrome, commonly known as Long COVID. Understanding the biological processes involved and the necessary medical evaluation is important for those experiencing this post-viral phenomenon.
How Common Are Post-COVID Heart Palpitations?
Heart palpitations are a frequent long-term cardiovascular complaint during COVID-19 recovery. During the acute phase of the infection, a temporary high heart rate, or tachycardia, is common due to fever, inflammation, and stress on the body. These acute symptoms typically resolve as the infection clears.
The concern shifts to palpitations that persist or appear for the first time well after the initial illness has passed. Studies show that heart palpitations are one of the most frequent cardiovascular sequelae reported by individuals with post-acute COVID-19 syndrome. The estimated prevalence ranges significantly, with some studies finding that approximately 18% to 20% of patients report this symptom persisting for months after infection.
Biological Mechanisms Causing Heart Rhythm Changes
The underlying reasons for post-COVID heart palpitations are complex and involve a combination of systemic inflammation and a resulting imbalance in the nervous system. The body’s immune response to the SARS-CoV-2 virus often leads to a state of generalized inflammation, sometimes referred to as a cytokine storm in severe cases. This inflammatory response can directly affect cardiac tissue, causing irritation that may lead to electrical instability and abnormal heart rhythms. In rare, severe instances, this inflammation can manifest as myocarditis, which is the inflammation of the heart muscle itself.
A more frequent mechanism involves the disruption of the Autonomic Nervous System (ANS), a condition called dysautonomia. The ANS automatically regulates involuntary bodily functions, including heart rate, blood pressure, and breathing. Viral infections, like COVID-19, can trigger an autoimmune response where the body mistakenly attacks components of its own nervous system. This imbalance often results in an overactivation of the sympathetic nervous system, the “fight or flight” branch, which causes an inappropriately fast heart rate.
Postural Orthostatic Tachycardia Syndrome (POTS) is a specific form of dysautonomia increasingly recognized after COVID-19 infection. Patients with POTS experience an excessive increase in heart rate, typically 30 beats per minute or more, when moving from a lying or sitting position to standing. This happens because the nervous system fails to properly constrict blood vessels in the lower body upon standing, causing blood to pool and requiring the heart to race to compensate for the drop in blood pressure. The resulting rapid heart rate is felt as palpitations, often accompanied by dizziness and fatigue.
The virus may also exert direct effects on the cardiac system, though this is a less common theory for persistent palpitations in Long COVID. The SARS-CoV-2 virus is known to bind to ACE2 receptors, which are found on various cells, including those in the heart. This binding can potentially cause direct injury to the heart muscle cells or the endothelial cells lining the blood vessels, which may contribute to electrical instability and the development of arrhythmias.
When to Seek Medical Care and Diagnostic Testing
While many post-COVID palpitations are non-life-threatening, certain accompanying symptoms require immediate medical attention to rule out serious cardiac events. Symptoms such as chest pain or pressure, severe shortness of breath, fainting (syncope), or lightheadedness are considered “red flags.” Any new or worsening symptoms, especially in individuals with a pre-existing heart condition, should prompt an urgent consultation with a physician.
A physician will typically begin the diagnostic workup by taking a detailed medical history and performing a physical exam. Several non-invasive tests are commonly used to assess heart function and rhythm abnormalities. An Electrocardiogram (ECG or EKG) provides a snapshot of the heart’s electrical activity at rest to identify any immediate rhythm problems or signs of heart muscle strain.
To capture intermittent palpitations, doctors often use wearable heart monitors, such as Holter or Event monitors, which record the heart’s electrical activity over a period of 24 hours to 30 days. Blood tests are also performed to exclude other causes of palpitations, such as anemia, thyroid disorders, or electrolyte imbalances. An Echocardiogram, which uses sound waves to create images of the heart in motion, is used to check the heart’s structure and pumping function, helping to detect conditions like myocarditis.
Treatment Approaches and Recovery Outlook
Management of post-COVID palpitations is highly individualized and depends on the underlying cause identified through diagnostic testing. For patients where dysautonomia, particularly POTS, is the primary driver, treatment often focuses on non-pharmacological interventions to manage blood volume and circulation. This includes significantly increasing fluid intake, often to two to three liters per day, and increasing salt consumption to help the body retain that fluid and boost blood volume. Wearing compression garments on the lower body can also help reduce blood pooling in the legs when upright.
Medications may be prescribed to help regulate the heart rate and manage blood pressure. Beta-blockers are a common class of drugs used to slow the heart rate and reduce the severity of palpitations. Other medications, such as midodrine or fludrocortisone, may be used to help improve blood pressure or increase blood volume retention. These pharmaceutical interventions aim to bring the autonomic nervous system back into a more balanced state.
The recovery trajectory for post-COVID palpitations and associated dysautonomia can vary significantly among patients. For many, symptoms gradually improve and resolve over a period of several months to a year, especially with consistent management and lifestyle adjustments. Recovery can be prolonged for some individuals, requiring ongoing management and a multidisciplinary approach involving cardiologists and neurologists. Most patients eventually see improvement in their heart rate and overall quality of life.