Ectopic Beats (Skipped Heartbeats)
Ectopic Beats (Skipped Heartbeats): A Complete Patient Guide
Ectopic beats are extra or early heartbeats that interrupt the normal rhythm. They are commonly described as skipped beats, missed beats, thumps, flutters or a pause followed by a strong beat. They are among the most common reasons for palpitations and are usually harmless, occurring in most people at some point, often more noticeable at rest or at night.
There are two main types. Premature atrial contractions (PACs) arise in the upper chambers, and premature ventricular contractions (PVCs) arise in the lower chambers. The “skipped” feeling is not a missing beat: the early beat comes with little filling, so is weak, followed by a pause and then a forceful normal beat that you notice.
In a structurally normal heart, occasional ectopics are benign and need no treatment beyond reassurance. The assessment aims to confirm this, to measure how frequent they are (the ectopic “burden”), and to look for underlying heart disease, thyroid problems or other triggers. Very frequent ventricular ectopics, over about 10 to 15% of all beats, can occasionally weaken the heart and are treatable.
Ectopics are felt differently by different people, and many people do not notice them at all.
What ectopic beats feel like
A skipped beat or pause in the heartbeat
A thump, flip or flutter in the chest or throat
A forceful beat after a pause
Single beats, pairs or runs, often when sitting quietly or lying in bed
What tends to bring them on
Caffeine, alcohol, nicotine and energy drinks
Stress, anxiety, tiredness and poor sleep
Large meals, lying on the left side and hormonal changes
Symptoms that need attention
Ectopics with fainting, dizziness, chest pain or breathlessness
Ectopics that increase on exertion or come in long runs
A family history of sudden death or heart disease
Most ectopic beats occur in a healthy heart, but several factors make them more likely.
Common triggers
Caffeine, alcohol, nicotine and stimulant drugs
Stress, anxiety, lack of sleep and fatigue
Dehydration and low potassium or magnesium
Some medicines, such as decongestants, asthma inhalers and thyroid tablets
Medical causes
Overactive thyroid and anaemia
High blood pressure, coronary artery disease and previous heart attack
Valve disease, cardiomyopathy and heart failure
Sleep apnoea and chronic lung disease
Pregnancy and life stages
Ectopics are more noticeable in pregnancy, the menopause and with age, and they are common in athletes.
The aim is to confirm benign ectopics, measure their frequency and exclude underlying disease.
1. History and examination
Your cardiologist will ask about the pattern of your symptoms, triggers, other symptoms, medicines, caffeine and alcohol, and family history, and check your pulse, blood pressure and heart sounds.
2. ECG
A resting ECG may capture ectopics and also checks for conduction abnormalities, pre-excitation, long QT or signs of heart disease.
3. Holter monitoring
24 to 48-hour or longer monitoring counts the number of ectopic beats, shows their type and pattern, and excludes runs of dangerous rhythm. The percentage of beats that are ectopic is called the burden.
4. Blood tests and echocardiogram
Thyroid function, blood count, electrolytes and kidney function are checked. An echocardiogram looks at heart structure and function, particularly if ectopics are frequent or ventricular.
5. Exercise test and cardiac MRI
An exercise ECG shows whether ectopics disappear or increase with exercise, and cardiac MRI may be used when frequent ventricular ectopics suggest an underlying heart muscle problem.
For most people, treatment means reassurance and reducing triggers.
Reassurance and lifestyle
Explanation that ectopics in a normal heart are benign and do not shorten life
Cut back on caffeine, alcohol, nicotine and energy drinks
Improve sleep, manage stress, stay hydrated and exercise regularly
Medicines
Beta-blockers reduce awareness and frequency of ectopics when symptoms are troublesome
Calcium channel blockers (verapamil or diltiazem) or other rhythm medicines are alternatives for selected people
Catheter ablation
For very frequent ventricular ectopics (generally above 10 to 15% of beats) that cause symptoms or weaken the heart, catheter ablation can reduce or eliminate them, with a good chance of success in many people.
Treating underlying conditions
Treating thyroid disease, anaemia, sleep apnoea, heart failure or coronary disease reduces ectopics when they are secondary.
Do not be alarmed. Ectopics are normal, and focusing on them tends to make them seem worse.
Reduce triggers such as caffeine and alcohol, and see whether a particular trigger matters for you.
Keep active. Regular exercise often reduces awareness of ectopics. If they occur during exercise, discuss it with your doctor.
Sleep and stress: prioritise sleep and consider relaxation techniques or talking therapy if anxiety makes symptoms worse.
Smartwatches may flag ectopics as irregular rhythm. Share recordings with a clinician rather than relying on them.
Keep a symptom diary to help assessment.
Support is available from the Arrhythmia Alliance, the British Heart Foundation and the NHS.
- In a structurally normal heart, ectopic beats are benign and have an excellent outlook.
Symptoms often fluctuate, improving with reduced triggers and with time.
Frequent ventricular ectopics can, in a minority, weaken the heart (PVC-induced cardiomyopathy), which is usually reversible with treatment.
Ectopics associated with heart disease, inherited conditions or runs of ventricular tachycardia need specialist management.
Most people are reassured after assessment and notice them much less afterwards.
It is reasonable to have persistent skipped beats checked at least once.
Arrange an assessment if you have:
Skipped beats that are frequent, persistent or worrying you
Palpitations with dizziness, breathlessness or chest discomfort
Ectopics during exercise, or runs of fast beats
A history of heart disease, or a family history of sudden death or cardiomyopathy
An irregular pulse found on a smartwatch or home monitor
Usually reassuring if:
Ectopics are occasional, occur at rest or with clear triggers, disappear on exercise, and your examination and ECG are normal.
The following features need prompt assessment, ideally within days.
Red flags
Fainting or near-fainting with palpitations
Chest pain or breathlessness with the ectopics
Ectopics that increase with exertion or come in long runs
Very frequent ectopics (many thousands a day) or persistent symptoms
Family history of sudden death under 40 or inherited heart conditions
Known heart disease or heart failure
What to do
Arrange a consultation with an ECG, rhythm monitoring and an echocardiogram.
Palpitations with the following need emergency help.
Call 999 immediately if you have:
Chest pain lasting more than 15 minutes, or with sweating or breathlessness
Fainting or collapse
Severe breathlessness
A very fast heartbeat with feeling extremely unwell
Signs of a stroke: face drooping, arm weakness, slurred speech
If someone collapses
Call 999, start CPR if they are not breathing normally and use a defibrillator if available.
Ectopic beats are early or extra heartbeats, felt as skipped beats, thumps or flutters.
They are very common and usually harmless in a healthy heart.
Types are atrial (PACs) and ventricular (PVCs).
Triggers include caffeine, alcohol, stress, poor sleep and thyroid disease.
Assessment includes an ECG, Holter monitor, blood tests and echocardiogram.
The ectopic burden (percentage of beats) matters more than the sensation.
Treatment is reassurance, reducing triggers and, if needed, a beta-blocker or ablation.
Fainting, chest pain, exertional ectopics or a family history are red flags.
Guidelines and sources
This page follows current European guidance:
Zeppenfeld K et al. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. European Heart Journal 2022;43:3997-4126.
These are the questions patients most often ask about ectopic beats and skipped heartbeats.
What are ectopic beats?
Extra or early heartbeats that interrupt the normal rhythm, felt as a skipped beat, flutter or thump. They are very common and usually harmless.
Why does my heart skip a beat?
It is usually an early (ectopic) beat that is weak, followed by a pause and a strong normal beat. The beat is not really missing. Caffeine, stress and tiredness make them more likely.
Are ectopic beats dangerous?
Not in a healthy heart. They matter if they are very frequent, occur with heart disease, or come with fainting, chest pain or a family history of sudden death.
What is the difference between PACs and PVCs?
PACs arise in the upper chambers of the heart and PVCs in the lower chambers. Both are usually benign, and a monitor shows which you have.
Do ectopic beats need treatment?
Usually not. Reassurance and reducing triggers are enough. A beta-blocker may be used for troublesome symptoms, and ablation for very frequent ventricular ectopics.
What causes ectopic beats?
Caffeine, alcohol, nicotine, stress, poor sleep, thyroid overactivity, low potassium and some medicines. Heart disease can also cause them.
Can ectopic beats weaken the heart?
Very frequent ventricular ectopics, over roughly 10 to 15% of beats, can in a minority. This is usually reversible with treatment, which is why the ectopic burden is measured.
Can I exercise with ectopic beats?
Usually yes, if the heart is normal and ectopics settle with exercise. If they increase with exertion, or you feel unwell, check first with your doctor.
Can I have a private heart monitor for skipped beats?
Yes. A telephone, video or face-to-face consultation in Peterborough or Corby can assess your symptoms, with nationwide cardiac monitoring, ECG reporting and echocardiography arranged.
- Are my ectopics atrial or ventricular, and how frequent are they?
- Is my heart structurally normal?
- What triggers should I avoid?
- Do I need treatment, and what are the options?
- Could ablation help me?
- Is it safe to exercise?
- When should I be rechecked?
- Do I need a heart monitor to measure how many ectopic beats I have?
- Could caffeine, alcohol, stress, a thyroid problem or low potassium be contributing?
- Will they get worse, or affect my long-term heart health?
Normal rhythm compared with premature ventricular (PVC) and premature atrial (PAC) ectopic beats.
Image: YitzhakNat, NSR and Ectopic beats (PVC and PAC), Wikimedia Commons. Licensed under CC BY-SA 4.0.
ECG strip showing a premature ventricular contraction (arrow).
Image: James Heilman, MD, PVC10, Wikimedia Commons. Licensed under CC BY-SA 3.0.
What an ectopic beat looks like
Normal beat: the sinus node fires on time and the heart contracts in rhythm.
Ectopic beat: a beat arises early from another site, with weak output.
Compensatory pause: the next normal beat is delayed, then fills the heart more, producing a strong thump.
Burden: the proportion of all beats that are ectopic, measured with a monitor.
If you have skipped beats or palpitations, you may benefit from a telephone consultation or video consultation to discuss your symptoms in detail, or a face-to-face consultation in Peterborough or Corby for a more comprehensive assessment.
Investigations such as ECG, cardiac monitoring and echocardiography may be recommended.
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Medically reviewed by Dr Salam Salloum, Consultant Cardiologist. Last updated: . This page is for general information and does not replace personal medical advice.