Don't miss a beat

Palpitations, although usually innocuous, can be the early warning sign of a problem that needs to be treated so you can resume your joy of flying.  

Everyone knows that old familiar fluttering feeling in his or her chest. We sometimes assume the worst, but don’t jump to conclusions too fast, as most of these feelings are totally innocent and a lot of the sensations of a “missed beat” are not even coming from the heart itself. Other causes of these sensations can come from the esophagus, diaphragm, or stomach. All that said, it’s still not a feeling that should be ignored, especially if you find yourself piloting an airplane when it comes on. Physicians call a change in your heart rhythm a “cardiac arrhythmia” and the sensation we feel is “palpitations.” 

A little background on how your heart beats, both normally and abnormally, goes a long way to understand if anything you are feeling is serious. The heart has two small collection chambers, the atria; and two large pumping chambers, the ventricles; and irregular rhythms can originate in any chamber. Electrical activity starts in a little bunch of nerves in the right atrium that is connected to the nervous system by the vagus nerve from the brain. The vagus regulates heart rate, rhythm, and force based on current physical circumstances. The heart beats automatically, so even if the nerves are disconnected, electrolyte shifts in the heart cells themselves will keep the heart going so your heart really can’t totally stop unless there is a devastating event. Most irregular heart rhythms from the small atria are often fast and irregular and are associated with a pulse that you feel as “extra beats.” Many arrhythmias generated in the large ventricles do not push much blood out of the heart and are more commonly felt as “dropped beats.”

From a medical standpoint, it’s not possible to diagnose these issues yourself, whether you’re sitting by the fireplace or blowing holes in the sky. However, there are clues that you can collect during an episode that will help your doctor figure out which of the above possibilities is going on and if there is any cause for concern. 

Keep track of the circumstances, such as when the sensation started and how long it lasted, what you were doing when it started, and what, if anything, stopped the feeling. It’s important to go back a little in time because many very common things can cause benign cardiac arrhythmias. Stomach and esophageal spasm, over-the-counter cold medications, coffee or anything with caffeine – like soda – and lots of different spicy foods are all likely culprits. Therefore, your past activities over the last 12 hours or so need to be part of the log you present to your doctor to help make a diagnosis. There are a few other really important things to keep track of for your doctor to analyze. The most important is whether you had any symptoms such as chest pain, pressure, shortness of breath, dizziness, or vision changes during the episode. 

If you’re on the ground and have any symptoms with an episode of palpitations, call an ambulance and get to a hospital. A benefit of getting immediate medical attention is that the emergency medical technician will place a cardiac monitor on your chest and right away be able to see if the sensations are from your heart, and if so, if the rhythm is innocent or something more concerning. If you have the misfortune to be up in the air, your choices are more limited. The first thing to do is contact ATC and inform them of a possible medical emergency. If you really feel bad, declare an emergency and have ATC give you clear instructions to a safe landing. 

All pilots should fly with supplemental oxygen on board even if you’re in a normally aspirated low altitude airplane. Any pilot shop or pilot catalogue sells these set-ups for a minimal amount considering all the benefits. You can purchase small 2-liter booster oxygen canisters that slip into your pocket or console and a few puffs will immediately push your blood oxygen saturation up. Low blood oxygen concentration that we all know of as hypoxia is a very common cause of both innocuous and potentially dangerous cardiac arrhythmias. Applying an oxygen mask or a few inhalations of oxygen might just solve the hypoxic issue right there. (Another reason to carry a canister of oxygen is that you can always offer a few puffs to an airsick or nervous passenger.) Hopefully your head will clear quickly and you can then make the immediate decision to land at the closest airport. Don’t hesitate to declare an emergency because most likely you will have medical care waiting when you land. 

Other causes of palpitations are things like fatigue, stress, and catecholamine release. Also keep track of the feelings and stress levels associated with the onset of symptoms. Obviously getting yourself into a stressful situation in the air can only be solved by flying to safety, so make those decisions to get back into VMC or on the ground quickly.

A critically important symptom to keep track of and report to your physician is whether the sensations of your palpitations are regular or irregular. Having a feeling of an “extra beat” every two beats is different from a random, irregular sensation and a very important medical distinction.

Once you go for a complete medical evaluation for these symptoms it will start with a history and physical exam that emphasizes the importance of bringing all of the above information with you. Your doctor will do a 12 lead electrocardiogram to see how the beat of your heart looks in all four muscle chambers. Then you will likely get a 24-hour ECG called a “Holter monitor” to see if episodic symptoms are cardiac in nature and if so, hopefully the device will capture the change in your heart rhythm for diagnostic purposes. If nothing turns up, a provocative test will be done, a “stress test,” to see if the symptoms can be reproduced with exertion and linked to your heart. In addition, your physician will want to get a look at your heart with an ultrasound device called a “2D cardiac echo” to see the size and shape of your heart and the 4 valves between the chambers. This is done because abnormal heart rhythms caused by leaks (regurgitation) or narrowing (stenosis) of the valves or dilatation of one of the chambers can be detected.

No matter what the results, they may not necessarily disqualify your medical ticket. However, palpitations, although usually innocuous, can be the early warning sign of a problem that needs to be treated so you can resume your joy of flying.

Kenneth Stahl, MD, FACS
Kenneth Stahl, MD, FACS is an expert in principles of aviation safety and has adapted those lessons to healthcare and industry for maximizing patient safety and minimizing human error. He also writes and teaches pilot and patient safety principles and error avoidance. He is triple board-certified in cardiac surgery, trauma surgery/surgical critical care and general surgery. Dr. Stahl holds an active ATP certification and a 25-year member of the AOPA with thousands of hours as pilot in command in multiple airframes. He serves on the AOPA Board of Aviation Medical Advisors and is a published author with numerous peer reviewed journal and medical textbook contributions. Dr. Stahl practices surgery and is active in writing and industry consulting. He can be reached at [email protected].

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