Palpitations and anxiety: when fear of a heart attack takes over your life

Why we are discussing this this week

World Heart Day takes place every September 29. In 2026, the World Heart Federation is continuing its “Don’t Miss a Beat” campaign, focused on recognizing cardiovascular warning signs and improving prevention.

Supporting references: [2] World Heart Day.

Recognizing warning signs matters. But recognizing them does not mean monitoring every heartbeat all day.

On September 2, the American Medical Association addressed precisely this tension: devices can provide useful information and encourage healthy habits, although alerts, scores, and constant monitoring can also cause excessive worry in some people.

Supporting references: [3] AMA · Devices and health.

The answer is not choosing between looking after your heart and your mental health.

It is learning what information needs medical attention, what monitoring is indicated, and when checking has become part of the suffering.

What cardiophobia is

The term cardiophobia describes an intense, persistent fear of having heart disease, especially a heart attack.

The person may interpret bodily sensations as signs of danger, repeatedly seek reassurance, and avoid activities they believe could trigger a problem. The fear may continue despite a reassuring medical assessment and explanations.

Supporting references: [4] Cardiophobia.

This does not mean they are pretending.

The sensations can be real. So can the fear. What needs assessment is the relationship between those symptoms, their interpretation, and the behaviors used to try to stay safe.

Naming the fear also does not automatically settle the diagnosis. It may be necessary to distinguish health anxiety, panic attacks, other psychological difficulties, and coexisting medical problems.

Can anxiety cause palpitations?

Yes. Anxiety and stress can make heartbeats more noticeable and increase heart rate. Exercise, insufficient sleep, certain medications, caffeine, nicotine, alcohol, and other substances also play a role. Palpitations can have medical causes too, such as arrhythmias, anemia, or thyroid disorders.

Supporting references: [5] NHS · Palpitations.

The word palpitation describes a sensation; it does not, by itself, identify the cause.

A particularly distressing cycle can occur in panic: the heartbeat is noticed, interpreted as a threat, and fear further increases bodily arousal. The NIMH describes this mechanism as a possible part of the panic cycle.

Supporting references: [6] NIMH · Panic.

A simplified example would be:

“I notice a heartbeat” → “It could be a heart attack” → fear increases → I notice my body more → “This confirms that something is wrong.”

Understanding this cycle does not justify ruling out a cardiac cause without assessment. It helps recognize that, once the medical situation has been clarified, another mechanism may also need treatment.

Related reading: Panic attacks: assessment and treatment in Lleida and online.

“They told me everything is fine”: what that really means

A reassuring assessment has value. However, it is important to understand what was investigated, what was ruled out, and what follow-up was recommended.

An electrocardiogram records a specific period. When palpitations are intermittent and there is a clinical indication, the professional may consider ambulatory monitoring to relate symptoms to heart rhythm. The choice of recording depends on the history, findings, and frequency of episodes.

Supporting references: [7] Consensus · ECG monitoring.

This avoids two opposite errors.

The first is concluding that any normal test proves that all current and future symptoms are psychological.

The second is thinking that, because no test offers an absolute lifelong guarantee, investigations must be repeated indefinitely.

At an appointment, I would propose clarifying a practical question:

“What findings do we have, what uncertainty remains, and which changes would justify seeking care again?”

The aim is to build a proportionate plan, rather than pursue impossible certainty or minimize a legitimate concern.

For further medical assessment: Professional protocol on palpitations, dysautonomia, and panic.

How can you tell whether it is anxiety or a heart attack?

There is no reliable home rule to settle this.

Age, the type of pain, a watch reading, or the impression that it happens when you are nervous are not enough. Medical assessment is what distinguishes a panic attack from a cardiac problem when symptoms overlap.

Supporting references: [4] Cardiophobia.

That is why rules such as “if I can speak, it is not serious” or “if I calm down a little, it is ruled out” should not be applied.

Nor is it necessary to live in the emergency department to address every familiar sensation. Once the condition has been assessed, the useful step is agreeing with the healthcare team on which episodes can be managed through the treatment plan and which new developments need attention.

The goal is to replace improvisation with clear criteria.

The smartwatch: a tool, not a certificate of safety

A watch can provide useful recordings. The problem arises when it is asked to do something it cannot: continually confirm that nothing will happen.

For example, Apple specifies that its ECG app does not detect heart attacks. It also explains that a sinus rhythm result refers to that particular recording and does not guarantee that the heart maintains that rhythm all the time or that no other health problem exists.

Supporting references: [8] Apple · Limits of the ECG app.

Two precautions follow:

The AMA recommends interpreting data in the clinical context and seeking care when alerts recur or are accompanied by significant symptoms.

Supporting references: [3] AMA · Devices and health.

The question is not whether the watch is “good” or “bad.”

It is about what it is used for and which decisions it supports.

What research has observed

A study published in 2024 analyzed 172 patients with atrial fibrillation, of whom 83 used tracking devices. Device users reported more symptom monitoring and concern and used more healthcare resources related to their arrhythmia.

Supporting references: [9] Devices and atrial fibrillation.

But the design was observational, and the participants already had heart disease. It does not show that watches cause anxiety across the population or that users were seeking care unnecessarily.

The cautious interpretation is different: monitoring may need clinical guidance so that data help rather than become a constant source of alarm.

When checking reassures for minutes and causes worry for hours

Health anxiety can involve frequent body checking, repeated reassurance seeking, constantly looking up information, and concern that tests have missed something. Physical activity may also be avoided for fear of being ill.

Supporting references: [10] NHS · Health anxiety.

Imagine someone checking their pulse whenever they think about their heart. The check briefly reassures them. Soon another doubt arises, and they measure again.

The therapeutic question would not be to prohibit every recording. It would be to examine what purpose that particular measurement serves:

Is it part of a medical recommendation?

Does it provide new information that changes a decision?

Or is it repeated only to reduce distress that quickly returns?

Trials on health anxiety start precisely from the recognition that reassurance obtained through consultations and checking does not always produce lasting improvement; specific interventions are needed in those cases.

Supporting references: [11] Therapy for health anxiety.

When should you seek help for anxiety?

There is no need to wait until you stop working or have daily attacks.

It may be a good time to seek care if, after an appropriate medical assessment, fear is still directing everyday decisions: you avoid going out alone, give up permitted activities, spend hours searching for symptoms, or repeatedly need reassurance.

These behaviors fit descriptions of health anxiety, particularly when they interfere with life and personal coping strategies are not helping.

Supporting references: [10] NHS · Health anxiety.

In an assessment, I would ask about specific consequences:

“What have you stopped doing because you are afraid for your heart?”

The answer may be more informative than simply counting how often you felt a palpitation.

How it is treated without neglecting physical health

Treatment needs a clear formulation. I would not start by trying to convince someone that “it is all in your head.”

First, coordinate the medical information

I would review symptoms, available tests, previous recommendations, and any recent changes. Questions requiring physical examination, monitoring, or cardiology assessment need to be addressed.

Coordination between professionals is especially important when panic or other anxiety symptoms coexist with physical illness. NICE recommends effective communication between the teams involved.

Supporting references: [12] NICE · Guideline CG113.

Then, work on fear and avoidance

Cognitive behavioral therapy can help change threatening interpretations and responses to sensations. For panic, it can include exposure to bodily sensations and resuming avoided activities within a planned intervention.

Supporting references: [6] NIMH · Panic.

Nor is it just about learning to relax. It may be necessary to work on fear of uncertainty, checking, constant reassurance seeking, and giving up activities.

Consider medication when indicated

There is no universal pill for cardiophobia. If panic disorder or another condition that warrants it is identified, medication can be considered according to severity, preferences, tolerability, and interactions.

NICE includes certain antidepressants for treating panic and advises against benzodiazepines as a maintenance treatment strategy because of poorer long-term outcomes. The choice must be individualized, especially when cardiovascular medication is involved.

Supporting references: [12] NICE · Guideline CG113.

A medication should not be started, stopped, or adjusted to “bring the pulse down” based solely on a watch reading.

An integrative perspective: heart, sleep, substances, and habits

The assessment should not artificially separate body and mind.

Insufficient sleep, stimulants, or alcohol and other substances can contribute to palpitations. That is why I would review these factors alongside medications and clinical history, rather than after assuming a psychological cause.

Supporting references: [5] NHS · Palpitations.

In my approach, lifestyle changes would have specific goals: improving rest, reducing identified triggers, and regaining movement within medical limits.

I would not recommend pursuing a perfect “stress” score, buying supplements because of an isolated number, or replacing follow-up with relaxation techniques.

Integration means deciding what each intervention contributes and how we will determine whether it helps.

I would also set life goals: walking with someone and then alone, attending a meeting without checking the pulse, or resuming an activity that has been abandoned. Recovery is not limited to reducing symptoms; it includes regaining autonomy, relationships, and personal goals.

Can an online consultation help?

It can be appropriate for assessing and treating some aspects of anxiety when the situation is stable and does not require urgent physical care.

The strongest evidence concerns specific programs, not any video call. A trial involving 204 adults found that internet-delivered cognitive behavioral therapy for health anxiety, with therapist support over twelve weeks, was not inferior to the in-person format studied.

Supporting references: [11] Therapy for health anxiety.

This does not justify promising identical results for every cardiac problem. In fact, a specific trial on cardiac anxiety in people with noncardiac chest pain found improvement with psychological interventions, but the internet program did not significantly outperform psychoeducation on its primary cardiac anxiety outcome.

Supporting references: [13] Cardiac anxiety · Trial.

The practical lesson is that what the treatment involves and whether it is indicated matter more than the screen used.

An online consultation does not rule out an arrhythmia or replace emergency care. It can help organize the problem, review treatments, and decide on the next step.

What I would review at the first appointment

I would organize the assessment around three questions.

What is happening in the body? When the episodes began, the circumstances in which they occur, which tests have been done, and what medical recommendations exist.

What happens after noticing it? What the person thinks, checks, and fears, and what they do to feel safe.

What has changed in their life? Sleep, work, relationships, exercise, travel, and autonomy.

I would also review previous treatments, medication, substances, and possible coexisting mood or anxiety difficulties.

The result should be an understandable plan: what needs medical follow-up, which psychological mechanism we will treat, and which goals will help measure recovery.

The person should not leave with only another reassuring phrase. They should leave with a better understanding of what to do.

Are you constantly watching your pulse and starting to give up activities out of fear?

If you have already had a medical assessment but fear of a heart attack continues to shape your day, a consultation can help distinguish health anxiety, panic, effects of substances or medication, and other needs requiring coordination.

Dr. Marc Agraz · Integrative psychiatry

In-person care in Lleida and online consultations when clinically appropriate. To prepare for the appointment, bring available reports, your current medications, and two or three examples of activities fear is preventing you from doing. The website allows you to choose the consultation format, day, and time.

You do not need to prove that the fear is “severe enough.” You need to be able to explain how much space it is taking up in your life.

A scheduled consultation is not an emergency service or a substitute for cardiology assessment. For new or concerning symptoms, seek medical attention; if a heart attack or immediate danger is suspected, call 112.

Frequently asked questions

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