Palpitations are one of the most common cardiac complaints after a COVID-19 infection, reported by roughly a third of people who develop lingering symptoms and, in some studies, by up to half.1PubMed Central. Cardiac Arrhythmias in Post-COVID Syndrome: Prevalence, Pathology, Diagnosis, and Treatment The sensation ranges from a brief flutter to a pounding heart that lasts hours, and it can show up weeks or months after the initial illness has resolved. Most of the time the underlying rhythm disturbance is uncomfortable rather than dangerous, but some patterns do warrant urgent attention, and the distinction is not always obvious from the sensation alone.
How Common Are Post-COVID Arrhythmias, and How Much Higher Is the Risk?
A systematic review and meta-analysis pooling data from multiple large cohorts found that people with long COVID had roughly 74 percent higher overall risk of developing a heart arrhythmia compared to controls.2PubMed Central. Increased Arrhythmia Risk in Long COVID: A Systematic Review and Meta‐Analysis The increase was not limited to one type of rhythm problem. Atrial fibrillation risk was about 49 percent higher, sinus tachycardia about 69 percent higher, sinus bradycardia about 58 percent higher, and ventricular arrhythmias about 72 percent higher in the long COVID group. Patients whose initial infection was more severe faced an even greater risk of developing arrhythmias afterward.
Those numbers describe the broad population. For any individual person, severity of the original illness, pre-existing heart conditions, and age all shift the odds. Mild infections are not a free pass, though. Many post-COVID palpitation cases arise in people who had a relatively mild acute illness and no previous cardiac history.3PubMed Central. Inappropriate sinus tachycardia in post-COVID-19 syndrome
Why the Heart Races After the Virus Is Gone
No single mechanism explains every case. Instead, several overlapping processes can knock heart rhythm regulation off balance. Which ones dominate varies from person to person, which is part of why the symptom profile is so inconsistent.
Autonomic Nervous System Disruption
The autonomic nervous system is the body’s autopilot for heart rate, blood pressure, digestion, and temperature control. COVID-19 can disrupt it, producing a condition called dysautonomia. People with long COVID often show lower heart rate variability, reduced vagal (parasympathetic) activity, and an outsized sympathetic “fight or flight” response.4PubMed Central. Cardiovascular autonomic dysfunction in “Long COVID”: pathophysiology, heart rate variability, and inflammatory markers The practical result is a heart that speeds up too easily and settles down too slowly.
The most recognized form of this is postural orthostatic tachycardia syndrome, or POTS, where heart rate jumps excessively upon standing. POTS appears to be the most common autonomic phenotype in post-COVID patients, with late-onset dysautonomia reported in about 2.5 percent of those with the post-COVID condition overall.5PubMed Central. Dysautonomia in COVID-19 Patients: A Narrative Review on Clinical Course, Diagnostic and Therapeutic Strategies Several documented case series have found POTS developing three to four weeks after infection, often in young, previously healthy women.6Autonomic Neuroscience. Investigating the possible mechanisms of autonomic dysfunction post-COVID-19
Another related problem is inappropriate sinus tachycardia, or IST, where the resting heart rate stays elevated without any positional trigger. In one study of 200 post-COVID patients, 20 percent met the diagnostic criteria for IST. Their daytime heart rates averaged about 98 beats per minute, compared to roughly 84 in recovered asymptomatic people and 81 in uninfected controls. Their vagal tone markers were also substantially reduced.3PubMed Central. Inappropriate sinus tachycardia in post-COVID-19 syndrome
Myocardial Inflammation
In a smaller subset of patients, the virus triggers ongoing inflammation of the heart muscle itself, known as myocarditis. Post-COVID myocarditis can take an arrhythmic form, in which new rhythm disturbances develop even while the heart’s pumping strength remains normal. These arrhythmias can range from harmless extra beats to more serious patterns like sustained ventricular tachycardia or high-grade conduction block.7Russian Journal of Cardiology. Subacute and chronic post-COVID myocarditis: diagnostics, clinical variants, treatment approaches This is one of the reasons that dismissing every post-COVID palpitation as “just anxiety” can be a mistake.
Microvascular Damage
Even after mild infections, some people develop dysfunction in the tiny blood vessels that supply tissues throughout the body. Research has found that peripheral microvascular endothelial dysfunction is prevalent in symptomatic long COVID patients long after recovery, and it correlates with elevated levels of NT-proBNP, a marker the heart releases when it is under strain.8The American Journal of Medicine. Peripheral Microvascular Endothelial Dysfunction and Increased NT-proBNP Levels in Post-Acute COVID-19 Syndrome A study using cardiac MRI found that stress-related blood perfusion through the heart’s small vessels was measurably lower in people after severe COVID hospitalization than in healthy volunteers.9JAMA Network Open. Long-Term Coronary Microvascular and Cardiac Dysfunction After Severe COVID-19 Hospitalization When the heart’s own blood supply is impaired at the microvascular level, the result can be palpitations, chest discomfort, and exercise intolerance even though coronary arteries look clear on a standard angiogram.
Autoantibodies and Immune Overactivation
A growing body of evidence points to the immune system itself turning against the body’s own signaling receptors. Researchers have found that autoantibodies targeting receptors involved in blood pressure and heart rate regulation, including angiotensin receptors, adrenergic receptors, and muscarinic acetylcholine receptors, are associated with altered heart rate variability and blood pressure regulation in long COVID patients.1PubMed Central. Cardiac Arrhythmias in Post-COVID Syndrome: Prevalence, Pathology, Diagnosis, and Treatment In other words, the immune system may be producing antibodies that directly interfere with the receptors the heart uses to regulate its own rhythm.
Separately, mast cell activation, a process in which immune cells dump histamine and other inflammatory chemicals, has been implicated. One study found that blocking histamine receptors improved cardiovascular symptoms in long COVID patients, supporting the idea that inappropriate mast cell activation contributes to some cardiac complaints.10PubMed Central. Antihistamines improve cardiovascular manifestations and other symptoms of long-COVID attributed to mast cell activation
When Palpitations Need Urgent Attention
Most post-COVID palpitations are uncomfortable but not acutely dangerous. The vast majority turn out to be sinus tachycardia or benign extra beats driven by autonomic imbalance. But the spectrum of COVID-associated arrhythmias is wide, and some patterns do require prompt medical evaluation.1PubMed Central. Cardiac Arrhythmias in Post-COVID Syndrome: Prevalence, Pathology, Diagnosis, and Treatment
Seek medical attention the same day if palpitations come with any of the following:
- Fainting or near-fainting: Passing out during a palpitation episode suggests the heart rhythm may be dropping blood pressure to dangerous levels, whether from a very fast rate, a very slow rate, or an abrupt pause.
- Chest pain or pressure: Particularly pain that radiates to the arm, jaw, or back. Myocarditis and ischemia are both possible in the post-COVID setting and both warrant workup.
- Severe breathlessness at rest: Feeling winded just sitting still, or waking up short of breath, can signal fluid backing up from heart dysfunction.
- Heart rate above 150 sustained for more than a few minutes: Rates this high at rest are unusual even with POTS or IST and raise the possibility of a sustained arrhythmia like atrial fibrillation or ventricular tachycardia.
- Irregular, chaotic rhythm: A pulse that feels completely erratic rather than just fast may indicate atrial fibrillation, which carries its own risks including stroke.
Palpitations that are brief, happen mainly on standing, and resolve when you sit or lie down are more consistent with POTS or IST. They still deserve evaluation, but the urgency is lower.
How Doctors Evaluate Post-COVID Palpitations
A standard resting electrocardiogram (ECG) can catch certain arrhythmias if they happen to be present at that moment, but many post-COVID rhythm disturbances are intermittent. Longer monitoring, typically with a 24- or 48-hour Holter monitor, is more useful for capturing what happens during daily life.11PubMed. Prevalence and Clinical Impact of Postural Orthostatic Tachycardia Syndrome in Highly Symptomatic Long COVID
If POTS is suspected, the gold-standard test is a head-up tilt table test. You lie flat on a motorized table for several minutes while baseline heart rate and blood pressure are recorded, then the table is tilted upright to about 70 degrees for up to 30 minutes while heart rhythm and blood pressure are monitored continuously.12PubMed Central. Case-control study of autonomic symptoms in the setting of long COVID with tilt table testing A sustained heart rate increase of 30 beats per minute or more (40 or more in adolescents) within ten minutes of standing, without a corresponding drop in blood pressure, is the hallmark finding for POTS. Many clinics will also use a simpler “active stand test” as an initial screen before ordering the full tilt.
Beyond rhythm monitoring, bloodwork is typically drawn to rule out thyroid disease, anemia, and electrolyte imbalances, all of which can cause palpitations and are easy to treat. An echocardiogram can assess heart structure and pumping function. Cardiac MRI may be ordered if myocarditis is suspected, as it can detect subtle inflammation and scarring that an echocardiogram misses.
Treatment Options That Have Evidence Behind Them
Treatment depends on what the evaluation finds. For the largest group, those with autonomic dysfunction driving a fast heart rate, the approach usually starts with lifestyle adjustments and adds medication if those are not enough.
Lifestyle and Fluid Strategies
Increasing fluid and salt intake is a first-line recommendation for POTS and IST. A structured dysautonomia management protocol that included raising daily fluid intake to about three liters and salt intake to about ten grams, along with pacing activities to avoid symptom crashes and doing calf-activation exercises, produced a measurable drop in heart rate within weeks, with an average reduction of nearly five beats per minute during lying tests.13PubMed Central. Testing a Personalised Dysautonomia Management Protocol in Patients with Orthostatic Intolerance and a Diagnosis of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome or Long COVID Five beats per minute may sound modest, but for someone whose resting rate is stuck in the high 90s, that shift can meaningfully reduce the sensation of palpitations.
Compression garments, especially waist-high stockings or abdominal binders, help by reducing blood pooling in the legs. Graduated exercise programs are recommended but must be introduced carefully, as overexertion can trigger symptom flares. Starting with reclined exercises like recumbent cycling and only gradually adding upright activity is the typical approach.
Medications
Beta-blockers are the most commonly prescribed first medication. In a small case series of post-COVID autonomic dysfunction, four out of five patients treated with beta-blockers reported improved or resolved symptoms.14PubMed Central. Autonomic dysfunction post–acute COVID-19 infection Propranolol, given in low doses of 10 to 20 milligrams up to four times daily, is frequently used because it also dampens some of the adrenaline-driven symptoms like tremor and anxiety. However, beta-blockers can lower blood pressure, which is already an issue for many POTS patients. Fatigue and exercise intolerance are other common side effects.15PubMed Central. Pharmacological and non-pharmacological management of long COVID
When beta-blockers do not work or are not tolerated, ivabradine has shown promise. Ivabradine slows the heart rate by acting specifically on the pacemaker cells of the sinoatrial node, without lowering blood pressure the way beta-blockers do. In a prospective study of 55 patients with COVID-associated POTS, about 78 percent reported significant symptom improvement within seven days of starting ivabradine, and objective measures of heart rate and heart rate variability also improved.16PubMed Central. Ivabradine effects on COVID-19-associated postural orthostatic tachycardia syndrome: a single center prospective study A separate randomized crossover trial found improvements in physical functioning and quality of life with ivabradine, with no notable side effects.15PubMed Central. Pharmacological and non-pharmacological management of long COVID
For patients where mast cell activation is suspected, over-the-counter antihistamines, both H1 blockers like cetirizine and H2 blockers like famotidine, have been used with reported benefit.10PubMed Central. Antihistamines improve cardiovascular manifestations and other symptoms of long-COVID attributed to mast cell activation This is still an area of active research, and not every patient with palpitations will respond. But the low risk profile of antihistamines makes them a reasonable trial in some cases.
Post-COVID Palpitations in Children and Adolescents
Adults get most of the attention in long COVID research, but children and teenagers can develop the same autonomic problems. Affected young patients commonly present with dizziness, palpitations, exercise intolerance, fatigue, and sometimes fainting. The tachycardia in pediatric cases often represents a compensatory physiological response, meaning the heart is speeding up to make up for other regulatory problems like impaired venous return, low blood volume, or altered brain blood flow, rather than a primary defect in the heart itself.17PubMed. Post-COVID paediatric dysautonomia: never the heart, always the brain-myth or maxim?
Studies of children with post-COVID health problems, including some who developed symptoms after vaccination, have shown elevated heart rates while lying and standing, increased stress indices, and reduced vagal activity, mirroring the adult pattern. Some met criteria for POTS; others had inappropriate sinus tachycardia. A subset was successfully treated with omega-3 fatty acid supplementation and standard medications.18PubMed Central. Dysautonomia in Children with Post-Acute Sequelae of Coronavirus 2019 Disease and/or Vaccination Parents dealing with a child who reports a racing heart after COVID should be aware that the symptom is recognized, physiologically measurable, and treatable. It is not something to write off as growing pains or attention-seeking.
The Link Between Sleep Disruption and Cardiac Symptoms
Palpitations and sleep problems frequently co-occur in long COVID, and the relationship likely runs in both directions. In one prospective study, about a third of long COVID patients reported persistent chest pain, palpitations, or tachycardia as symptoms that appeared within three months of infection and lasted at least two months.19PubMed Central. Sleep Disturbances as a Consequence of Long COVID-19: Insights from Actigraphy and Clinimetric Examinations The same patients frequently had disrupted sleep architecture measured by actigraphy. Poor sleep increases sympathetic nervous system activity, which can raise resting heart rate and worsen palpitations. Meanwhile, palpitations themselves can cause nighttime awakenings and difficulty falling asleep. Breaking the cycle may require addressing both the sleep disruption and the cardiac symptoms in parallel rather than treating one and waiting to see if the other resolves.
Tracking Symptoms at Home
Consumer wearable devices are increasingly useful for people living with post-COVID palpitations. A case report demonstrated that smartwatch-derived ECG biomarkers, combined with a simple posture test (measuring pulse change from sitting to standing), correlated well with a patient’s self-reported fatigue and recovery trajectory over time.20PubMed Central. Monitoring of cardiorespiratory vagal desynchrony using novel biomarkers derived from smartwatch electrocardiograms in a patient recovering from long COVID: case report While smartwatch data cannot replace a diagnostic-grade Holter monitor, it can help you and your doctor track trends, identify triggers, and gauge whether treatment is working.
A practical home test you can do with nothing more than a timer involves lying down quietly for five minutes, checking your pulse, then standing and checking again at one, three, five, and ten minutes. Recording this daily and noting any symptoms gives your doctor a useful longitudinal picture, especially if your symptoms are intermittent and unlikely to show up during a scheduled clinic visit. If your heart rate consistently jumps by 30 or more beats per minute on standing and stays elevated, bring those numbers to your appointment. That data can speed up the path to a tilt table test and a definitive diagnosis.
What the American Heart Association Has Said
In a formal scientific statement, the American Heart Association acknowledged that both COVID-19 infection and COVID-19 vaccine-associated myocardial inflammation and autonomic disruption remain concerns.21PubMed Central. Cardiac Arrhythmias and Autonomic Dysfunction Associated With COVID-19: A Scientific Statement From the American Heart Association The statement underscores that these are recognized medical entities, not fringe diagnoses. If you encounter a provider who is unfamiliar with post-COVID autonomic dysfunction, pointing to the AHA statement can be a helpful way to advocate for further evaluation. The recognition by major medical organizations has also expanded insurance coverage for relevant tests like tilt table studies and cardiac MRI in post-COVID patients, though access still varies by region and insurer.
The RAS (renin-angiotensin system), the hormonal pathway that helps regulate blood pressure and fluid balance, is also heavily implicated in how COVID affects the cardiovascular system long-term.22PubMed Central. The Pathophysiology of Long COVID throughout the Renin-Angiotensin System The virus enters cells through the ACE2 receptor, which is part of that system, so its disruption during acute infection can have ripple effects on blood pressure regulation and fluid retention that persist well after the virus clears. This may partly explain why some patients with post-COVID palpitations also experience blood pressure instability, particularly swings between high and low readings throughout the day.