Based on PubMed | Are heart palpitations a recognized symptom of fibromyalgia, and what are the possible causes and recommended evaluations?

Heart palpitations can occur in people with fibromyalgia, and they are often linked to autonomic nervous system issues (the body’s “automatic” control of heart rate and blood pressure), rather than primary heart disease. ^[1] Palpitations and dizziness frequently become noticeable with posture changes (for example, going from lying down to standing), suggesting conditions like postural orthostatic tachycardia syndrome (POTS) may coexist with fibromyalgia. ^[1]

Are palpitations a recognized symptom?

• Many individuals with fibromyalgia report additional symptoms beyond widespread pain, including dizziness and fatigue, which can relate to autonomic dysfunction and present as palpitations. ^[1]
• During formal testing, fibromyalgia has been associated with palpitations triggered by standing and other orthostatic challenges, supporting that palpitations are a recognized complaint within the fibromyalgia spectrum. ^[1]

Why do palpitations happen in fibromyalgia?

• Autonomic dysregulation: People with fibromyalgia often show increased sympathetic “fight-or-flight” activity and reduced parasympathetic “rest-and-digest” activity, which can raise heart rate and promote palpitations. ^[2] This imbalance is measurable with heart rate variability (HRV), showing lower high‑frequency (parasympathetic) power and higher LF/HF ratios. ^[2]
• Orthostatic intolerance/POTS: A common finding during head‑up tilt testing in fibromyalgia is POTS, defined by a heart rate increase of more than 30 beats per minute after more than 3 minutes upright, often accompanied by palpitations and lightheadedness. ^[1]
• Arrhythmia tendency: Women with fibromyalgia in Holter studies have shown more supraventricular extrasystoles (premature beats from the upper chambers), which can feel like palpitations. ^[2] These rhythm changes are thought to be linked to the autonomic imbalance described above. ^[2]

Red flags and differential possibilities

• While palpitations may relate to fibromyalgia’s autonomic features, other causes should also be considered, such as anemia, thyroid imbalance, medication or stimulant use (including caffeine), dehydration, anxiety, structural heart issues, or primary arrhythmias; an evaluation helps distinguish these possibilities.
• Palpitations with chest pain, fainting, shortness of breath, or a known heart condition warrant prompt medical assessment.

Recommended evaluations

• Clinical review: A detailed history of triggers (standing, heat, meals, stress), duration, and associated symptoms like dizziness or fatigue helps clarify autonomic involvement. ^[1]
• Physical exam with orthostatic vitals: Measuring heart rate and blood pressure after lying down and during standing can reveal orthostatic tachycardia consistent with POTS. ^[1]
• Electrocardiogram (ECG): Screens for baseline rhythm issues and conduction problems. ^[2]
• 24‑hour Holter monitor or event monitor: Detects intermittent palpitations, premature beats, or tachyarrhythmias, and provides HRV metrics that reflect autonomic function in fibromyalgia. ^[2]
• Head‑up tilt table testing: Often helpful when palpitations and dizziness occur with posture changes; can confirm autonomic dysfunction and POTS in fibromyalgia. ^[1]
• Lab tests: Depending on the clinical picture, tests may include thyroid function, complete blood count, electrolytes, and ferritin to rule out common contributors.
• Lifestyle and medication review: Identifying caffeine, alcohol, decongestants, certain antidepressants, or pain medications that may raise heart rate.

Practical management approaches

• Hydration and salt: Increasing fluids and, when appropriate, salt intake can support blood volume and reduce orthostatic palpitations; discuss exact targets with your clinician if you have blood pressure or kidney concerns. ^[1]
• Gradual conditioning: A structured, gentle exercise plan (starting recumbent and advancing slowly) can improve autonomic stability and reduce palpitations over time. ^[1]
• Compression garments: Waist‑high compression stockings can help prevent pooling of blood in the legs and lessen orthostatic symptoms. ^[1]
• Sleep optimization: Since nonrestorative sleep is common in fibromyalgia and can worsen fatigue and autonomic symptoms, addressing sleep quality may help reduce palpitations. ^[1]
• Medication options: In selected cases, clinicians may consider beta‑blockers, ivabradine, or agents used for orthostatic intolerance to manage heart rate; choices depend on individual profiles and coexisting fibromyalgia treatments. ^[1]
• Trigger awareness: Limiting stimulants (caffeine, nicotine), managing stress, and pacing activities can reduce episodes.

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Quick comparison: autonomic findings and rhythm changes in fibromyalgia

Aspect	Finding in fibromyalgia	Clinical relevance
Autonomic balance (HRV)	Reduced parasympathetic HF power; increased LF/HF ratio	Reflects “overactive” sympathetic tone, contributing to palpitations. [2]
Orthostatic response	HR rise >30 bpm after >3 minutes standing (POTS)	Palpitations and dizziness on standing; tilt testing is informative. [1]
Arrhythmia burden	More supraventricular extrasystoles on Holter	Feels like “skipped” or “fluttering” beats; usually benign but noticeable. [2]

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Bottom line

• Palpitations are commonly reported by people with fibromyalgia and are often tied to autonomic dysfunction, especially with posture changes. ^[1]
• Objective studies demonstrate measurable autonomic imbalance and a higher burden of premature supraventricular beats in fibromyalgia, supporting palpitations as a plausible feature. ^[2]
• A targeted evaluation including orthostatic vitals, ECG, Holter monitoring, and tilt table testing where appropriate can identify the cause and guide treatment to improve symptoms and quality of life. ^{[1] [2]}