Can Multiple Sclerosis Cause Heart Palpitations? Prevalence, Evaluation, and Treatment

Multiple sclerosis (MS) can be associated with heart palpitations due to autonomic nervous system involvement, although palpitations are not among the most frequently recognized MS symptoms. ^[1] Autonomic dysfunction in MS affecting heart rate and blood pressure control has been documented and can present with cardiovascular symptoms such as a racing or irregular heartbeat, lightheadedness, and orthostatic intolerance. ^[2] Because palpitations have many possible causes, an evaluation generally looks for both autonomic (neurological) and primary cardiac or systemic contributors. ^[3]

---

Why MS Can Lead to Palpitations

• Autonomic nervous system (ANS) involvement: MS lesions may disrupt central autonomic pathways that regulate heart rate, vascular tone, and blood pressure, leading to dysautonomia (autonomic dysfunction). ^[1] This can manifest as inappropriate increases or decreases in heart rate, blood pressure instability, and symptoms such as palpitations, dizziness, and fainting. ^[2]

• Overlooked symptom domain: Autonomic disturbances occur with a frequency similar to motor symptoms in MS but are often under-recognized during routine evaluations, which can delay targeted care. ^[1] In practice, cardiovascular, bladder, and gastrointestinal autonomic symptoms may co‑exist, suggesting a broader autonomic issue rather than an isolated heart problem. ^[2]

---

How Common Is It?

• Autonomic dysfunction prevalence: Controlled studies show autonomic symptoms including cardiovascular complaints are significantly more common in people with MS than in healthy controls. ^[2] Formal autonomic cardiovascular tests (Ewing battery) often reveal abnormal parasympathetic and mixed sympathetic‑parasympathetic dysfunction in MS, with definite parasympathetic derangement reported in roughly half of participants in some cohorts. ^[2]

• Clinical takeaway: While exact population‑level rates of palpitations in MS are not firmly established, autonomic cardiovascular involvement is common enough that palpitations and orthostatic symptoms warrant consideration as part of MS care. ^{[1] [2]}

---

Differential Diagnosis: Not All Palpitations Are From MS

Palpitations are usually benign but can have many triggers, so it’s important not to attribute them to MS without assessment. ^[4] Common non‑MS causes include stress or anxiety, caffeine and stimulant use (including decongestants), fever, thyroid issues, anemia, dehydration, or primary arrhythmias. ^[3] Because occasionally palpitations signal a heart rhythm disorder, clinicians look for red flags like syncope, chest pain, shortness of breath, or a known heart condition. ^[5]

---

Recommended Evaluation

History and Physical

• Characterize the sensation (racing, pounding, fluttering), onset/offset, triggers, duration, and associated symptoms (dizziness, fainting, chest discomfort, breathlessness). ^[6] A focused review of stimulants, medications, hydration, and recent illness is helpful. ^[3]

Cardiac and Autonomic Testing

• Electrocardiogram (ECG) and ambulatory monitoring (Holter/event recorder): To detect arrhythmias during symptoms. ^[6]
• Orthostatic vitals or tilt‑table testing: Assess heart rate and blood pressure responses to standing to identify orthostatic hypotension or postural tachycardia patterns typical of autonomic dysfunction. ^[7] Tilt‑table testing can distinguish neurogenic orthostatic hypotension (blunted heart rate response with BP drop) from non‑neurogenic forms (exaggerated heart rate increase). ^{[8] [9] [10]}
• Autonomic function tests (Ewing battery): Deep breathing, Valsalva maneuver, active standing, and blood pressure response to sustained handgrip to quantify parasympathetic and sympathetic integrity. ^[7] These standardized tests often reveal abnormalities in MS and guide management. ^[2]

Additional Workup When Indicated

• Labs for anemia, electrolytes, thyroid function, and medication review to rule out common systemic causes. ^[3]

---

Treatment and Management

Treat Reversible Causes

• Reduce caffeine/nicotine and avoid stimulant decongestants; optimize hydration and salt intake if appropriate; review and adjust medications that may provoke palpitations. ^[3]

Manage Autonomic Dysfunction

• Non‑pharmacologic strategies:
  • Increase fluid and, when suitable, salt intake; use compression stockings; elevate the head of the bed. ^[7]
  • Avoid prolonged standing, hot environments, and rapid position changes, which can worsen orthostatic intolerance. ^[11]
• Pharmacologic options:
  • For orthostatic hypotension, agents such as midodrine or fludrocortisone may be considered under medical supervision. ^[7]
  • For postural orthostatic tachycardia patterns, beta‑blockers or other heart‑rate–modulating therapies may be used selectively. ^[7]
• Specialist referral: Autonomic neurology or cardiology clinics can provide comprehensive testing and individualized care for complex dysautonomia. ^[12]

When Palpitations Reflect a Primary Cardiac Issue

• If monitoring identifies arrhythmias, treatment follows cardiology guidelines for the specific rhythm disorder (e.g., supraventricular tachycardia, atrial fibrillation), which might include medications, ablation, or other interventions. ^[6] Red‑flag symptoms like syncope or chest pain warrant urgent evaluation. ^[5]

---

Practical Step‑by‑Step Plan

1. Document episodes: Time, triggers, activity, posture, and associated symptoms to improve diagnostic yield. ^[6]
2. Initial tests: ECG, basic labs (thyroid, electrolytes, hemoglobin), and review stimulants/medications. ^[3]
3. Orthostatic assessment: Measure BP/HR supine and after 1–3 minutes standing; consider tilt‑table and autonomic function testing if orthostatic symptoms are present. ^{[7] [8]}
4. Ambulatory cardiac monitoring: Use Holter or event monitors to capture rhythm during symptoms. ^[6]
5. Targeted management: Combine lifestyle measures with medications tailored to orthostatic hypotension or tachycardia patterns; treat any identified arrhythmia per cardiology standards. ^{[7] [6]}

---

Key Points to Remember

• MS can contribute to palpitations through autonomic dysfunction, but palpitations have many causes and need a thorough, structured evaluation. ^{[1] [3]}
• Autonomic cardiovascular abnormalities are common in MS cohorts, and standardized testing frequently reveals parasympathetic or mixed dysfunction. ^[2]
• A combined cardiology–neurology approach, including orthostatic and autonomic testing, often yields the best management plan. ^{[12] [7]}

---

Summary Table: MS-Related Palpitations vs. Common Non‑MS Causes

Aspect	MS‑related autonomic dysfunction	Common non‑MS causes
Mechanism	Central autonomic pathway lesions causing abnormal HR/BP control. [1]	Stress/anxiety, caffeine/stimulants, anemia, thyroid disorders, dehydration, primary arrhythmias. [3]
Typical associated symptoms	Dizziness, orthostatic intolerance, fainting; often co‑exists with other autonomic symptoms. [2]	Jitteriness, sleep disturbance, chest discomfort, or no associated symptoms depending on cause. [3]
Diagnostic focus	Autonomic tests (Ewing battery), orthostatic vitals/tilt‑table, rhythm monitoring. [7] [2]	ECG/monitoring, labs for systemic causes, medication/stimulant review. [6] [3]
Treatment	Hydration/salt, compression, trigger avoidance; midodrine/fludrocortisone or rate‑modulating drugs when indicated; specialty referral. [7] [12] [11]	Remove triggers, correct systemic issues, treat arrhythmias per cardiology guidance. [6] [3]

---