QALY | What Heart Palpitations and Ectopic Beats Look Like on Your Apple Watch ECG

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Introduction

Do you remember the last time your heart was fluttering, jumping, pounding, or skipping a beat? These heart palpitations are alarming, and you may have experienced a premature electrical impulse in the heart’s cycle known as an “ectopic beat,” or “premature beat.” Now, see them directly on your Apple Watch ECG, Fitbit ECG, Samsung watch ECG, or any other ECG. Here's how.

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Why Do Ectopic Beats Occur?

Your heart is a thing of marvel — most cells in your heart are capable of beating all on their own. To keep your heart beating at a regular pace, a cluster of cells known as the sinoatrial (SA) node acts as the heart’s natural pacemaker. Sometimes, however, one of your other heart cells beats at a faster pace and causes other cells to follow the new march of its drum. This leads to a premature heartbeat, also known as an ectopic heartbeat.

When your heart experiences these premature beats, a brief pause usually follows where the SA node resets itself before the next beat. This can cause a feeling of an extra beat or a skipped beat, along with a fluttering sensation. Usually, ectopic heartbeats are asymptomatic: nearly everyone experiences a few ectopic heartbeats every day. But frequent occurrences could be linked to heart problems.

So what are the different types of ectopic beats? And how can you spot palpitations on your Apple Watch, Fitbit, or Samsung ECG? Let’s dive in.

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Types of Ectopic Beats

Ectopic heartbeats fall into one of three buckets depending on the source of the electrical impulse: PACs (atrial), PVCs (ventricular) and PJCs (junctional).
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Premature Atrial Contraction (PAC)

pac, pac vs pvc, premature atrial contraction — *PAC beat on an Apple Watch ECG. Notice how the PAC beat occurs earlier than expected, has a normal QRS complex, and is followed by a longer pause before the next normal beat.*

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A premature atrial contraction (PAC) occurs when an extra heartbeat originates in the atria — or top of the heart — in a location other than the SA node.

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How to Identify a PAC

The hallmark of a PAC is a premature P wave observed before the next expected normal beat. This premature P wave usually has a different shape: it can be wider, or taller, narrower or shorter, even upside-down. This really depends on where exactly in the atria the PAC is coming from. If it comes from somewhere near the SA node, it could look like a normal P wave. Additionally, a normal-looking QRS complex follows most PACs. Finally, PACs cause the natural pacemaker to "reset," which results in a longer interval before the next normal beat.

Premature Ventricular Contraction (PVC)

pvc on ecg, apple watch pvc, pvc vs pac, pvc example, pvc imag — *PVC beat on an Apple Watch ECG. Notice how the PVC has a wide QRS complex, no preceding P wave, and looks different from the normal heart beats.*

A premature ventricular contraction (PVC) occurs when an extra heartbeat originates in the ventricles, or bottom of the heart.

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How to Identify a PVC

You can identify a PVC by its wide and bizarre QRS complex. The QRS complex of the PVC beat is typically wider than that of a normal beat. Also, PVCs interfere with the normal sinus rhythm by coming in before the next anticipated beat. Finally, you’ll notice that there’s no P wave before the QRS complex of a PVC beat.

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Unifocal vs. Multifocal PVC

Unifocal PVCs look identical in appearance, and they originate from a single ectopic site.

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*Unifocal PVCs. Notice how the PVCs are identical in appearance, in this EKG Apple Watch recording.*

Multifocal PVCs, on the other hand, arise from two or more ventricular sites. They also have different QRS shapes.

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pvc, pvc ecg, apple watch pvc, ecg reader, ecg interpretation — *Multifocal PVCs. Notice how the PVC at the top has a different shape than the two PVCs at the bottom, in this EKG Apple Watch recording.*

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Premature Junctional Contraction (PJC)

pjc, pjc ecg, ecg reader, pjc vs pac — *PJC beat. The PJC beat has no P wave, in this Apple Watch EKG recording.*

A premature junctional contraction (PJC) occurs when an extra heart beat originates at the connection between the top of the heart (atrium) and the bottom (ventricle), in or near the atrioventricular (AV) node.

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How to Identify a PJC

To identify a PJC, look for a premature QRS complex that shows up before the next expected normal beat. The P wave is either absent or upside down, and you’ll usually see it after the beginning of the QRS complex. Additionally, the QRS complex will look similar in shape to that of a normal beat.

Frequency of Premature Beats

Ectopic beats can either be isolated, or they can appear in groups.

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Isolate: Single occurrence of an ectopic beat.

pac, pac ecg, pac vs pvc, pvc vs pac, pac example — *An isolated PAC.*

pvc, pvc example, pvc vs pac, pac vs pvc, pvc ecg, isolated pvc — *An isolated PVC.*

Couplet: Two consecutive ectopic beats.

pac couplet, pac vs pvc, heart palpitations, ectopic beats — *A PAC couplet, also known as an atrial couplet. This occurs when two extra heart beats in a row originate at the top of the heart (atria).*

pvc, pvc couplet, pvc vs pac, pac vs pvc, ecg reader, ecg app — *A PVC couplet, also known as a ventricular couplet. This occurs when two extra heart beats in a row originate at the bottom of the heart (ventricles).*

Run: Three or more consecutive premature beats.

pvc run, ventricular run, pvc vs pac, heart palpitations, ectopic beats, pvc, pac vs pvc, ecg reader — *A PVC run, also known as a ventricular run.*

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pac run, pac vs pvc, pvc vs pac, atrial run, ecg app, ecg reader — *A PAC run, also known as an atrial run.*

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Pattern of Ectopic Beats

Ectopics can often occur in repeating patterns. Let’s look at the most common ones.

Bigeminy: An ectopic occurs after every normal beat.

bigeminy pvcs, bigeminy pvc, pvc vs pac, pac vs pvc, heart palpitations, ecg reader, ecg app — *PVCs in bigeminy pattern, also known as ventricular bigeminy. Notice how there’s a PVC occurring every other beat.*

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pac bigeminy, bigeminy pac, pac ecg, pac vs pvc, pvc vs pac, ecg reader, ecg app, heart palpiations, ectopic beats — *PACs in bigeminy pattern, also known as atrial bigeminy.*

Trigeminy: An ectopic occurs after every two normal beats.

pvc trigeminy, trigeminy pvc, ventricular trigeminy, heart palpitations, ectopic bats — *PVCs in trigeminy pattern, also known as ventricular trigeminy. Notice how for every two normal beats, there’s one PVC.*

pac trigeminy, atrial trigeminy, trigeminy pac, pac vs pvc, pvc vs pac, heart palpitations, ectopic beats — *PACs in trigeminy pattern, also known as atrial trigeminy.*

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Are Ectopic Beats Cause for Concern?

Heart palpitation anxiety is not fun, but people are finding ways to find relief and gain peace of mind. Nearly everyone experiences a few ectopic beats every day, which is completely normal. Most people don’t feel these extra heartbeats; however, some are particularly sensitive to them, often describing the sensation as a “skipped heartbeat” or “extra heartbeat.” With a higher number of people reporting heart palpitations during COVID, many folks are sending their Fitbit ECG, Samsung ECG, and Apple Watch ECG to human experts through the QALY app for heart palpitation monitoring.

If more than 1% of your heartbeats throughout a full day are ectopic, this may be a sign that there’s something going on. It’s difficult to know if you have frequent ectopics with a single, 30-second ECG strip. However, if you see more than one ectopic on the same 30-second ECG strip, this should make you wonder whether or not you may have frequent ectopics. This may be a good reason to check additional ECGs and talk to your healthcare provider, who will likely want to check your ectopic count with a continuous heart monitor.

Frequent ectopic beats can be caused by either electrical problems in the heart, or problems with the structure or heart muscle itself. Conditions such as high blood pressure, diabetes, and obesity can lead to abnormal heart muscle and, consequently, more ectopic beats than normal. Those with advanced heart conditions such as coronary disease or heart failure can also have more ectopic beats than normal. Conversely, a very high number of ectopic beats (such as over 15% PVCs) can lead to heart weakening. For these reasons, it’s always a good idea to talk to your healthcare provider if you seem to have frequent ectopics.