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Forum Name: Arrhythmias

Question: Elevated heart rates lasting 2-4 hours


 SirWence - Tue May 13, 2008 1:46 am

Hello, I am looking for some help and advice. (I guess I should give some vitals.. I am 22 turned so a few months ago.. I am 6 feet tall and 180 lbs so not over weight.. I smoked for 1 1/2 years QUIT and will never smoke ever again, I do not drink period - my family says we have no real history of heart disease. or disorders to their knowledge )

For about a year now I get these heart rates which are roughly 160-180 they will last roughly 2-4 hours each time at which point they being to slow back down to a normal resting rate.

I spoke to my doctor about this a year ago and have had a follow up last September and everything seemed ok them. she put me on toprol 25 mg once a day. and then after a few days (she had me phone her with my bp and how my pulse was etc) lowered it to breaking the pill in half and taking it once per day.

I have had moments of this elevated heart rate (they also always seem to accompany or maybe even be caused by panic attacks as I have been diagnosed with Panic disorder and GAD)

If I do not take the beta blocker they will take from my experience before having it 2-4 hours to return to below 100 then normal . If I take the beta blocker durning it usualy within 45-65 minutes my heart rate is back to normal or atleast at or below 100.

I can tell you that exact timing as I just went through the event. It started at 12:10 am est time - I tried breathing and xanax I had taken 1.5 mg since waking up at 10:30 pm est. But it raced no matter . I knelt down to pick up my stress ball and when I stood back up my heart raced even faster and then it well did its thing started racing.. I no longer check how fast it is as - to be quite frank with you it makes me more anxious. but I can usually tell just by senseing it was roughly 160-180 ish and I took my beta blocker at 12:42 AM est and by 1:35 am EST my heart rate was down to 89 bpm I have not checked it since as I perfer to avoid making myself more anxious. My heart rhythm during these also stays even aside from the occasional 'skipped beat'.

In the past I have had an EKG done and on the check up in sept my doctor did a heart listen? she spent about 5-7 minutes simply listening to my heart beat from the front sides and back. As she also did when I had my EKG done (I had the EKG done before by about maybe 1 month or so these racing issues came about: the EKG was NSR with a slightly elevated rate of 113 my doctor said it was in her opinion white coat syndrome causing the elevation because other wise both doctors on called agreed it looked normal)

My questions are simple but maybe not.

What do you think this could be caused by. I have no way to see a cardiologist at this moment and any advice would be amazingly helpful

What should I do.. is the beta blocker enough.. are these heart rates harmful?

Are there any long term effects to the beta blocker or the heart rates.

Thank you very much I appreciate this
 John Kenyon, CNA - Thu Jul 10, 2008 1:23 am

User avatar Hello Sir Wence -

Your symptoms as described suggest several different possibilities. You have told us you have been diagnosed with panic disorder and GAD, so some cardiac symptoms are not surprising. The problem, as you've already suggested, is that panic attacks can cause rather rapid heart rates, but also rapid heart rates can cause intense anxiety or trigger panic attacks. This is a big problem for clinicians as well as patients.

You've given us one significant bit of information in that you state the rate gets up as high as it does, lasts for several hours, remains regular during that time, then slowly winds down to the normal range. If you were suffering from supraventricular tachycardia the rate would likely be at least that fast (and probably even more rapid) but would convert abruptly to normal, often with a long sinus pause at the end of the episode.

So it's not SVT, and since it's regular it's not atrial fibrilliation. Since it reaches as high as 180, it's unlikely to be atrial flutter either. This leaves just two possibilities: one, that you are having episodes of junctional tachycardia (a non-lethal but pretty annoying arrhythmia) or, more likely, you are operating on such a high level of adrenaline that your anxiety, when stirred up, causes your heart to speed up to unusually fast sinus tachycardia rates. This is not unheard of, although it is more common to see sinus tach rates in the 120-140 range. Sinus tach always winds down slowly, as the anxiety (and consequent adrenaline overdrive) subsides.

A beta blocking agent would seem ideal in either case.

You have numerous pluses in your favor, such as having quit smoking young (and having decided to never start again -- you get big points for that decision); you also have no known heart disease in your family history, which is a very big plus.
Other pluses are a normal EKG and an understanding of your anxiety-based problems, which are not something you can just "get over." You might consider, if you haven't already, looking into cognitive therapy, a specialized, behavior-modifying type of therapy that is not simple talk therapy and does not run on endlessly. Results with this are often very good with anxiety, although there can be a physical predisposition to panic disorder, so there are limits to what can be accomplished.

Now then, about the Toprol: this is an excellent beta blocker, probably the best all-around for general use. It is very well tolerated, you get good results with a very low dose, and since it is cardioselective (acts mostly just on cardiac beta receptors) it doesn't have near the side effects of some other beta blockers. There is no long-term risk nor any danger of unwanted side effects (other than possibly some early feeling of fatigue) with long-term use, so long as it is taken as directed, which is the rule with any prescription drug anyway. The only problem, and you may have actually run into this without realizing it, is that to be effective beta blockers must be taken consistently, at very close to the same time every day. You mustn't stop taking the Toprol without a doctor's direction, and then it should be tapered off over a period of one to two weeks. Since you sometimes don't take it, you may actually be triggering episodes of anxiety and rapid heart rate. This is a very common side effect from not taking a scheduled dose. It is called a rebound effect, and people with known heart disease can cause life-threatening problems by doing this. In your case this is unlikely, but you may well be triggering the very symptom you want to avoid. Beta blockers are helpful in combating anxiety (although they are not normally prescribed for that alone), since they block the uptake of adrenaline by the heart muscle, and so slow the heart rate and lower the blood pressure and cardiac output. I would think 25 mg. would be ideal for your situation -- or even 12.5 if it works for you -- but you must take it on a regular basis or else have your doctor taper you off it and try some other approach. Since Toprol won't cause any harm and can almost certainly help control your episodes of tachycardia, I would be inclined to suggest you stick with it, but take it on a regular basis. Since it is only once-a-day dosing it isn't too much of a burden.

I think this is probably your best bet for now, to resolve to take the Toprol on a regular basis, and then look into the possibility of cognitive therapy as a possible long-term solution to the anxiety problem, which is something you could certainly do without if possible.

Best of luck to you and please do stay in touch.
 Blackrain99 - Thu Jul 10, 2008 3:45 pm

Ah thank you very much for your reply. I hope you had a good 4th of july.

I do take it everyday, however my sleep cycle has become so varied it has become at different times until recently. My sleep cycle has stablized in a .. abnormal time frame.. sleep until 2:30-3:15 pm each day. and I take the 12.5 mg of toprol 2-4 hours after awakening each day. Does that sound a good enough way to be doing it.. I keep track when I take them each day the last 3 days (not counting today)

beta blocker 12.5mg 6:52 pm
beta blocker 12.5mg 7:13 pm
beta blocker 12.5mg 7pm

If that is considered regular enough ( I hope so ) I will be sure to keep it so as I did not know what you pointed out that a rebound could be taking effect.

Also I now take 2.5 mg of xanax per day to help control the anxiety

I saw my PCP/internist on May 28th And she did listen to my heart for about 5 - 10minutes and It was going at a decent clip probably 125bpm she didn't seem concerned nor did she think I required an EKG or Holter Monitor but she did say if I felt either would help to relieve my mind to call her and she would set either up for me. Do you think either would be warranted?

I also now have a therapist whom is trying to teach me many relaxation techniques though Neither of us will deny the slow if any progress. And Anxiety disorders do sadly run in my family on my fathers side.

Also I space out the xanax doses 1mg when I wake up .5mg 1-2 hours laters then 6-8 hours later another .5mg and 4-6 hours another .5mg.

But one thing even before the appointment I keep getting this odd sensation that my heart muscle is 'weakening' or beating that is to say with less all around strength. Now I am will to bet that has more to do with my Anxious perception of what my heart and by proxy of course pulse is doing. But it feeling weak is disconcerting, But I do believe my doctors listening would have picked up on it if it was really weak..

It has been a long process and I assume it will continue to be , but if you could give me your views on any or all of the above I would appreciate it greatly and again thank you for your initial response I found it both helpful and informative.


Thank you very much.
 John Kenyon, CNA - Fri Jul 11, 2008 11:25 am

User avatar Hello again -

Thanks for the update. It's helpful for sure. First, as to the regularity of the Toprol dosing, you are more than regular! If you can keep it within a one-hour window you are doing really well. I'd guess you've removed any possibility of any rebound effect. It would take several hours, at least, to notice it anyway, and at the lowest dose (which you are taking) it might be negligible anyway.

Next, your most recent visit to your PCP. While she seems quite comfortable with her assessment of the problem as anxiety-based, I suspect a resting 12-lead EKG would be helpful to your peace of mind and also serve as a useful baseline document. So long as nothing out of the ordinary shows up aside from the mild sinus tachycardia (which is just a little bit unusual), then you could let the issue go, and perhaps relax more, which could only be helpful.

You are using Xanax to its fullest potential by speading it out over three daily doses, but there are a couple of minor problems I see with this, which you might discuss with your PCP next time you meet: one, Xanax, as a short-duration "rescue" drug, is not the most appropriate pharmacological approach to this sort of problem -- although it is still the drug of first resort for many physicians who do not specialize in psychopharmacology. Frequent and long-term use has a slight but real risk of dependency, although technically so does any drug which keeps a problem in check without actually curing it. Clonazepam (or Klonopin) can be taken twice a day, which first of all allows for less keeping track, and so less thinking about why you are even taking it; second, its effect is more constant over the 12 hours, so there is a lot less up-and-down than with Xanax, which was intended to abort panic attacks or episodes of acute anxiety but was not designed as a therapeutic approach; finally, there are other approaches which work for many (but not all) anxious patients, such as a number of the SSRI family of anti-depressant drugs, which also have a longer dosing interval, which has the same important advantage of not bringing so much attention to itself. I think Xanax has its place in the battle with anxiety and PD, for instances where the problem breaks through or intensifies on occasion, but something you can take only once or twice a day, such as clonazepam, really does have a symbolic effect as well as a practical one. There is also the matter of less sedative effect, which for some people can be an issue with Xanax (although again, your dose is pretty low).

I do think the EKG being done might have some potential benefit in terms of easing your mind, as also as a proper tool to fully assess your health and a baseline for what's "normal" for you and your heart. I do strongly suspect this is entirely an anxiety-based problem, and yes, the perception on your part of your heartbeat's having grown weaker is strictly a subjective one. We can get so tuned into our somatic sensations that we lose all perspective as to what they are tellng us, which is why it's good to have another party check from time to time, preferably your PCP or at least a skilled nurse or technician. If your doctor has listened to your heart with a stethescope then she knows the actual force with which your heart is beating, so you can rest easy about that.

It is difficult to learn to "forget" to pay so much attention to your heart's rate, rhythm, force, etc., but since there is no clinical evidence of any actual disease, this would be a good goal as well as a good marker that you are becoming less anxious and concerned about your heart's functioning.

Chronic anxiety, as well as panic disorder, can run a long, obstinate course, but with the proper clinical approach it can at least be managed and your quality of life and peace of mind can be much improved.

I hope all this is useful to you, and please do stay in touch.
 SirWence - Fri Jul 11, 2008 3:46 pm

Ah Thank you, and sorry for using a different name, I couldnt remember my password until today. Wanted to thank you for the advise and at this point I spread my xanax out over the day as best I can. My doctor is on vacation for a week and a half due to family emergency, And I would prefer to have her do anything that needs doing EKG wise though she might just give me a 6 lead EKG , is that adequate enough? And I sadly woke up an hour later then usual today so changes things a bit dose wise I think not by much though.

I wanted to just ask if you thought the 6 lead EKG is ok and when you do you think the best time to take the beta blocker is I generally have waited 3-4 hours after waking up to make sure its in my system for the majority of my waking time.
And after I talk to my doctor, and probably get the EKG done I will update you and if you don't mind ask a few more question and show you the EKG.

Thank you very much you have been of great help.
 John Kenyon, CNA - Sun Jul 13, 2008 11:13 am

User avatar Hello -

No problem about the name change. I think I followed you OK.

You're being responsible and careful with the Xanax dosing, so that should work out fine for you until or unless the medication is changed to something that lasts longer and requires less mental computation.

As for the Toprol, again, as long as you take it within an hour or two of the 24 hour window of the previous dose, there should be no problem there. It can take up to 12 hours without it for some people to notice something wrong, and at the low dose you're taking you could still take the regular dose even that late, although I would advise against that as a routine practice, and besides, as with the Xanax, you appear to be very careful about the dosing schedule, so you should be fine there. The goal with Toprol, as with any routine maintainance drug, is to get the most steady possible effect. So the closer to regular intervals and daily use, the better. It doesn't matter when you take it, morning or evening, or even mid-day. Just choose a time when you are least likely to find yourself without access to the pill and some water.

Now then, about the 6 vs. 12 lead EKG: while I'm not sure I understand why a doctor would even offer a six-lead EKG, perhaps that is the equipment available to her? To meet the universal standard of diagnostic criteria, a 12-lead is the one used (or in some cases even a 15 lead has been made standard); still, a six-lead EKG, for purposes of diagnosing an arrhythmia or, in your case, a tachyarrhythmia, should be adequate, since the rhythm can be visualized in just one lead, and the additional ones only help to visualize any electrical abnormalities that might explain why it is happening. So a six-lead EKG should be fine for your purposes, if that's all you can get. It's just a little unusual, since now 12-lead EKGs are common even in the field (many EMTs and paramedics now have access to portable 12-lead equipment on ambulances now, where a few years ago they were working with one or two leads at most).

By all means do get back to us after you've had the exam and EKG, and let us know what you learn. In the meanwhile it would seem you're doing everything right, so just keep doing that and try to minimize stress and anxiety as much as you can.
 oldschool87 - Thu Dec 10, 2009 1:38 am

Hi I am 18 years old and for the past few weeks I've been having an elevated heart rate that lasts for a hour or so. At some points I've been having 90-100 beats per minute after i start walking or stand up. Right now I'm taking a gcf injection to promote growth of stem cells because im a donor. Ive also started working out everyday (no running) for the last 3 weeks(not including this one).

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