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Forum Name: Arrhythmias

Question: PAC's in bigeminy.


 jazzmowsky - Mon Apr 06, 2009 6:42 pm

Hi,


I have recently found this forum and would very much like the help of John Kenyon. I am in the UK, am 54 and have had for the past 15 years episodic PAC's which have come and gone down the years. I have them when I am unwell or stressed or eat challenging foods. For the past three years I have been taking 80mg sotalol am and 80mg pm, usually twelve hours apart. Twelve weeks ago after flu the pattern of the PAC's changed considerably and I am now in almost constant bigeminy or trigeminy, the only relief I have is when I sit down or lay down to sleep. I have called our paramedics out and they have captured the arrythmia on a strip, and I have been seen in the local cardio clinic in arrythmia aswell. The registrar diagnosed PAC's and said that they were nothing to worry about, he wanted me to have a treadmill test, no echo as I had one three years ago, and to change to cardicor once the stress test was complete. I have had a 48 hr monitor in the last week which captured my arrythmia, and also the treadmill test, as yet I have not received my results. I am due back at clinic in late May. I tried 2.5mg of cardicor for four days but had an unpleasant reaction to it; low BP as in 80/55, slow and very irregular heartrate and shaking and dizziness. My GP discontinued it and put me back on sotalol again. I am very frightened as the pattern of my life has completely changed, as soon as I am on my feet in the morning the arrythmia returns and only stops when I lay down at night. My GP suggested that the sotalol is perhaps not effective and said to stop taking it so for three days I have cut my dose by half, but all day today I have had a heart rate of over 100 which has been in bigeminy relentlessly all day and I am at my wits end. I am sitting now and all is settled and quiet and I would not know there was anything wrong. I am terrified of walking around, or exerting myself unduly in any way. When I had the treadmill test last week, the PAC's disappeared when my heart rate reached 140 but I found the whole thing so frightening that I couldn't go on with it for the full required length of the test. Although menopausal and taking simvastatin, my general health is okay, I am not overweight, avoid all the triggers for arrythmia as much as possible, and I also accept that this situation is causing anxiety that is possibly making the situation worse. I am worried that the doctors are missing something vital, can't understand why my heart rhythm is so out of kilter. I am told I should not have symptoms, but as soon as bigeminy begins, I am disorentated and nauseous and out of breath. Please can someone help at all ? I am verging on desperate. Thank you for your time.
Kindest wishes. Julie.
 John Kenyon, CNA - Thu Apr 09, 2009 2:16 am

User avatar Hello Julie--

First, while the presentation you describe is fairly unusual, it is far from unheard of, and absent any structural heart disease it is not, in and of itself, dangerous. However, that doesn't account for the tremendous degree of anxiety and general discomfort it can cause. Why some people have just random PACs while others have them in group beating patterns such as bigemeny is unclear, but the result is the same, and when the problem is aggravated by movement or exertion, there is usually some obscure structural abnormality that is responsible. Again, though not dangerous, this will definitely cause most people to feel inhibited about their activities and this leads to deconditioning, anxiety and more premature beats.

You may have had a normal echocardiogram three years ago, but that's hardly reason to pass on one now. Things can be missed and things can have changed. Some of the possibilites are mitral valve prolapse, which can often be missed (quite legitimately) on a given day, while visualized on another; and a more unusual abnormality often responsible for frequent PACs, which is known by the alarming (but misleading) term atrial septal aneurysm. This is not an aneurysm in the sense we normally think of one, but rather a failure of the tissues of the atrial septum to fully merge together prior to birth. The gap that's left in the space between often places stress on the fibers trailing off the sinus node, causing freqent PACs or even supraventricular tachycardia. This can also be missed on regular echo and sometimes requires a transesohphageal echocardiogram (TEE) to be visualised. It's an off-chance, but since your problem is so frequent and consistent, there is a greater likelihood of some structural abnormality. Of course the best way to get to the bottom of this would be to arrange a consult with an electrophysiologist (if you haven't already done this). An EP specialist is much more likely to pick out clues that could lead to identifying the problem.

The Sotolol prescription doesn't seem especially wise, honestly, as this is mostly effective against atrial fibrilliation, and whoever told you you shouldn't have symptomstoms obviously hasn't experienced this problem. You are very likely to have symptoms, even though they are benign. The are still extremely unpleasant.

While anxiety really will usually only make the symptoms worse,it's pretty difficult to control andxiety while the problem continues happening with no medical help. The cardiocor probably wasn't a great idea either, and I'm wondering why a regular beta blocker has not been tried (something like metaprolol, for instance).

Extremely frequent PACs, whether in group patterns or randomly appearing, are both common and very unpleasant. They are not serious in themselves,but there i s no reason why you shouldn't begiven every opportunity to live free of most of this aggravation. A regular beta blocker and a consult with an EP specailist may well help resolve most, if not all of the problem. We all weill have some of this happen from time to time throughout our lives, but this is excessive and you deserve a better, more thoroug workup by a subspecialist who may well be able to resolve this for you or at least make it much more tolerable.

Please follow up with us here as needed and hang in there. This can also get better spontaneously. Good luck to you and please keep us updated.
 jazzmowsky - Thu Apr 09, 2009 4:21 am

Hello John.

Thank you so much for the reply. Here in Leicester I am not sure how to get an appointment with an EP specialist other than go through my GP. I will talk to him once my results have arrived back from the hospital. Where I go is termed a centre of excellence for cardiology, but we don't get such a thorough assessment as it appears patients do in your country. I am totally and utterly desperate to get this resolved - my GP is very sympathetic, the only quicker route to a specialist is via the private system and we could not afford to do that. In the meantime I am literally clinging on day for day, am in tears writing this. I have read many of your posts and could not believe the level of information that you give here. My last appointment went something like, well they are just premature beats and I have to adapt to living with them. These last three months have been hell and because I am actively caring for my daughter Nikki every day , even the action of walking around the house is unbearable. I hear what you say about the medications that have been prescribed. I can just about tolerate the sotalol and the cardicor was a disaster, I did worry the out-of-hours GP that came to the house, my BP was so low, but I was okay within a couple of days. I am frightened to do without the sotalol completely, but that is anxiety realise that. I don' know how to get an echo as they have said a definite no to that, I feel in my heart of hearts that something must have changed to create this non-stop arrythmia, but without prompt medical assistance I am unable to begin to resolve this. All I can say for now is thank you for getting back to me, I will contact my GP and try and get something more definitive done. Kind regards to you John.

Julie.
 jazzmowsky - Thu Apr 09, 2009 4:21 am

Hello John.

Thank you so much for the reply. Here in Leicester I am not sure how to get an appointment with an EP specialist other than go through my GP. I will talk to him once my results have arrived back from the hospital. Where I go is termed a centre of excellence for cardiology, but we don't get such a thorough assessment as it appears patients do in your country. I am totally and utterly desperate to get this resolved - my GP is very sympathetic, the only quicker route to a specialist is via the private system and we could not afford to do that. In the meantime I am literally clinging on day for day, am in tears writing this. I have read many of your posts and could not believe the level of information that you give here. My last appointment went something like, well they are just premature beats and I have to adapt to living with them. These last three months have been hell and because I am actively caring for my daughter Nikki every day , even the action of walking around the house is unbearable. I hear what you say about the medications that have been prescribed. I can just about tolerate the sotalol and the cardicor was a disaster, I did worry the out-of-hours GP that came to the house, my BP was so low, but I was okay within a couple of days. I am frightened to do without the sotalol completely, but that is anxiety realise that. I don' know how to get an echo as they have said a definite no to that, I feel in my heart of hearts that something must have changed to create this non-stop arrythmia, but without prompt medical assistance I am unable to begin to resolve this. All I can say for now is thank you for getting back to me, I will contact my GP and try and get something more definitive done. Kind regards to you John.

Julie.

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