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Forum Name: Arrhythmias

Question: Anxiety and PACs - heart disease?


 norwegian - Wed Nov 11, 2009 9:35 am

Hello, from far north :)

My history is about as follows:
Discovered some premature beats about half a year ago, after a hard day at work with lots of stress. Disappeared after a couple of hours, but kept coming back. Because of this, i visited a doctor and was put on ECG - which was fine. No premature beats.

I wasn't completely relaxed, and requested a Holter, a stress ECG and eccocardiography, which was conducted in august, september and november.

Holter results (and resting ECG with cardiologist: Average HR 75 (Holter) some PACs, low number (not sure how many), most of them during exercise. No PVCs. Resting ECG: QTc 400ms, QRS 105 ms, HR 72. Normal PR-time, everything else OK.

I continued to get PACs during exercise (probably caused by anxiety and adrenaline). My stress ECG results: No arrythmia, 225w work load, O2 99%, BP at rest 115/70, BP at max load 210/90, max heartrate 200, no dizziness, no ST changes, only 1 PAC at rest after stress test, at HR 120.

Ecco: All results normal, was extremely scared at the ECG before ecco, HR 110, sinus tachycardia, QTc 438 ms!! I know that Bazetts formula is inaccurate at high HR, but it still scared me. The T-waves seems normal, but I'm afraid of LQTS / Torsades. After ECG my BP was 145/85, HR 130 during ecco. Immediate drop to 80 when cardiologist told me everything was fine. No PACs/PVCs during ecco.

Afterwards the cardiologist told me that PVCs (?) was completely normal and it was nothing to worry about. I haven't found a single PVC on any test, and I don't understand why this suddenly is PVC's? Is PVCs worse than PACs (I worry about R on T PVC, etc.) Do this exist in healthy hearts?

Anyway, the premature beats during exercise are more or less gone. My cholesterol is fine. I feel 2-10 premature beats during a day, and probably 15-20 before sleep. I feel this as a "long" heartbeat, a short break and a hard beat. Sometimes i get palpitations, regular, hard and fast HR. I still feel anxiety. Everyone tell me this is normal and nothing to worry about, but why have they appeared? And how do I make them go away? Can they be caused by some underlying heart disease that is not found yet? Can PACs cause supraventricular tachycardy? Can PVCs cause V-tach?

27y, non smoker, regular exercise, some chest pain but I believe this is muscular.
Is all this just caused by anxiety?
 John Kenyon, CNA - Tue Nov 24, 2009 11:50 pm

User avatar Hi there -- You've come away with a remarkably nice comprehensive cardiological workup result! The only thing it showed up was some anxiety during part of the exam, but that's not unusual, and since you're fairly knowlegeable about certain parts of this process (but not others) it would suggest a somatic obsessiveness associated with some mild anxiety. Hopefully the totally negative exam and tests and what I will tell you here will help alleviate the rest of that.

First: Premature atrial and ventricular beats (PACs and PVCs) are extremely common in the healthy population as well as those with heart disease. They are neither diagnostic nor prognostic of anything. We now know even the R-on-T phenomenon (which you really ought not know about at all, but since you do, we'll take that into consideration) is no more dangerous than no R-on-T. In other words, in the critical care setting post MI (I'm going to assume you've done enough research to understand these terms) half the patients who suffered a dangerous arrhythmia did not have R-on-T beforehand, and half who did had no lethal arrhythmias as a result,rendering this phenomenon virtually useless -- but something that is routinely charted when the patient has had a heart attack. Other PVCs and PVCs have no intrinsic meaning, even though they can occur in the setting of various types of heart disease, because they also happen in nearly all healthy people to a greater or lesser extent.

Your initial Holter results were beautiful.

Without being monitored it is impossible to be certain whether a flip in the chest is caused by a PVC or PAC, and it doesn't really matter. PVCs are somewhat more common, but some have more of on, some of the other. Many have both. Most doctors see mostly PVCs. The fact you've only showed up PACs is statistically interesting but absolutely meaningless.

The QTC was on the far side of normal, but of course it was still normal, it varies under varying conditions and, as you've pointed out (and again, really shouldn't know this) Bazett's formula becomes less and less reliable (or the long side) with increased rate. The fact remains it was within normal limits (WNL) anyway. There is a line for a reason.

Anyone might reasonably be "afraid of LQTS/torsades" if one had either of these things, but you don't, so no need to worry or even think about them. Easier said than done, of course, once the genie is out of the bottle. Your alternative would be to go into the medical field, perhaps as a paramedic or cardiology tech, since you've already got some useful knowlege in this area. No, I'm perfectly serious. It's something to think about.

At 2-10 premature beats per day (atrial or ventricular) you're probably way below the average. I personally had a Holter done once (for research purposes) and turned up over 2700 PVCs. It was just one of those days!

You've asked if PVCs or PACs are worse. Neither is "worse" than the other, and neither is dangerous nor significant. The R-on-T issue is almost always discovered by lay people out of context, which is the danger of reading up on this stuff. PVCs don't "cause" V-tach, but V-tach, since it is a run of consecutive PVCs, begins with one. This is a technicality of language only. They don't cause V-tach. And even runs ("triplets" or longer), though still considered V-tach by some clinicians, are almost always meaningless too. In fact the only time ventricular arrhythmias are of concern is when they occur in the setting of a damaged (dilated, scarred) left ventricle with a low ejection fraction. These people are already unwell, so are already being treated for congestive heart failure. They are manifestly unwell.

You also ask why these premature beats have appeared. This is one of those questions that can only be answered with a non-sequitur, because like allergic reactions, "I never had this before" answered by "Well you do now." They don't happen (or are not noticed) til they do. You've probably had them before but for some reason are more aware of them now, and this is sometimes solely due to the timing of the premature beats, which can make them far more noticeable depending upon whether or not the tricuspid valve happens to be closed when one fires off.

I hope I've reassured you with all this. While I always encourage patients to be their own advocates and realize it helps if the patient can be somewhat knowlegeable about their complaint in order to describe it well, sometimes a little knowlege can be a dangerous thing, especially in medicine and without the proper context. Again, since you have a proclivity for this stuff, you might want to consider making it a career. It's often true that nursing or tech work takes the anxious person's attention aay from himself and places it where it can do far more good. Just a thought. There's an awful lot more to learn , but you'd at least have a leg up in the cardiology part.

Otherwise I find nothing remarkable in your data at all. You're in great shape with perhaps a little anxiety to work through. I hope this is helpful. Good luck to you and please do follow up with us here as needed.
 norwegian - Wed Nov 25, 2009 4:30 am

Good morning, and thanks for a very good answer.

I realize that my knowledge about heart diseases is too high for a "non-medic" to handle. My diagnosis from cardiologist is strong cardiac neurosis, and "innocent / benign premature contractions". I strongly believe that, if I would just accept the first explaination (you don't have a heart disease) without reading articles from cardiology journals, this would have been easier.

It's interesting what you say about making medicine a career. This was actually my first plan, but my grades was a bit too low. Instead, I got a masters degree in business and administration, I guess I could start studying medicine now, but it's not easy to combine medicine with economics. One of the degrees would then be a waste. But my family strongly suggest me to be a doctor.. maybe you are right.

I don't consider myself to be a hypochondriac. I'm not worried about cancer, or other diseases, except heart disease. But I guess the cardiac neurosis diagnosis is correct.

I got a note with the results from echocardiography, which was no valve diseases, no hypertrophy, no shunting, left ventricle ejection fraction 55-60%, normal size heart, ventricles and atrias, no signs of myocarditis or pericarditis, no arrythmia during the test. Aorta abdominalis 17mm. ECG results: All normal except sinus tach.

From this, I have a couple of questions (that are probably stupid and a consequence of anxiety and too much reading). I had a HR of 130 and palpitations during the test, would that overestimate my EF (that in my opinion is a bit low) caused to hard beats?

The reason I ask, is when I'm relaxed (and have a HR 50-55, this is typically after exercise when I guess I get rid of some adrenaline and stress, my resting HR is usually higher) I sometimes feel I don't get enough air. This is probably caused by anxiety and hyperventilation, but (of course) I get afraid of beginning heart failure and that my EF when resting if lower.

I also have a follow-up question about the relationship between PAC's and SVT (see, I get better, I don't ask about PVC's and V-tach anymore). Can PAC's cause SVT in a healthy heart (is it the PACs that trigger SVT?). A couple of days ago, I had problems sleeping, got anxious and felt a lot of premature beats. Suddenly, my HR increased to 120, with very "light" pulse. When breathing in, the HR was even higher and lighter (and reversed when breathing out). My HR slowly decreased, and in about 15-20 minutes, it was normal. I guess sinus arrythmia and slow HR recovery is contraindications to SVT, but can it still be SVT? Does SVT cause fainting?

Thanks again for a very good answer, you're doing a great job!
 John Kenyon, CNA - Wed Nov 25, 2009 12:48 pm

User avatar You're very welcome.

I've noticed over the years that some of the best doctors, nurses and techs have just a suggestion of OCD, and also personally believe "cardiac neurosis" may be a manifestation of OCD. Just my idea, but the point is I also feel this, pointed in the right direction, can sometimes make for a really good MD, nurse or tech, especially in the area of cardiology. It also draws their attention from themselves to the people for which they're caring, which is a win-win. Was just a thought, but I'm interested you'd already considered this. Also you don't sound especially hypochondriacal in general (it is a much misunderstood problem).

Your echo results could hardly have been better! Congratulations on that.

I'll try to answer your new questions now, and remember, the only stupid question is one you decide not to ask.

The increase in resting heart rate (and cardiac output, as is likely a result of some anxiety) can affect one's EF to a small extent, not enough to matter, though. What needs to be kept in mind is that all signs and measurements for the most part vary from moment to moment (BP will vary, heart rate, EF, all that stuff) depending on the time of day, activity, caffeine/no caffeine, etc. We do try to narrow the variables as much as possible (which is why certain drugs, foods, caffeine, etc., are curtailed for 12 hours or more before testing). Being WNL is the goal. There are some variations which are so regular as to draw attention, but usually even these don't have any useful meaning. We're not operating by a CPU, so speed or strength of various measurements will vary quite a lot during a day.

The sensation of not getting enough air is classic for the anxious patient and hyperventilation, which can be done totally unwittingly (and usually is) just makes that sensation all the more pronounced. The brain thinks it doesn't need any more air, so the whole process feels funny at those times.

EF will vary some, but as long as it's between 50-70 on any given day it's considered WNL and just fine. It won't drop below its own threshold without a disease process, and if there's a disease process it can't up itself enough to accomodate more than a limited amount of exertion. It's a pretty trusworthy thing to go by. You're good in that department.

While SVT is generally less of a concern -- isn't life threatening so much as annoying -- it, like V-tach, will usually begin with a PAC, but for precisely the same reason, because the whole episode is really al PACs. The question of triggering is actually more difficult to answer for SVT because there are a lot of different mechanisms that can cause it. It can also be "lone" and spontaneous. These episodes are usually brief and there's no apparent reason for them. It can be difficult, outside the monitored seting, to tell the difference between a "slow" SVT and simple sinus tach. When the rate gets up over 200 BPM, though, you can be pretty sure that's what it is. That's not what's happening with you, and sinus tach can easily get into the 130s. Again, kind of a moot issue. The fact your rate normalizes slowly rules out SVT, though, because it flips on and off like a switch, doesn't start and end gradually.

Good to hear from you again, and hope this clears up the majority of your misgivings. A little reassurance can go a long way sometimes.
 norwegian - Thu Nov 26, 2009 4:49 am

Good morning and thanks for your reply.

I read your answer last night (this is GMT +1) and I had, for the first time in a while, no problems sleeping, and woke up completely rested today. It was an amazing experience, and I thank you for that.

Anyway, I know my problems are not completely solved yet, and I have a long way to go considering "thinking right". It's interesting how you consider "cardiac neurosis" (I'm not sure if this is the right expression, directly translated from norwegian, the word is "heart neurosis", but I believe this is the same) in fact an OCD (like those people who never trust they locked the door or switched of the oven). But you may be right. Before sleeping last night, I tried to focus on my right toe instead of my heart. And it actually worked quite well, I noticed no palpitations or premature beats.

It's also remarkable how norwegian doctors (and GP's especially) considers PVC's more dangerous than US cardiologists do. My GP says that "PVC's are rarely seen in healthy hearts, it's something we usually see in patients with MI or heart failure"

Further, I belive that many of my worries is caused by the fact that my dad had a CABG 3 months ago. He recovered remarkably well, but the problem was that he suspected CAD 10 years before the surgery, and no doctor believed him. One day he was considered completely healthy, the next day he was on CABG.

Anyway, thanks for your extremely quick and qualified replies, these services cost about $35 in Norway and haven't helped me much in the past.
 norwegian - Fri Nov 27, 2009 3:34 am

Sorry to bother you again, but something new came up, it seems my Holter actually wasn't so beautiful.

I went to a doctor to learn more about how to treat cardiac neurosis and anxiety. He wanted to go through the Holter results again, and found the analysis results.

I didn't want to see them, because one of my strategies now is to trust doctors and read as little as possible. Anyway, when he found the stack of papers and asked if I wanted to see them - it's a little like watching scary movie scenes - you don't want to look, but you do it anyway.

Well, I had 15 PAC's, less than I expected. They came mostly during activity, as I noticed. Nothing wrong here. But, I found some strange results while sleeping, from 4AM to 6AM, my HR was in range 38(!!) to 90. Rest of the night from 42-95. Is it normal with so high HR variance at night? Is so severe bradycardia normal at night? No one told this to me..

I also found 50 PVC's - most of them at night. No one have ever mentioned PVC's on Holter to me, it's not noted in my journals, or in report to my GP. The doctor said "this must be wrong", and even better "if this was right, it would be dangerous, and your Holter would not be considered normal" (not helping....)

Is it possible that my cardiologist was lying to me, to make me feel better?

Anyway, I was told by the doctor to forget heart diseases, and to tell the truth, I didn't see any PVC's (bizarre and wide QRS complexes) on the Holter prints, and neither did the doctor. You have told me that 50 PVC's is well WNL, and I guess thats OK, it's more the bradycardia (and high HR) that scared me. Is this possibly a sick sinus syndrome? And what maybe scared me most, is my cardiologist actually lying to me, or can Holter computers generate several analysis errors?
 John Kenyon, CNA - Sun Dec 06, 2009 9:55 pm

User avatar Cardiac neurosis is a term I prefer not to use, but is fairly accurate sometimes in describing what develops either as a result of self-monitoring or over-acute awareness of somatic (bodily) behavior. This matches, in terms of anxiety, a variant of OCD, although there are certainly those who would argue it's an incorrect application of the term. I'll stand by that analysis, however.

That said, there is that interesting Holter monitor development. First, as to the cardiologist "lying" to you, what I would prefer to call this, if in fact it happened (and we can't be certain, can we?) would be selectively informing the patient. I don't think it's a good idea in most cases, but I'm not a doctor; I'm definitely not your particular doctor. I won't second guess him on this matter. However, what showed up on the Holter monitor, the few PACs and 50 PVCs, is definitely unremarkable and not at all dangerous nor any cause for concern. Stating this "cannot be right" and "if it were right it would be dangerous" is definitely not helpful. It also makes no sense. At this point I begin to wonder about the doctor. There is nothing in what you've relayed that would be considered dangerous. I wouldn't use the term "lying" but might at this point substitute "confused."

As to the variance in rate while sleeping, it's not as dramatic as it may appear, but is somewhat unusual, especially the low of 38 BPM. This is not surprising, actually. Neither is the high of 95. What is slightly unusual is seeing that large a difference in one patient. Were it sick sinus syndrome (SSS) however, there would be more sinus pauses, even more rapid heart rate (actual tachycardia, which would run at least into the 140s) and likely atrial fibrillation as well. If this only took place during sleep it wouldn't even remotely suggest SSS, but rather just a very broad example of the normal variance occurring during a sleep cycle. So again, not especially remarkable. The PVCs likely occurred during slower periods and the PACs probably during faster ones. This would correspond to various parts of the sleep cycle, dreaming, etc. and is a normal "tidal" effect. Some people may not go quite as low or as high, but they will get down into the 40s and up near 90 routinely, so you're only a little bit outside what is quite common.

I do hope this is helpful. I like your idea of trusting the doctors and trying not to infer things from the reports. However, I am also wondering about this particular doctor and what he means by certain things said and unsaid.

Good luck to you. I think you're in good shape. Please keep us updated.
 norwegian - Tue Dec 08, 2009 3:36 am

I went to see an internist regarding this problem.

He went through the Holter test, (this time, I stayed away from the papers), and results as follows:

Low HR: Sinus bradycardia, and completely normal (according to him)
No signs of Sick Sinus Syndrome
No AV block
The PVCs were single and unifocal according to test summary (not that he saw them, and my cardiologist said they didn't exist)
Single PACs

Like you all have suggested, this is a mental problem, and not a heart disease.

It was quite interesting that he answered 15 of my questions with "this is an irrelevant question" or "you can't stop having wrong focus".

I guess you all are right. I need to learn that a PAC or PVC is not more dangerous than an ordinary heart beat. I know it's not an easy process, and I still have problems sleeping (I sometimes feel that my heart and body is stopping before sleep), of course this is only my imagination. I get scared, and this is causing my "SVT runs" (that are not SVT runs) described earlier.

I know that it's not SVT, simply because I can feel a couple of premature beats during the runs. And this is impossible during an ectopic tachycardia, I believe.

My internist gave me a specific order, quit reading medical topics unless I wanted to be a MD. I guess that is right, too.

Thanks for your help, you have great knowledge about cardiology topics and mental health.
 John Kenyon, CNA - Tue Dec 08, 2009 11:43 am

User avatar It's not an easy thing to digest, and I'm not necessarily sold on your doctor's "tough love" approach, but the bottom line is it's something that won't cause harm. The fact it feels very unpleasant just makes it diffcult to focus elsewhere, which really is the best way to resolve most of this and make the remainder tolerable. You've taken a big first step by acknowleging this part. Keep up the good work and stay in touch.
 norwegian - Tue Jan 05, 2010 6:47 am

Hello, and happy new year.

I'm definitely feeling better now, but I have three questions (that are really not bothering me as much as before). I believe I have to "learn to live my life" again, and learn that benign symptoms in fact are completely benign, if that made any sense.

My first question: Sometimes when I feel my heart beats without checking pulse (feeling heart beats in fingers, head, etc.) they sometimes tend to skip one or a couple of beats. Not the feeling of premature beats with the following hard beat. Im not sure if this is real, though, maybe the pulse is just lighter for a couple of beats, during breath or something, and I never sense it when I'm actually checking the pulse (which I usually don't do anymore). If there actually is a skipped beat, can this be some kind of AV block? Do this appear in young otherwise healthy people, and would the symptoms present in this way? And, wouldn't this start with a 1st degree AV block? My PQ time is normal at all ECGs, and no AV block is noted on Holter. Can this phenomena just come and go?

Second questing concerning alcohol: During christmas I met my friends for a couple (or maybe a little bit more) of beers, two times. After I came home, I started to get some kind of tachycardia (HR 110-120). After a couple of hours sleeping, I wake up, and my body was like during exercise. Sweating, heart rate 130-140, sensation of high body temperature. Next morning everything was normal. What is this? Is it the "holiday heart" phenomena (AVNRT) or just a physiological reaction to alcohol?

Third question regarding blood pressure. I sometimes get a bit lightheaded when standing up or walking. My physiotherapist says this is tight muscles in neck / shoulders. My BP is at last measure between 115-125 / 70, and my GP says it's the best BP he has ever measured. However, how low BP is considered too low, and can cause dizziness when standing?

And, just a last question: Is it actually possible (without an ECG) to sense the difference between a PAC and a PVC? I must say, its hard to put the Holter PAC/PVC issue completely away. When it's noted in report "spread single PACs, otherwise normal findings" this correlates bad with "15 PACs and 50 PVCs" (because 50 is more than 15). Is PVCs registered on Holter tests usually PACs with aberrancy in young people?

I remember this part of dialogue with my cardiologist after my holter test:

- You have some premature beats...
- OK? I suspected that..
- They origin in the atria..
- Good, that was a relief..
- But they wouldn't be dangerous even if they origin in the ventricles..
- But they don't?
- No.

And..

- How many PACs was registered?
- Eh.. I don't remember..
- High number of low number?
- Low number.

Like you probably understand, this doesn't make sense to me.

Anyway, thanks for great help, I believe I will handle this after some time. However, as you can see, questions appear sometimes, and with some reassurement, I believe I can get completely well.
 John Kenyon, CNA - Sun Jan 31, 2010 2:39 am

User avatar I'll try to answer your questions in order. First, the issue of percieved skipped beats based upon somatic sensation of which the vast majority of people are unaware to begin with: This is not a reliable indicator of what's going on rhythm-wise. Sometimes we feel consecutive pulses in the periphery and sometimes we do not. Much depends upon dilation of capilaries, posture, etc. The loss of a pulsation in the skin or peripheral vasculature not only is not helpful in "reading" the pulse, it is utterly unrealiable. Best strategy: try to lose awareness of these pulsations or, at best, come to terms with the fact they are totally unreliable indices.

Second: Holiday Heart is generally applied to episodes of atrial fibrillation resulting from binge drinking occurring only around the holidays. However, less problematic sinus tachycardia can be caused also by even light drinking in some people. It is not "holiday heart" as understood, but is a bodily response to alcohol consumption based upon the cause and effect of blood vessel dilation caused by alcohol ingestion. In those so predisposed, there is a tendency to this dilation lasting up to 24 hours, with consequent mild sinus tach to help offset the drop in blood pressure. It generally resolves by morning and is not a medical concern.

Third: Lightheadedness upon rising, standing or rising and walking, especially after prolonged sitting is extremely common and normal. It may be due to tight/tense neck muscles or may just be a slow baroreceptor response. If it becomes disruptive there is the possibility of neurocardiogenic syncope or postural hypotensive tachycardia or POTS, but this is still within relatively normal limits although it can be a minimally disruptive passing phenomenon. Those with POTS learn to adapt to the problem by living and moving at their own pace. However, it is but one end of a spectrum that is generally normal. If it presents a problem in passing, one then must learn to stand and wait a moment before beginning to move about. Otherwise is perfectly normal.

Finally: It is sometimes, but rarely, possible to distinguish between a percieved PVC and PAC. It is generally extremely difficult to near-impossible to tell the difference subjectively. A few overly somaticized patients manage to get it right once in a while, but the exercise itself is pointless. Both are essentially benign anyway. The fact that a doctor may or may not be willing to discuss a Holter report in actual detail is often shrouded by a desire to minimize the interest of the patient in something which is inherently meaningless.

Hope this answers these questions for you.
 norwegian - Wed Feb 03, 2010 6:07 am

Thanks for your answer.

No further questions - I just wanted to thank you for all help.
You are doing a great job, and your answers are far more helpful than those I have got from my MD's.

Thanks again!

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