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Forum Name: Arrhythmias

Question: Anxiety over long runs of PVCs/PACs


 maxjax - Sun Dec 20, 2009 3:11 pm

I am 36, female, average weight, 10 months postpartum with my second child. I have had PVCs and PACs for over 10 years. I was told these were benign and have never been on medication to treat them. I have a history of anxiety and panic attacks, and needless to say, these flip-flops in my chest don't help! I have had numerous workups to try and ease my anxiety, most frequently during my last pregnancy about a year ago, a normal echo and stress test with only PACs appearing, and a holter (on a really active day) with about 500 PVCs and 3000 PACs. My doctor (who has now retired) repeatedly told me that I was too healthy to be in his office and to not worry about them unless I started passing out.

My question is that since last spring I have, thank goodness, only a few of them a day but have instead been occasionally having episodes of what seems to be long strings of the ectopic beats. I'll feel very nervous or panicky about something and feel a surge of adrenaline in my chest and then a few isolated skipped beats which turns into a string of skipped beats which I feel as flip-flops in my chest. It can vary in length from 3 or 4 to maybe 30-60 secs. of them. These are different than the bursts of a couple of them I have felt in the past that seems unrelated to anything. Those were quite fast in succession and over in a flash. This doesn't feel very rapid, but more like my regular heartbeat with slight pauses in between, but I feel the flipping with each beat. If I can relax they seem to go away or anyway they resolve on their own. I don't have any other symptoms, but to be honest I am usually immediately sent into a panic so I'm not really breathing well or anything, but running for the car to go to the hospital:) (We are pretty far from a hospital though so I'm afraid I wouldn't get there if something is really wrong). I'm afraid that they might be runs of v-tach or something dangerous, but they don't seem to match up to anything I've seen described on the interenet. I've had a very rough year with the new baby and having to move in with my mom and my husband away for work, so I know I am very anxious right now. My therapist says that I am creating these and that I need to relax and ignore them. My family agrees. I want to know if it is safe to just ignore them. If I had something serious enough to be concerned about would I have more symptoms? I know I can find a new cardiologist in my new town and try to get an event monitor, but I feel that would just encourage me to be even more neurotic about them. I'm tired of going for workups everytime I feel something new in my chest and I just want to get on with my life without feeling that I'll keel over any minute. I think I am one of those people who have read too much about these and is too aware of their heart! Anyway, I wonder if you have any insight about what new arrythmia this could be and if it seems okay to ignore it. I can't take any medication for them as I am still nursing my baby. Thanks very much.
 John Kenyon, CNA - Tue Dec 22, 2009 11:41 pm

User avatar Hi there -- First, you have my unconditional sympathy. This is one of the most common, yet most frustrating medical problems, the variety of ectopic beats and rhythms and how the not only produce but are also produced by anxiety. They are all, as your doctor has inadequately explained, benign -- even when the occur in people with serious heart disease.They are not diagnostic of heart disease even though they can occur with it, because they also occur in normal, healthy people. This renders them medically meaningless, but doctors tend to forget patients are not medical "cases" but are people who require a few minutes of extra time to have these things explained properly, otherwise, as I'm sure you've exerienced, the short, brush-off of "it's nothing" only leaves one feeling more certain somethng's being missed. It's not, believe me, but doctors could often save themselves and their patients countless hours of interaction and friction by simply taking a little time up front to really clarify these things. Which is one reason for The Doctor's Lounge. You've come to the right place.

In the anxious patient in particular these arrhythmias and ectopic beats become a huge problem because they are self-promoting. They are caused by anxiety -- although they also occur normally anyway -- but also can cause tremedous anxiety. It becomes a vicous cycle.

You've gained some insight into the basic culrpits, PVCs and PACs (which are commonly known to increase a great deal during some pregnancies, and also during times of hormonal change), but the worst thing about anxiety-related symptoms is how they change patterns almost as though there is some malice involved. What you describe as having now is one of two basic things: either it is ventricular bigemeny (a pattern where every other beat is a PVC, which is a regularly irregular rhythm), or it is an "escape" rhythm, one of those where an ectopic site in the heart decides it needs to take over for the sinus node. These are slightly faster than the underlying rhythm, and in people with severely slowed sinus rates (various types of heart "block") it actually is beneficial. However, when it occurs in an otherwise healthy person, it simply seems as though the heart is pounding or beating forcefully and not especially fast -- maybe 10 beats faster than it was before the irrititable focus took over. The reason these are felt at all is because they sometimes are not in synchrony with the sinus beat, so they take place when the tricuspid valve is closed (not the normal state of affairs) and this causes the beats to feel more strong, even though they are usually quite regular. There are two types of escape rhythm, one arising from the atrioventricular node (acccelerated juntional rhythm or AJR), and accelerated idioventricular rhythm (AIVR) -- the latter carrying the "idio" prefix because no one really knows where it arises or exactly how it works. Both are, however, completely benign. Both tend to run between 60 - 100 beats per minute, depending upon the underlying sinus rate (rarely more than 10-15 beats above that), so when properly synchronized are not noticed at all. If however they are out of synchrony with the sinus impulse, they will be felt as palptiations and can be very annoying. All three of these potential culprits are not only harmless, they can pass unnoticed or can be very uncomfortable, and in an already anxious patient they will, of course, and especially since they are new and different, cause new anxiety and/or panic. They needn't, but this is the nature of the combination of these things and anxiety: Each makes the other worse.

The obvious solution is to break the cycle. These things do go away on their own, sometimes quite quickly, but the more adrenaline released due to anxiety caused by the new and therefore frightening arrhythmia, the longer it will last and more often it will recur, til the patient finally "burns out" on that symptom, at which time it tends to pretty much go away.

Your heart has simply added something to its repertoire. It will no doubt recycle all these annoying things during times of stress, and whatever causes the greatest anxiety will, by definition, repeat itself til it no longer gets the reaction.

The good news is you've pretty well exhausted the possibilities now. The bad news is: Breaking the anxiety cycle is easier said than done.

That is what it is, though, and knowing this is not dangerous is an important tool in disabling it.

If all else fails, given you have established anxiety and panic disorder issues, there is another route to go aside from beta blocker drugs and anti-anxiety meds: cognitive behavioral therapy (CBT), a self-limited, interactive form of psychotherapy involving literal homework, and not an open-ended type of "talk" therapy. It is aimed at modifying the patient's reaction to certain stressors and can be very effective.

Reassurance sometimes can work as well, however, and that's what I'm offering you here: reassurace. You are having very common, even "normal" events happen, but anxiety distorts the perception of them as well as the frequency. For some people knowing this is enough. It is the least the medical professional can do, to offer a comprehensive explanation of what's going on. Telling you you're healthy would seem, to a doctor, to make perfect sense, but not if there's no explanation as to why you don't feel healthy. I hope I've at least achieved that with you.

Good luck to you and please do follow up with us here as needed.
 maxjax - Mon Dec 28, 2009 11:11 am

Thank you for your very thorough and thoughtful reply. I am feeling somewhat reassured, but thought patterns are difficult to change! I just wanted to clarify that during the runs of palpitations, I don't feel so much of a pounding as a flutter or flip-flopping with each beat, sometimes quite light, that feels exactly like PVC/PAC. Could this really be nothing but an escape rythym as you described? I don't know if it feels like bigemy as each beat feels like a regular rythym and the same. I guess I am having a hard time believing that something that feels so weird and scary could be harmless. I got such mixed info from my doctor. Like sometimes he said that we should try and catch my new palpitations on a monitor, but then when it got down to it he said not to worry about it if I wasn't passing out. I wish that he had been able to say that no matter what sensations I was having in my chest, they are all harmless. I am still concerned that I might be having or might have in the future, v-tach, which is what really frightens me. What would a long run of PVC's (v-tach) feel like? And how would I know if palpitations I was feeling were something to worry about? I know you said they were all benign, but I need to be hit over the head one more time...
 maxjax - Mon Feb 01, 2010 10:02 pm

Hi again. I have done some (internet) research on the rhythms you mentioned, esp. AIVR, which the internet said was rare in healthy patients and mostly found in people with heart disease. So now I'm wondering, could I have heart disease? My last tests were 18 months ago...maybe I have peripartum cardiomyopathy? Is this possible?

I also want to clarify, is AIVR just a run of pvc's at a slow rate and ventricular tachycardia a run of pvc's at a fast rate? And how do we know what is what and when to worry? That is my main question. If I'm having a lot of fluttering do I just assume, without symptoms like fainting, that I am fine? Or does the duration matter? Like last week I was lying in bed on my left side and felt 4 flutters in a row fairly quickly followed by a couple regular beats, then several more flutters in a row. I jumped up to get ready to go to the hospital, but no more came so I went back to bed. Now I am very worried that it will happen again. But my old doctor said that as long as all I was feeling was palpitations then there wasn't anything to worry about. But what if I'm having v-tach? Shouldn't I worry about that? Or will I pass out or have other symptoms if I have a long enough run to be worrisome? And how rare is long runs of dangerous rhythyms in normal hearts? Is v-tach dangerous in normal hearts?

Also I saw that AIVR could be caused by an imbalance betw. the sympathetic and parasympathic nervous system. My anxiety does seem to be triggered easily. Maybe something else is wrong with me? Why can't I believe your reply that I am fine? Can you put my mind at ease that I'm not going to have any sustained dangerous rhythyms?

Thanks for your help.
 missvampy - Wed Jun 09, 2010 7:15 am

Hi Maxjax, I have been getting palpitaions and fast heart beat up to 140bpm, very similar to your situation, I have anxiety panic disorder. I have been having these heart issues for over 3 years, but worse in the last year half, I get the same responses from my doctor, "don't worry about it, take a valium". But I feel that this heart problem is just being brushed under the carpet amd that my doctor just thinks it due to anxiety. I don't like taking the Valium and only take 2 mg or less, it doesn't bring my heart rate down. I know when I am anxious. Now alot of these heart palpitaions followed by pounding racing heart that lasts for hours happen when I am watching tv , or checking my email, stuff like that, they have even happend while I am asleep and wake me up , I am resting, and I am not stressed or anxious. Then the days after my heart rate is just high all day sitting around 80-100. The times when I am anxious and stressesd the palpitaions seem different and don't last as long. I also get fast heart rate when I stand up and move around, and when I go to have a shower. I get dizzyness and some chest pain shoulder pain and a feeling like I can't swallow. I have had 12 lead ecg that have shown t wave inversion or flat t wave or something like that and also picked up Tachycardia. My doctor has put me on Atenolol, then she told me to stop .so I did and my heart rate went back up again, then I ended up in the hospital with heart rate up to 144, but when the ambulance got me to hospital , the hospital ecg came up normal but with heart rate at 100 and occasional s2 split ( What does this mean) and they sent me home with letter to give to my doctor, but the ambulance one was different showing t wave issue, and they said it needs to be looked at. So worrying as I worry I may have a heart attack. I am back on the Atenolol, and my doctor has booked me in for a stress test , but the wait could be up to month or longer, and I am worried something bad could happen. I wonder if the t wave issue is because of the atenolol ( beta blocker), I am worried all the time now after the last event as my heart hasn't gone that high before, it usually goes as high as 120 resting with palpitations...worried :(

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