I’m a 24 year old male.  I’m in pretty good shape and eat healthy.  I usually run four to five times a week.  No caffeine, smoking, etc.

I’ve been having heart palpitations for over a month and half now.  The problem itself isn’t exactly new.  It first showed up three years ago.  I would have sporadic episodes around twice a week.  The symptoms included: chest tightness along the sternum, heart palpitations, a cough with the palpitations, and the severe episodes were accompanied with an adrenaline or anxious feeling.  At the time I had blood work and a stress echo tests.  Both came back negative and by the time I got the results, the problem had gone away completely.

This time around the problem started the same: sporadic episodes maybe twice a week, then the problem got worse suddenly.  One night four weeks ago it kept me up all night.  I went to the hospital early in the morning.  EKG was negative, and the ER doc thought the symptons were related to GERD or acid reflux.  He recommended Prilosec, so I started taking it twice a day.

Since than the problem has gone from a sporadic, to a daily issue.  Almost every day and definitely every night I have heart palpitations.  Now for the most part, they occur at my rest heart rate.  It is a double beat pause, double beat pause, etc.    

Now the palpitations I’ve been experiencing seem a little different then most reports I’ve read.  The palpitations really depend on my position, and because of that I cannot lay down flat on my stomach, back or sides without having them.  So when I sleep at night, depending on the severity, I have to raise my head until they stop.  Some nights it is higher than others, some lower; and on occasion, I’ve needed to fall asleep vertically on a couch to stop the the palpitations.  One other thing, I can make the palpitations stop just by moving, coughing, or best yet sitting up straight or hunched forward.  So for instance, if I’m laying down flat at night and the heart palpitations start.  I can just cough and they’ll stop for few seconds, then they'll come back, then I'll take a deep breath and they'll stop for a few seconds, then they'll come back, I'll reposition or move myself a little and they'll stop for a few seconds, they they'll come back.  On the hand, if I were to sit up straight, they’d go away completely.

The chest tightness bothers me all day.  I’m not kneeling over in pain, it is more annoying now than painful.  The worst of the chest pain seems to center right below the bottom of my sternum.  And when it flares up, it feels like a lego block is stuck in my upper abdomen right below my sternum.  However this lego feeling isn’t always the case.  The longer I’ve had this problem.  The harder it seems to be able to pinpoint exact locations of discomfort.  The only constant is the tightness along the sternum.

One way I've slowly learned to deal with the palpitations is aerobic exercise.  It doesn’t help the chest tightness/pain, but it does help the palpitations.  I’ve even found myself running on a treadmill at 1 AM to help me fall asleep because the palpitations were bothering me.

Now I’ve had several tests done: echocardiogram, chest x-ray, and an endoscopy.  All were negative.  Although, the biopsy from the endoscopy haven't came back yet.  I also have blood tests and an appointment for an event monitor coming up.  So hopefully these tests will tell me more.

So essentially, I’m asking an almost impossible question.  What could be the culprit?  And does, anyone have similar symptoms or advice?

Okay, I've read your posting and understand your complaint. First off, I'll tell you that your difficulty is extra-cardiac in nature, meaning that the problem lies outside of the heart itself. While the symptoms you are experiencing are affecting the heart's normal sinus rhythm, the heart itself is fine.

Palpitations of the type you are experiencing are caused by inappropriate stimulation of the Vagus nerve. This nerve, also more formally known as the 10th cranial nerve, is the largest nerve in the body and has connections with the heart, lungs, GI tract, the larnyx among other areas and it explains why coughing can interrupt the palpitation sequence. The Vagus nerve innervates the GI tract as the gastric nerve and it's this connection that bears the most common relationship to benign palpitations. If your GI tract becomes irritated for any reason, it is possible for the Vagus nerve to become stimulated and via the parasympathetic nervous system, it can send inappropriate signals to the heart. For an explanation of how this works in more detail, please read my postings in the general forum section entitled HEART PALPITATIONS 101 PARTS 1 throuh 6. This will tell you a little more about how the nervous system is involved here.

Sharp or centralized acute pain that is located just beneath the sternum can arise from several conditions, from pacreatitis to cholecystitis or gall bladder disease(in the case of a "root" stone"), duodenal ulcers, gastritis, even irritable bowel syndrome if other causative exclusions are evident. It's very important that you not be lured into focusing upon your heart simply because that is where you experience the most salient features of your symptoms. Testing can provide peace of mind, but needs to proceed into determining the underlying cause, which in this case is not the heart itself. Thyroid conditions and other disorders like pheochromocytomas can all cause similar symptoms but I just don't believe that's the case where you're concerned.

Since you have blood work, I would suspect that your physicians have already performed a serum amylase to determine if pancreatitis is a consideration. The endoscopy works very well in determining whether GERD and esophogeal errosion is evident. I doubt the biopsy will come back positive, however, for anything of significance. If you're exeriencing a lot of indigestion in the way of eructation, more commonly known as belching and you are having excessive flatulence and changes in bowel habits, then looking at your gall bladder and the possibility of a duodenal ulcer is an option, allbeit luke-warm.

It's also important to realize that none of these consideration have to be present in order for you to experience benign palpitations and acute or chronic anxiety can easily produce conditions necessary for them to occur. Particularly where GI symptoms are experienced, many people unwittingly swallow copious amounts of air, a condition known as aerophagia, and it can produce some pretty far-reaching effects in the way of discomfort. As trapped air is forced through the lumen of the intestines, it can irritate the lining and in turn, irritate the gastric nerve. Changes in eating habits can also exacerbate symptoms in this regard as well.

If you've had any type of serious change to your life in the previous months, be aware that this can establish the premise of anxiety and associated symptoms that are not normally recognized as such. If you've recently lost of loved one, are going through divorce, changed jobs, moved to a new location, etc., then these issues and many like them are all valid precursors for potential anxiety to develop. I'm not stating it to be the case here, but you should carefully examine this area of your life to determine whether a possibility exists.

The fact that you describe your symptoms to fluctuate greatly is a good indicator that the underlying problem is very unlikely to be associated with any serious pathology which more often than not only tends to get worse with time. It is also the case that when people first experience these symptoms, they add to their anxiety a great deal because it is frightening and there is little one can do to alter the symptoms and associated worry it causes, leading to the belief that they are getting much worse in general.  

I believe that your tests will likely turn up very little to suggest an underlying physical cause and if so, I urge you to explore whether you may be suffering from anxiety. The holter monitor is widely used, but I doubt if it will reveal anything of significance at all and you also have to realize that as physicians, we don't need to see evidence of benign palpitations to contemplate their presence. They are a diagnosis of exclusion, meaning if all the known pathological causes are ruled out, then the cause is benign in nature and certainly harmless to you in all regards. If you believe there's a chance you could be experiecing anxiety, then there are many ways to effectively deal with the condition and put you back on track, more importantly diminishing your physical symptoms.

Let me know your test results if you care to and I'll be glad to talk to you more about your situation. You're going to be just fine.

Best regards and Good Health    

Thanks everyone for their replies.

RLR.  Could you point me in direction of some reference material, about the hyper-stimulation of the vagus nerve and how it causes arrhythmias?

I been using an event monitor for about 6 days now, and have caught my symptoms numerous times.  I’ll post as more tests come back.

Hopefully something will announce itself as the culprit.  As I doubt anxiety or stress is the cause.  Although I haven’t brushed this possibility off outright.  I have lowered my stress levels just incase.

In the meantime I have been running 7 days a week.  As that is the only thing that seems to keep the palpitations at bay.  Otherwise it seems hit or miss on whether I’ll get sleep that night.  Although the running does nothing for the constant tightness along my sternum.  As they say, beggars can’t be choosers.

Another odd thing is I’ve been experiencing shortness of breath and clammy hands in the evening after dinner.  This has been occurring for the past three or four days now.  The shortness of breath lasts for a few minutes, goes away, comes back.  It is very odd, because I feel fine, besides the shortness of breath of course.  It is like a panic attack, without the panic.  Who knows.  I’ll try changing my diet at dinner and see if that changes anything up.

RLR wrote on Feb 13^th, 2008, 8:44pm:


I can almost without a doubt, unequivocally say that it isn't anxiety.

Beside the obvious reason; I don't have feelings of fear or apprehension.  I've also been experiencing pain in the upper abdomen and the middle back.  I just don't see it.

Hello

I just need to add, I found it extremely difficult to except my problems were anxiety related, although mine are to do with GI irritation, IBS, etc.. and hormones as well.  but although I do not think the anxiety is the direct cause it causes for us to tense ourselves, so when we eat drink etc our stomach and bowels are working against tense muscles and increased acid.  

Your problems may be else where and you are doing the right thing getting checked out, but if all your tests come back negative, please do not spend hours and hours scouring possible disorders etc.. as you will not believe what anxiety and stress can do to your body.

I hope you get sorted soon.

Kath x

I went to see my PCP earlier this week.  Passed the buck again, referred me to a cardiologist, as it COULD be pericarditis.  Pericarditis at first made since; as all the other wrap it up, fast turnover equals more money, pseudo-diagnoses do.  If the pericardium was inflamed, it would make sense that the palpitations come when I lay down and stop when I sit up.  It would also explain the near constant chest tightness(otherwise known as the vise grip stuck in my chest) and the dry cough.  

But pericarditis for THREE MONTHS, in addition, I don't see how pericarditis causes a dull upper abdominal pain that resonates through to the back and up into my shoulder blades.  Or for instance, why when I press down with my hand, right below my ribcage, the pain will increase.

As you may have noticed, I have a general discontent and frustration for the process so far.  I feel like I'm stuck in the Sea of Molasses otherwise known as the healthcare industry.  It has changed my perspective.  Maybe the experience will be a good thing in the end.

I just wish I had hindsight on my side and I knew what the next step was.