Hi RLR & other readers,

Long time reader but first time poster here.

I am a 27 year old Australian guy with a history of anxiety disorder.  Non smoker, rarely drink, normal body shape but not enough exercise. I have a pretty normal life, with a nice family etc but have experienced a few stressful events this year (floods, building a house, sickness in family) and am a fairly sensitive soul.

I encountered my first panic attack in 2008, following a few months of glandular fever.  At that point, I developed a lot of PVC's and concern about my heart.  I saw a cardiologist and had an ECG, stress echo & holter test.  I was told that my heart was structually fine and I was getting a few ectopics here and there.

Since then my worry about my heart has come & gone, and I've been able to deal with it to some extent.  I tried a beta blocker at one point & also Oxazepam for my anxiety - neither seemed to help with my anxiety or heart palpitations that much.

The thing that worries most is that I feel I've developed bad heart flutters (or PSVT) over the past 6 months.  I think I've had them in the past, but never to this extent or severity.  I'm particularly concerned that this PSVT wasn't caught when I had my last set of tests and hence my worry about my heart, panic attacks & general wellbeing are worse than ever.  

For example, it would not be unusual for me to experience a few episodes of PSVT every week lasting up to a minute, on and off through the day.  This is often accompanied by dizziness, nausea, pale appearance and leads to full blown panic attacks - especially if I'm at work or playing in my band or after I try go for a run.  I've noticed there is some correlation with my stomach, as they are worse when my stomach is upset & notice I belch alot during particularly bad episodes .

I have an understanding GP who is helping me deal with my anxiety through a management plan of therapy, acupuncture and medication.  She said she is willing to send me back for another holter test if I want, but doesn't feel it is essential.

I wanted to get your thoughts as to whether my symptoms (increased incidence of heart flutters/PSVT & anxiety attacks) warrants further tests from my cardiologist? As I mentioned, those tests were done in 2008.

I really feel like I'm sinking into a black hole I have an understanding partner, family & workplace, but this is really overtaking my life.  Some days seem OK, others are a complete write off.  It feels like a slippery slope & I don't look forward to things as much as I used to.  I understand that anxiety can have an adverse effect on our bodies, but sometimes its hard to accept it when the physical symptoms are so crippling!

Have you met patients like me before? Your thoughts and wisdom are most appreciated.

Pat

Your pattern of symptoms is extremely common and it's difficult in many cases for patients to make the separation between physical symptoms and physical disease.

With respect to the PSVT, was this formally diagnosed and in your medical file or are you describing these "flutters" using the term? Paroxsysmal Supraventricular Tachycardia, or in other words Atrial Tachycardia, is not commonly described as a fluttering effect, but more often the sensation as though a motor is running inside the chest. PVST is simply prolonged tachycardia of the atria and can also sometimes be clinically described as Paroxsysmal Atrial Tachycardia, or PAT.

Runs of PAT occur very commonly in otherwise healthy persons and in of itself, is not cause for concern. But again, these are features that must be clinically defined by a licensed medical doctor through diagnostic evaluation and not merely terms to be used by patients in the attempt to describe their symptoms. When describing symptoms, it's aways critical to articulate what you feel and not what you have, if you see my point.

GI disturbances actually do affect the heart's performance and this phenomenon is termed gastro-cardiac response. Realize that the vagus nerve innervates the GI tract as the pneumogastric nerve. Whenever a disturbance of the GI tract is sufficient to produce bloating, it causes pressure to be exerted against the diaphragm. This scenario can sometimes result is wayward nerve impulses, or evoked potentials, to travel upward along the vagus nerve to its terminal endings, one of which is the heart. The heart muscle responds to these impulses much as other muscles, the eyelid for example, would respond to a wayward nerve impulse that results in a twitch of the muscle.

The disturbance caused by these impulses does not actually interfere with the heart's normal pacers. In some instances, transient down-spikes in blood pressure can occur and baroreceptors in the carotid arteries send feedback to the cardiac center in the brain to correct the circumstances to avoid lack of perfusion to the brain, the result of which is syncope, or fainting. The quickest method for blood pressure to be restored is to increase cardiac force. This is why patients can often encounter a sequence of strong, forceful pounding heartbeats that may result after a palpitation sequence. It is the body's way of merely restoring the body to baseline normality. The events in no way suggest that the heart is experiencing difficulty and no harm whatsoever occurs to the heart muscle. Palpitations will not shorten your life by even as much as a second in time.

Panic disorder is a combination of neurochemistry and emotional lability that results in a threshold event, or attack. Certain aspects of the body's physiology run amok to the extent that the threshold event and aftermath re-establish baseline normality. Realize that the antecedent, or predisposing force is typically an unusually strong surge of fear directed at an unknown and unpredictable threat or danger, causing overwhelming helplessness and sense of imminent doom. Patients often feel washed out for several hours following the events until such time that body chemistry is fully restored to its baseline levels.

The key here is to first recognize that the basis of fear in virtually all instances of panic disorder is extremely irrational in nature. It represents a distinct reality despite its contrary nature to logic and reality. It's potential to do harm in the mind of the sufferer, however, is what prevents it from being challenged and overcome. You should know that there are very common themes among the underlying factors which predispose an individual to panic disorder and it's important for you to try and explore these commonalities to determine if they are a present force with respect to your panic.

The identification of these factors, together with dispelling their irrational hold on you will go a long way to diminishing circumstances which rise to the level of panic threshold events. There is most often an inherent inadequacy which is perceived, the nature of which often influences the combination of emotional and physiological responses to spiral out of control, resulting in panic.

We'll speak more, but suffice it to say that perception has the greatest impact upon your predicament and I can tell you will all certainty that you are not in any actual danger and nothing physical is actually wrong with your heart. Your fear that something of this nature is looming constantly is what is producing the range of corresponding symptoms.

You're going to be just fine. Spend some time reading the various responses from members here and we'll speak more about ways in which you can overcome your present difficulty.

Best regards,

Rutheford Rane, MD (ret.)

Okay, it's important to realize that as physicians, we don't need to "see" the events you describe in order to determine their nature. Patients commonly become fixated on this premise and it has a great deal to do with knowing that their doctor has actually observed the event, which in the patient's own mind is confirmatory.

When we evaluate an ECG strip, we're looking for characteristics that patients aren't aware of at all and it is this critical list of characteristics that we use to determine whether an actual problem exists. If these signs are not present, then no disease or problem exists. No exception. So any palpitation events that the patient is experiencing are entirely benign. You also need to know that in cases where benign palpitations mysteriously fail to show up when being evaluated, it's a highly positive sign that they're being induced by the vagus nerve and not representative of pathology. True disease is present regardless.

Again, you're going to be fine. If you feel that an extended Holter monitor will yield reassurance, then by all means you should speak with your primary care physician or specialist to arrange the test. The results, however, will produce little more than a yawn and will not suddenly identify some mysterious issue at hand. It doesn't work that way.

Best regards and Good Health

Vagus nerve-induced palpitations do not challenge the heart's performance capabilities and would not place you at any risk of some type of cardiac event.

With respect to exercise, always perform to whatever extent that you feel comfortable doing so with the awareness that your heart can handle exertion to the normal extent as measured and recommended in numerous healthcare recommendations on the topic. The presence of benign palpitations does not challenge these recommendations nor alter their guidelines in such instances.

As with all exercise, simply remember to engage in exercise using moderation and "pushing through" is fine as long as you do not exceed normal parameters for exercise regimen.

You'll be just fine.

Best regards,

Rutheford Rane, MD (ret.)

Hi RLR and others,

Just thought I'd give you an update on my situation.

I started taking some anti-depressant medication and trying to get back into some sort of exercise regime for the past 3 months.  I must say that this has helped decrease my anxiety levels a fair bit.

That said..

Am still very much getting these darn flutters of fast beats (seemingly) out of nowhere.  I deal with them better now, insofar as I don't get as worked up waiting for them to subside.  Again, some days it will seem to be happening all through the day and other days it doesn't seem to happen at all.

Is it really possible to go through your whole life getting these things without it causing you harm? I guess that's what I have trouble coming to terms with sometimes.

I think I have come to accept that, as you have explained to me previously, that these flutters are vagus nerve induced and therefore can cause no harm.  This does make me wonder though whether I should go back to my cardiologist now that I understand a bit more about this condition?  After my stress test and echo in 2008, I was given the all clear in terms of structure of my heart etc, but I never got the opportunity to discuss vagus nerve activity with my cardiologist at that stage.

I am going to see a nutritionist next week as I'm sure my GI tract and gas contributes to these palpitation events.  It will be interesting to see what she has to say.

Anyway, as you can see, I'm still very much over analysing what is going on with my heart.  Anxiety medication and therapy are helping but I certainly can't say that the fear has disappeared completely, as I find it impossible to 'ignore' the physical symptoms 100% of the time.

RLR, any comment you can provide regarding my situation would be most appreciated (as are any comments from others here on the forum).  Perhaps its just going to take me longer to overcome this issue than I thought it would!

Cheers,

Pat

Well, I certainly think the point has been well made that vagus nerve-induced palpitation events are entirely harmless. They are not focused upon in the realm of clinical research because they are not considered to fall within any class of illness, disorder or disease which challenges the health of human beings. Although they certainly produce ample emotional difficulty, they simply do not cause actual harm in the way of morbidity and mortality.

Like many others experiencing the phenomenon, it's important that you better understand their actual nature but there is no magic treatment of any kind available to cause them to abate. They are caused by certain levels of stress, both physically and emotionally, which causes the central nervous system to respond in very characteristic ways.

Changes to these stressors, as well as gaining a firm understanding that the palpitations events are harmless in absolutely all regards will go a long way to imparting change in their presence and intensity. It is critical for you and others here to understand that certain perceptions about these palpitation events that produce apprehension or fear can cause the brain to act in very basic, fundamental ways to protect your survival. The compelling concern that something is wrong is largely the brain working to identify the actual threat and prevent it from constituting a threat. The more you fear yourself to be at this specific level of threat, the more the brain will exercise due diligence in trying to identify the threat and resolve it. This is largely what compels individuals with benign palpitations to seek repeated diagnostic testing that sometimes reaches to great depths and regardless of repeated negative findings, the pursuit continues and often calls the test results into question, rather favoring their internal instincts that something is being overlooked.

The tests you've undergone indicate negative results. Negative is negative, not uncertainty. If the tests are negative, there is no presence of an underlying organic cause for the palpitation events. You are not now, nor have you ever been, in any element of danger or at risk from the presence of these palpitation events. Altering your perception to one that is accurate and based upon the presence of undeniable facts will permit the instinctual drive to protect your survival to downgrade to normal baseline and your "symptoms" will abate.

You'll be fine.

Best regards and Good Health