Hello RLR.  I had a question about Structural Heart Disease.  I went to the ER with another intense night of palpitations (3 nights in a row) after they had gone away for the most part since I stopped eating 2 hours before bedtime.

I started to exercise again, and they have come back with a vengeance.  They have been very intense thuds about every 2 or 3 minutes.  I had blood work done and it all came back normal.  The doctor essentially told me like every other time that I am perfectly fine, but made the statement "if you were 70 I would tell you it could be caused by structural heart disease"

He said the only way to know if you had that, would be with an echocardiogram, but said he wouldn't recommend getting one because he doesn't see any reason to do so.  Unfortunately someone with panic disorder does not hear that and not worry.  I have had an echocardiogram before, several years ago, between 5-7 years ( I don't remember exactly)

I can't afford to get another one as they are over 1,200 dollars and I can't just lay out that kind of money right now.  He mentioned that if it was negative back then it would come back negative this time because it takes alot longer than that to develop.  Is this actually the case?  I don't always trust ER doctors because they are in a hurry and I don't feel like they are as face to face as doctors you see in a clinic.

Any help on this would be greatly appreciated.  

P.S. My blood tests always come back with low potassium.  Is this something that would be causing this as well as anxiety?  Also, I don't know which cardiac enzyme it was, but they said normal is 0-100 and mine was 7.  Curious what these cardiac enzymes are and what they mean.  Thanks again, Tom.

4NorthTL wrote on Sep 13^th, 2011, 12:43pm:


Yikes!  Makes me realize how lucky I am that we have the National Health Service.  

I'm sure it's fine, I mean if you had the palpitations when you had the echo test before and the results were fine why would the palpitations suddenly be a sign of a diseased heart?  

Okay, take care not to over-draw the comment made by your doctor and in the strictest sense, we're not speaking about the same sort of instance in your case and that of a 70 year-old patient. Benign palpitations of the type you are experiencing are extra-cardiac in nature, meaning that they arise from outside the heart. More specifically, they are derived through mere inappropriate stimulation of the heart muscle by the vagus nerve.

By contrast, structural heart disease in a 70 year-old man can produce arrhythmias that raise question as to whether the heart muscle is being challenged or failing under performance. Again, there is no association between yourself and the instance posed.

While I can somewhat understand your lack of trust in ER physicians, I started out my career in the realm of emergency medicine and our typical pace does not suggest that the practice of medicine is incompetent Realize that the patient's interpretation of what takes place during a visit and evaluation in the ER is most often very disparate from that which actually takes place from our own perspective. We see thousands of patients and we make certain that careful attention is given to evaluating every patient under specific criterion that best determines whether actual illness or disease is underlying the patient's complaint. In the case of palpitations, the patient is largely in the ER to obtain reassurance that nothing is wrong, while the physician must strictly give attention to whether a problem actually exists. If not, then they must unfortunately move quickly to patients where imminent intervention may be required. It is simply an extremely poor resource where patients seeking reassurance can obtain it. If they feel that the physician has not given them proper attention, then they become frustrated that something might be overlooked or under-valuated in their opinion and leaving them with the sensation that something could still be wrong.

I'll share with you here that in all instances of benign palpitations, the emergency department is on the opposite end of where you actually need to be in the time of need. Realize that only the patient has determined the palpitation events to posses a quality of risk, for in reality there is not one shred of risk associated with the type of disturbance you and other here regularly experience. None. It is a perception derived by lack of understanding in how these palpitation events actually occur, together with their misinterpretation as some type of warning sign, that compels patients to seek emergent care as though it constitutes a prelude to a cardiac event of some type. Nothing could be further from the truth in any such instance.

Patients also become highly frustrated that the palpitation events will often and very mysteriously disappear upon their arrival to the ER and they repeatedly urge the physician to try and "catch" the events on ECG so that they can be evaluated. What patients fail to understand is that we haven't been trained according to the impressions about ECG that the patient has, but rather by formal clinical training best designed to recognize and act upon the presence of certain signs. We're not looking for the palpitation to occur, but rather we're examining the test strip for all of the characteristic signs that we know can produce actual arrhythmias. If those signs are not present, then no disease exists.

Patients with anxiety, particularly health anxiety, are most often disappointed by visits to their doctor because although all tests turn up negative, their symptoms nevertheless persist. Patients persist in their belief that physical symptoms are a direct association with physical disease and therefore, something must be overlooked in these instances or tests being performed are insufficient.

The question must come to the mind of all such persons at some point about whether they could just possibly be wrong about their own perceptions and that what compels them to continue searching for an underlying physical cause is failure to accept the actual facts at hand.

WHen all tests are negative and the skills of the physician are brought to bear upon the problem and continually find no source of an actual problem, the patient must pause to consider whether they are the ones creating their own dilemma. Benign palpitations are very real indeed, but their origin and actual capacity to harm are entirely misinterpreted by the patient on the relentless quest to prove otherwise. Indeed, it is this very compelling inclination being demonstrated by the anxious patient that must at some point, come under self-examination for it demonstrates the actual underlying nature of what drives the person affected by anxiety in general and not simply concerning their health worries.

I'm here to tell you that nothing is actually wrong with your heart and you can proceed to the doctor and have all of the tests available, only to find out that the result is still negative. What you have to do in order to reverse the present circumstances is alter your perception to one based entirely in fact rather than presumption or speculation.

You're just fine and you can exercise, go dancing, hiking or any other activity you care to undertake without fear that you're placing yourself in some kind of jeopardy. Remember that you're the only one who believes this potential to exist. There is no evidence at all to actually suggest it's the case and I just want to reaffirm this with you. You should give thought to that fact.

Best regards,


Rutheford Rane, MD (ret.)