Okay, welcome to the forum and I've read your posting. I'll first respond by sharing with you that your predicament is quite common, shared by many persons who experience benign palpitations.

It's important for you to understand that these particular events are extra-cardiac in nature, meaning that they originate from outside the heart and more specifically, by way of the vagus nerve as a consequence of stress, anxiety and in equal instances, GI difficulties. It's purely a matter of physiology in motion and nothing to do with the palpitation events constituting a sign of trouble regarding your heart's performance.

One of the reasons that patients who experience this type of event become so frustrated is that their own perceptions lead them to believe that since the symptom is associated with the heart, then common sense dictates that the underlying cause is associated with the heart as well. Concerns are elevated because most people relate any irregularities associated with their heart to be a potential warning sign that something is wrong and that an impending cardiac event is looming. When you proceed to your primary care physician or specialist, the events more often than not subside and with very good reason; This type of harmless palpitation event is manifested by the parasympathetic nervous system. Apprehension about what the doctor might discover typically causes a rise in sympathetic tone that becomes dominant. Thus, the palpitations events temporarily subside.

From analogous perspective, you can think of the sympathetic nervous system as the accelerator pedal side of things, elevating heart rate and respiration, vasoconstriction and increased BP, decreased GI motility, increased cognitive vigilance and so on. It prepares the body for action. By contrast, the parasympathetic nervous system constitutes the brakes once action is completed, i.e. decreased heart rate and respiration, vasodilation and diminished BO, increased GI motility, decreased cognitive vigilance etc. These two nervous system components components create dynamics between activity and relaxation. So for instance, when your blood pressure rises to significant levels at the doctor's office, a phenomenon we call white-coat hypertension, it is due to elevated sympathetic tone as a consequence of apprehension and discomfort by what the doctor may find. Once everything has been determined to once again be okay, you find that your blood pressure lowers once again to a baseline more normal for you.

When the palpitation events do occur during diagnostic evaluation, they will technically appear as either paroxysmal atrial contractions or paroxysmal ventricular contractions depending upon precisely when they enter the cardiac cycle. The key issue, however, is the origin of the events. Beta-blockers work by reducing the amount of cardiac force necessary by the heart to carry out its functions. We use this drug primarily in instances where patients have experienced a cardiac insult of some type and in the presence of this drug, the heart doesn't have to work as hard. Beta-blockers also help regulate heart rhythm to some extent as well. An added benefit of the drug is that it produces a mild anxiolytic effect and for patients experiencing anxiety, this is a good option. Calcium channel blockers work by tempering the conduction activity of the heart as a means to reduce any irregularities in rhythm.

So we have two instances where drugs either work to reduce mechanical force by the heart or conduction patterns in order to safeguard against problems which might arise. Neither drug is effective in the instance of vagus nerve-induced palpitation events, which are more akin to the factors which produce a muscle twitch elsewhere in the body with the exception that in this particular case the muscle happens to be the heart. The mention of GI problems as one of several precipitating factors which lead to benign palpitation events is due to the fact that the vagus nerve innervates the GI tract as the pneumogastric nerve. Any inflammation, i.e. bloating within the lumen of the intestines, can exert physical pressure against the diaphragm and consequently produce wayward parasympathetic nerve impulses which travel along the vagus nerve to all of the terminal endings, one of which is naturally the heart. All that is taking place during a benign palpitation event is the heart muscle responding to a wayward nerve impulse, nothing more. So the drugs mentioned work quite well with respect to internal mechanical and conductive issues related to the heart, but they are unable to influence a basic external excitation from the vagus nerve. There are drugs such as scopolamine which can dampen vagus nerve activity that could theoretically diminish the potential for palpitations of this type to arise, but the side-effects make it far too contraindicated for use in treating such events.  

Benign palpitations are actually quite common and most humans have experienced them in the very isolated context of arising subsequent to being suddenly startled or frightened. I'm sure you've often heard someone speak about the aftermath of a sudden fearful event, exclaiming "Gosh! That made my heart skip a beat!" or "That made my heart leap out of my chest!" What these people are unwittingly describing is a vagus nerve-induced palpitation event. It's temporal proximity to a fearful occurrence establishes reasonable cause and therefore, persons experiencing them do not rush to their doctor with fears that something is wrong with their heart. It is deemed a logical manifestation as a consequence of being suddenly frightened.

In the case of chronicity, however, the patterns are much different. In such instances, persons with frequent palpitations in the absence of a direct known cause results in the establishment of fear and apprehension consistent with the duration of the symptoms.

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Dear Dr. Rane,

Thank you for your insightful and informative response. I’m not sure that I’ve read anything any better written in quite a long while.

You honed in something that I had long forgotten or taken for granted, ‘You trust the outcome because it is based upon know facts’. I suspect that this just might be the crux of the issue at hand.

Engineers, as a rule, tend to thrive on facts (as well as logic). Alter the expected outcome (regardless of the facts) and you’ll have a rather perturbed engineer. However, it’s generally accepted (grudgingly) that occasional ‘alterations’ are something that you have to deal with (i.e. Upper Management wanted a different outcome).

The problem that comes into play is when ‘occasional alterations’ become the norm. Unfortunately that seems to be what I’ve experienced the past 3 years. My contemporaries and I have discussed this subject at length. Any concerns that we’ve had have been largely dismissed.

So you tell yourself, ‘Learn to live with it, you’ve got a good job, etc.’ However, I’m beginning to wonder if I haven’t started to be less sure of my outcomes regardless if they are professional or personal.

If my sense of confidence has been unwittingly eroded, perhaps it explains my seeming unwillingness to accept the facts and the resultant outcome as my cardiologist has explained. It’s an interesting premise.

Best Regards,

Indeed, the perceived forfeiture of professional standards in any context can give rise to significant stress and anxiety. It's important in such instances to realize that the moment anyone alters your work product, or instructs you to alter such product, it is no longer under your authorship regardless of what may be presumed by any person.

While the difficulty experienced is testimony to the challenge being directed toward your character and adherence to principles, an inflexible perspective can only yield a singular outcome. It is very often the case that a professional's work product is manipulated for the sake of another's goal. Outcomes are manipulated with regularity due to the broad interests all vying for the most ideal result.

The key for professionals who constitute the actual backbone of principles and ethics must only view applicability up and to the point their work product is manipulated by others, or where they are directed to provide a specific result or outcome. Subsequently, as is the case with many such professionals, a personal reservoir is often established where the accuracy and adherence to one's professional standards are maintained. This coffer becomes the realm wherein continuity is maintained between the professional and their work product, unblemished by efforts of others to whom they they are nevertheless responsible. In doing so, the separation between the work product and any variable outcome is established and permits the professional's internal standards to remain intact and a clear distinction is held in record between what was originally yours and what has come under the influence and ultimate authorship of another.

Factors which come into play in such instances are known as ego-syntonia and ego-dystonia. Ego-syntonia constitutes your alignment with the principles so vital to the accuracy of your profession, rigidly maintained in order that confidence in your skills is unquestioned. Ego-dystonia constitutes the repulsion from thoughts or actions which may be unavoidable in some way and which establish unwanted representations of your self-identity and self-concept.

There are many strategies incorporated by persons who find themselves under self-scrutiny of this type, one familiar example arises from the approach that "if you can't beat 'em, join 'em." This sort of approach is typically adopted by persons find assimilation through release from the objections which bind them. Others find themselves incapable of violating their self-standards and principles regardless of the consequences. This sort of extreme inflexibility is on the other end of the spectrum and produces variable psychological dissonance, or ego-dystonia. Persons so conflicted can rise up in anger, even violence in order to avoid any relegation to a lesser of personal standards.

The key to success in a world where all factors are not always under the control and influence of individuals is to establish measures by which one's standards remain above question and influence, while also yielding to those who may elect to bring challenge to one's principles.

Thus, while such measures are different in each case, methods are devised to achieve a genuine ego-syntonic plateau by divorce of any relationship to intellectual or tangible production that by any other influence, is no longer yours. In fact, this is quite true indeed and in so many instances throughout societal concourse, we see clear evidence of this very procession. By engaging in this medium, we are able to protect the sanctuary of principles and standards by not only relinquishing ownership, but personally declaring invalid any production which has been subject to any measure of influence other than our own. In doing so, it becomes an act of protection to our self-concept and the abolishment of any wayward guilt which may be imposed by feeling compelled to retain ownership and representation of production no longer ours.

Introspection, or internal exploration often brings objectivity into light regarding circumstances that give rise to challenges which are very often self-imposed. Identifying suitable methods to win these struggles is very instrumental in restoring one's place in life and once again under individual, rather than shared, control. It is the deliberate movement away from feeling divided by outside influences and becoming centered once again that restores self-confidence. The methods by which this is actually achieved are quite variable indeed, with the paramount commonality being that it is performed in a manner acceptable and thus, ego-syntonic in nature.

Quiet objection prevents men from being led while luring the fool into believing he leads.

Best regards,

Rutheford Rane, MD (ret.)

Okay, nothing at all out of the ordinary here. Heart rate variability following exercise is entirely normal in the manner you describe. We only become concerned when there is an extended refractory period following exercise which exceeds the normal timeframe. This is not the case where your own circumstances are described.

What produces the ultimate need to seek reassurance is a constantly growing pattern of subjective interpretations that invoke apprehension because they are not based upon facts, but unfounded speculation upon which you can neither confirm nor deny. It has simply drawn the issue to such a level that you feel compelled to rule out a problem which in reality, never existed as a problem at all, but merely inconsistent by what you have previously known.

The human body does not function with the precision of a fine watch, but rather within a range or normality. We are biological entities and the attribute in our favor is that anything less than perfect precision still represents normal in most all instances, the heart included. The problem with health anxiety and vigilance to physiological functions is that people draw a standard that in their mind constitutes normality and any consequently, any deviation represents a problem.

The presence of palpitations will never damage your heart, nor deprive you of evan as much as a second of a full life. You can continue to exercise as much as you care to within the constraints of normal moderation suggested for any person.

As for the PPIs, they do not "cause" palpitation events. This is merely reported as a side-effect by patients taking the drug during clinical trials and regardless of the actual cause, all side-effects must be listed as reported by the patient. In actuality, the vagus nerve innervates the GI tract as the pneumogastric nerve. Any GI inflammation, alteration in GI function or changes in bowel habits, distention as a result of trapped gas within the intestinal lumen can press against the diaphragmatic musculature or gastro-esophageal junction. Consequently, these disturbances are sufficient to induce wayward evoked potentials, or nerve impulses, which travel upward along the vagus nerve proper to its terminal endings, one of which is the heart, resulting in a response by the heart in the way of a vagus nerve-induced palpitation event. So the presence of the events within the timeframe of PPI treatment during the clinical trials caused patients to believe the medication has a causal effect regarding the palpitations.

Switching from a PPI to an H2 antagonist is certainly an elective choice, but I'm constrained to point out that it will not likely produce any change in the presence, frequency or intensity of vagus nerve-induced palpitation events. Of incidental note, such changes do often occur as a placebo effect in persons who believe certain medications or supplements can have a positive influence upon the palpitations based upon what they are told by others or read for themselves and make the natural presumption. This is very common with beta-blocker drugs that are often prescribed in efforts to reduce symptoms, or alternatively magnesium supplementation. Many describe variable patterns of subjective relief, only to find the events returning within several weeks to a month.

To use your own analogy, if your automobile suffered a flat tire you would very likely be able to diagnose and remedy the problem. If, however, the MAF sensor was causing harmless but sometimes dramatic disruption with the car's performance, you might speculate many things to be the source. Some of those speculative causes might be minor, together with others that constitute major automotive work and which produce a degree of apprehension about repair costs.

The same is true of your heart and the presence of palpitations. Without the proper medical background and experience, any number of potential causes and outcomes rise to the occasion and produce a good deal of apprehension. To the trained healthcare professional, the actual facts surrounding the difficulty is typically light-years' distant from what the patient speculated and worried about with a good deal of apprehension and even fear.

You're fine and there is nothing wrong with your heart. You are in no danger as a result of the presence of vagus nerve-induced palpitation events. They arise from outside the heart, not within and their capacity to do you any degree of harm is altogether impossible due to their actual origin and function. By analogy, these palpitations can no sooner damage your heart or produce a cardiac event than plugging in your toaster will cause your sink faucets to leak. They are entirely unrelated and share no causal relationship. The same is true regarding the palpitations and your heart. I've often used the analogy of a telephone to illustrate this premise as well. Many people have accidentally dialed the wrong number, only to have the unintended electrical signal activate the phone of the unintended recipient. Simply because the signal was accidental, does not constitute damage to the phone because it is designed to respond to this type of electrical impulse, nor does it suggest that the unintended recipient must now stand guard to try and ensure that no subsequent erroneous calls take place.

The same is true of the palpitation events and your heart. These impulses are entirely benign and arise as a consequence of irregular stimulation and once they reach the heart, the cardiac tissues respond as they do in any instance of nerve impulse transmission. Simply because it occurs does not even remotely suggest that it has to be pathological or that the events will somehow damage the heart. It is an entirely benign event and no different than other wayward nerve impulses which cause tissues to react in unfamiliar ways, such as the twitching of an eyelid from time to time.

You'll be just fine. Nothing at all wrong here.

Best regards and Good Health

Hello Engineer,
I have been reading your discussion with Dr. Rane and found it very interesting.
I am an engineer as well and I work at solving problems and finding root causes. You can now imagine that founding the root cause for my PVC's has been a total failure, I have graphed all the factors I could think about and was not able to find a pattern, after that frustration, fear and anxiety took me into their hands. Gladly I found this website and other friends that have helped me very much to release and finally accept that it is ok not to have the control of everything and not to know exactly the cause of everything. It is hard because you have been trained to do exactly the opposite and if you add the bad company of the anxiety that is there to whisper you the scary "what if  x happens?", you can be trapped.
However I think everyone needs to go through his/her own path to overcome this problem, I am done with gathering data and trying to look for the cause, I decided (and this was a conscious decision) to believe in Dr. Rene explanations, I decided to feel fine even if the palpitations exist, I decided that I wanted my life back. I am still in the process and I still have hard moments but I am not backing up on my decision.

I wish you all the best in your own process and when you finally overcome it, please write back and tell everyone.

Kind regards,
SK