Dear Dr. Rane;

I have read your Palpitations 101 overview and have some additional questions. I have been diagnosed with having frequent benign PACs about 1300/day with the occasional PVC. I accept these will not harm me.  However there is an outstanding issue which still seems to trouble me.  

I have a constant tightness/heaviness behind my sternum area that sometimes radiates as a pain into my back between my shoulder blades.  It can tighten even more for a brief moment every 30 seconds to a minute such that it might be related to the palps or an esophageal spasm.  I have seen my general practitioner who seems perplexed at the cause and prescribed Ativan which did not help when it kicked in. Cardiologist and stress test are normal. Echocardiogram normal. Blood tests are normal.  Tried Zantac for a week to see if it may have been GERD, still no relief.

I'd like to believe it is a result of anxiety however it seems to resolve lying down or reclining but returns sitting or standing up.  It is not a burning feeling, it doesn't correlate with breathing or pressing around the sternum.  It can get worse after meals where I experience more tightness, increased palpitations and some nausea. Do you believe my symptoms are a result of the Vagus Nerve being stimulated or could this be a GI issue or a Hatial Hernia?  I'd appreciate your thoughts.

Thank you in advance for taking the time to answer my and everyone else's concerns on this forum.

Okay, I've read your posting and concerns. Let's discuss a few relevant facts.

The premise of non-stop adrenaline is only a consideration based upon clinical evidence of pheochromocytoma, a tumor which causes chronic stimulation of the adrenal glands and the consequence of which can be adrenal exhaustion, or Addison's disease. This is not the case at all in your instance and the features of adrenal exhaustion are quite dramatic and unmistakable. Likewise, the features of excessive epineprhine (adrenaline) production produce symptoms far more dramatic than the pattern you are describing and features such as significant hypertension that is resistant to treatment are most often present.

While selective beta-blockers do provide a mild anxiolytic effect, they are essentially ineffective for the purpose described. The primary therapeutic target and efficacy of beta-blockers is to reduce cardiac force and help diminish the potential for arrhythmias in patients who have suffered a cardiac insult, or heart attack. They do not suppress epinephrine but rather merely diminish its effects upon cardiac tissues.

There are two possible causes for your chest discomfort and the first would raise the question of whether your doctor has ruled out chronic pericarditis. The symptoms of the condition vary and is typically worse when lying down as opposed to standing with subsequent inflammation demonstrating less dramatic presentations than the initial onset, which could extend months previous to the present symptoms. A gadolinium-enhanced CT is sufficient to determine the presence of the condition and despite the absence of a pericardial friction rub or ECG findings, the condition can still be present.

The second cause is quite common among persons exhibiting signs of significant anxiety into the realm of what is termed anxiety with somatic features. Basically, the extent of anxiety is sufficient to induce physiological manifestations often misinterpreted to be signs of illness or disease. With regard to chest discomfort, DaCosta's Syndrome is frequently observed in such patients and while some of the more specific features vary, the general symptoms are often characterized as being similar to those of myocardial infarction. The patient experiences what seems to be pectoral angina that may or may not demonstrate referred pain between the scapulae or to the left arm, with supportive signs of squeezing or dull ache sub-sternally. ECG and cardiac enzyme studies are typically normal. DaCosta's Syndrome most often abates with anxiolytic treatment by therapeutic agents specifically designed to treat anxiety.

Features of anxiety can typically produce generalized malaise and sensations of physical weakness, but these features do not rise to the level of adrenal exhaustion. Furthermore, over-production of cortisol as a consequence of significant stress can induce what seems to be generalized weakness and lethargy, although tests for cortisol levels should only be considered where observable features of Cushing's Syndrome are observed.

Esophageal spasms can induce similar chest pain, but the discomfort is often worse when lying down rather than standing and are most often observed in the presence of significant GERD. The nausea in your case is more explained by indigestion following meals. There has been rare occasions where cholecystitis can present as sub-sternal discomfort as a result of a stone lodged in the common cystic duct and in the presence of GI discomfort following meals, this potential should be ruled out in cases where the cause is less obvious. Pain from this disorder can also produce colic pain more proximal to the right scapulae and is sometimes diminished or resolved via eructation, or belching. A study of serum amylase should also be performed to determine any potential involvement via the pancreas, the symptoms of which are sub-sternal discomfort which radiates to the back. If the serum amylase is elevated, further evaluation is recommended.

Hiatal hernias are one of the most misdiagnosed and over-diagnosed conditions in medicine and most true herniations of this type are asymptomatic and discovered purely incidental to evaluations for other conditions or concerns. I would not think it to be the case here but in both the instance of esophageal spasm and questionable hiatal hernia, a trial prescription of brand name Librax, pharmaceutically Chlordiazepoxide and Clidinium, acts as a smooth muscle relaxer and will provide demonstrated relief in most cases of the conditions mentioned. The drug should be extended through a 4-week trial in order to exceed the typical threshold of placebo response that typically accompanies this sort of therapeutic trial. If relief is sustained, then further evaluation should be conducted.

Your symptoms would be inconsistent with vagus nerve involvement.

Best regards,

Rutheford Rane, MD (ret.)

I have very similar symptoms with heart palpatations, sternum pressure and associated anxiety.  However, I had an MRI which found a herniated disc at T-4.  I have pain on the right and it goes around the rib cage to my sternum. Curiously, Klonpin relieves my anxiety, heart palpatations, and sternum pressure.  I take .5 mg on an as needed basis - only when things flair up and certainly not everyday.  It works and life is much better.  Though, I would like to resovle the herniation and vertebrae stenosis problem. I wonder if this problem ever gets resolved these other issues would also be resolved.  The connection seems plausible.