Good Afternoon,

RLR thank you for your continued advice and guidance as I am trying to regain my old self back. I write to you in regards to a question about a Right Bundle Branch Block and general guidance.

The second time I went to the ER last November the ER doctor informed me I had a Right Bundle Brand Block when he looked at the EKG, and that it is seen in a lot of people. What I want to know does that have any correlation to my Inappropriate Sinus Tachycardia? No other doctors since then have mentioned that and I've had multiple EKGs post that ER visit.

I really am struggling to discern my anxiety from true physical symptoms. I thought  Inappropriate Sinus Tachycardia was a diagnosis by exclusion, however my Cardiologist diagnosed it based off a 7 day holter monitor - when my anxiety was at my peak. Could this have contributed to a wrong diagnosis? He put me on 25mg of toprol xl which seems to do nothing and his response is that he will up it to 50. As someone who is not medically trained, and having doctors with differing opinions I never know what the right answer is.

I am working on Anxiety with my psychologist with the cooperation of my GP and I am taking .5mg of xanax in the morning and late afternoon. This has helped curb my worst case scenario thoughts, however I am still left with a sore chest and weakness in my legs. I've only been doing this for 3 days now and I don't expect a miracle but I feel like I am stuck in limbo. How do I accept anxiety when actually have being diagnosed with a medical condition?

My GP and ER doctors have chalked it up to anxiety, the Cardio and Pulmonary doctors believe I have IST and want me to get an EP study. I even went to an EP doctor recommended by my Cardio and he didn't believe I was a good candidate. However my Pulmonary Dr wants me to get a second opinion.

I believe I have anxiety on a very high level but I am not certain if it is what caused all this or is a resultant. I am at a loss on how to proceed. No amount of reflecting seems to help me decide this.

I miss the days of being younger when you would get sick you would get an antibiotic and feel better in days. I am going on 4 months of agony, a lot of it I am sure is self induced, but I need to make some critical decisions but I am not sure what the proper choices are.


Here are the choices in my mind:
Do I believe that I have IST and try to increase the beta blocker dosage to see if it helps?

Do I treat anxiety with my psychologist and stop searching for an underlying medical condition?

Do I try to treat both at the same time?

Do I get a second opinion from a different Cardiologist?

Do I follow through with my scheduled electrophysiologist appointment in March recommended by my pulmonologist? (An EP study scares me)

Do I get a new GP who will review all my tests and make a recommendation? as my current GP doesn't want to see me for 3 months as he believes this is all anxiety.


This is basically a cry for help - I've turned to my family who all provide wonderful support but they are not medically trained and are unsure themselves. I have family members who do not believe I could be capable of having anxiety - and I have family members who believe that at this point this is all it could be. I am so stuck in the middle it is making everything worse. I have been bounced around by the medical community - where one doctor refers me to the next and then to the next. You can see how ones insecurity would grow. I don't even know my own body at this point - is this pain real or self induced.


Thank you for reading my rant. Any help is welcome.

"Here are the choices in my mind:
Do I believe that I have IST and try to increase the beta blocker dosage to see if it helps?

Do I treat anxiety with my psychologist and stop searching for an underlying medical condition?

Do I try to treat both at the same time?

Do I get a second opinion from a different Cardiologist?

Do I follow through with my scheduled electrophysiologist appointment in March recommended by my pulmonologist? (An EP study scares me)

Do I get a new GP who will review all my tests and make a recommendation? as my current GP doesn't want to see me for 3 months as he believes this is all anxiety."

Let's see if we can invoke some reduction of the possible choices you've highlighted. First of all, family members are great for emotional support and their advice is often mixed. With respect to the dilemma at hand, however, they are unable to provide you with objectivity from a clinical standpoint.

The second point before we look at your concerns is that most of the choices do not have to be made with any sacrifice of the others. The manner in which they are being presented appears to suggest that you must choose the best course to proceed as though any other decision sends you in the wrong direction. This is not necessarily true.

Do I believe that I have IST and try to increase the beta blocker dosage to see if it helps?

There is no harm whatsoever in increasing the strength of your prescription in this regard to determine whether it provides a reduction in symptoms. A trial of 8 weeks or so should be sufficient to make a reasonable conclusion. This option is available to you regardless of any other decisions made. Beta blocker therapy in the dose range being contemplated by your doctor is quite mild indeed and is safe for you to take in determining in your own mind the source of the problem.

Do I treat anxiety with my psychologist and stop searching for an underlying medical condition?

This is sort of a trick question if you don't mind me illustrating the fact that your scheduled appointments with your psychologist are designed to provide the insight necessary to answer to such a question. If you believe that the underlying cause for your difficulty is organic in nature, then you should persist in searching out the cause until it is either found or you no longer believe it to be the case. Where you choose to intervene along such a path is entirely your choice and necessary for you to feel both competent in your decision and more importantly, comfortable with the choice.

Do I try to treat both at the same time?

Again, this is not the sort of problem that dictates a single course of action and it's important to try and let matters steer the course for you and temper them with what makes you comfortable. You may be establishing a condition of ultimatum out of both frustration at the circumstances and the compelling need to find the answer. The bottom line is that none of this would be relevant if the symptoms would abate, regardless of whether they constitute an underlying organic disorder or represent the somatic features of significant anxiety.

Do I get a second opinion from a different Cardiologist?

If you have questions regarding the diagnosis by your present cardiologist, then it's always a good idea to seek out another professional opinion. The only caveat is making certain to draw the line where you intend to stand if the second opinion supports the first. In other words, seeking opinions can become a sojourn of sorts and patients rarely recognize that they are sometimes driven by what they wish to obtain rather than what is available, if you see my point.

Do I follow through with my scheduled electrophysiologist appointment in March recommended by my pulmonologist? (An EP study scares me)

This is actually a very common obstacle put in place by patients when seeking help. There is a concerted effort to find a cause for their symptoms and the avenue for doing so is an increase in the number and type of diagnostic studies relative to the concern. Once testing is established, the patient becomes highly reluctant to follow through and is based either on a fear of the invasiveness of the test itself or the results which might be produced. You can see the irony of persistently seeking a cause for which the increased potential for discovery becomes a matter to be avoided. In other words, I need more testing but I'm scared of what the tests might reveal, a testimonial to the moving target features of anxiety.

Do I get a new GP who will review all my tests and make a recommendation? as my current GP doesn't want to see me for 3 months as he believes this is all anxiety.

This is again, a common difficulty for patients who feel frustration with their circumstances and the medical community. What you're stating here is that you want a doctor who will treat you for the cause you believe to exist rather than what the doctor professionally contends based upon their training and experience. The essence of your statement is "do I get myself a doctor who responds to my needs or stick with the one that's ignoring me?"

Perspective will probably help with this one. A patient is basically driven by the need to be well. They have symptoms which they wish to have abated by their doctor, a very basic and customary exchange. The doctor is interfaced between medical science and the patient and their task is more driven by a passion for science than one of compassion, the nature of which is quite variable among clinicians. Their primary view of the patient is in the context of a study of human health and disease and they apply their training and experience to the presented case in order to make decisions in accordance with best standards of practice. It is rarely, if ever, observed that a physician begins experimenting with various techniques or medications in the hopes that it will somehow increase diagnostic accuracy over and above the strict regimen of clinical medicine.

Your difficulty here is that you feel alone in your quest for answers and your patience tested by the medical community which is supposed to constitute the resource capable of accurately defining and resolving your health problems in a timely manner. Whether they meet this responsibility with any degree of success is, for the patient, based upon whether their symptoms remain and the cause singularly defined.

Your confidence in the healthcare system is under challenge by virtue of the fact that you are being left to make clinical decisions on your own and based upon a diverse and even conflicting set of viewpoints.

What matters at this particular point is that you find relief. All of the options described by you are available and each is reasonable. If you fear having tests performed, take a close friend with you and plan a little reward once everything is completed. It's normal to be apprehensive about tests. It is impractical to your needs, however, to avoid it altogether.

Set your course and proceed. The indecision that many people experience is in most cases nothing more than the avoidance of doing what you know to be logically necessary but emotionally troublesome.

You'll be just fine. Let your doctor adjust your medication, take a friend and go have the EP study performed and share your thoughts with your psychologist about it all. Sometimes a careful blend of choices is the right path to proceed. Exercise them as it suits you. None are harmful.

Hold me fast from purgatory, for the indecision which lures me there would bind my fate.  


Best regards,

Rutheford Rane, MD (ret.)