THANK YOU FOR TAKING MY QUESTIONS.

Good evening!

I am so very thankful that I found this site. It is very informative and reassuring, to say the least.

I'm a 35 y/o female. Weight 125 Height 5'1" I am also an ex-smoker. I smoked from 18-33 (with the exception of two pregnancies during this time, to which I quite for nine months both times).

My experience with palps (i.e. PACs) is NOT new. I've been battling them since I was 19, so about 16 years. The single, random PAC does not scare me. It's not a pleasant feeling, but it doesn't send me into panic mode. What DOES, in fact, scare me, however, are couplet and triplet PACs.

My palps took a three year hiatus, but decided to reappear last summer when I began to experience sudden episodes of tachycardia, typically ranging from 140-160 BPM. One night, my tachy woke me from a sound sleep and I had an overall unwell feeling. I went to the ER, where they performed an EKG and said it was showing possible ischemia and they immediately admitted me. I do not know exactly what the EKG abnormality was. They also tested my electrolytes, and found that my potassium was low.

This scared me greatly, to the point that they had to give me an anxiety med just to calm me down. They also gave me a potassium pill. I **think** my potassium was 3.1 on a 3.5-5.1 scale). The next morning I had an echocardiogram, and a nuclear stress test. The echocardiogram was clear, and the exercise portion of my stress test was clear. My EKG during the stress test was clear, except for the original abnormal finding, the same one that occurred in the ER. I don't remember the specific results, but I was told that I performed the exercise portion of the stress test as would be expected from someone ten years younger than me. I has NO symptoms whatsoever during the test. Everything sounded great.

BUT, then the thallium report came back, showing moderate blockage. HOWEVER, I have breast implants, and the cardio suggested that the implants may have caused interference. STILL, he wanted me to have the CT angiogram, but said it could be done on an outpatient basis, and he was comfortable discharging me, although recommending the CT angiogram to be done within the week. I will type the results of the report on a new post below.

At this point, my family pleaded with me to go to a top cardiac hospital. The one I was at was a small, local ER. The cardio discharged me, with a script for the CT angio. I was home for three days and decided to go to the top cardiac hospital ER. I did not have any symptoms, I just wanted evaluated. I told them what I had been through at the other ER, and they did and EKG, and also contacted the other hospital for my records. My EKG was still abnormal, but they said it, "wasn't as bad as the earlier one from the other ER". They ran a battery of blood tests and everything came back normal, with the exception of my calcium score, which was elevated: Calcium: 11.1 (8.4-10.2)

So...I'm admitted, again, based on the records of the other ER, and not because of any symptoms or testing done in this ER. I met with the cardiologist in the morning and I am given another EKG.  It is now normal and he recommends a stress echo. I pass the stress echo with flying colors. The cardio feels that my nuclear stress test was a false positive and that I am fine.

I am given a script for Cardizem and Xanax, which I take when I get tachy.  I was dischargd. I go home and about a week later my palps return after being on long hiatus. I hadn't had them throughout this entire ordeal, but shortly after my discharge they came on with a vengeance. There were days when I would be in bigeminy for an hour.

I scheduled an appt. with the cardio from the second hospital, and he ordered a 24 hour Holter monitor, which showed 14 PACs. Yes, I said 14 (and no PVCs). I've never had PVCs, so I wasn't surpirsed there, but  I couldn't believe that this was the day that my PACs decided to behave. From this result, he advised me to stay the course and continue on my Cardizem/Xanax route. For the record, I only take .125-1.0 mg of Xanax probably a week.

I had a follow-up two months later and my EKG was normal, as was my potassium and everything else. He released me to my PCP.

Three months later, the tachy episodes were still happening, and my palps decided to start coming in runs. I don't know that they are runs for sure since they aren't documented, but after dealing with these stupid things for 16 years, I'm fairly confident in my ability to differentiate singletons from couplets, and triplets.

So I go back to the cardio and he has the nurse run another EKG, and its back to being abnormal, reading, "non-specific T-wave abnormally". He orders her to do another one, and it says the same thing. So he orders an electrolyte panel, and everything is fine (including my potassium), but my calcium is now slightly elevated. The cut-off is 10.4 and mine was 10.6
What is interesting is that my calcium was also elevated in June 2012, when I was admitted to the top cardiac ER. HOWEVER, it was re-checked in the fall, and it was normal, again. Now, it is back to being slightly elevated. I recently (within the last two weeks, as I already mentioned) re-checked for a CBC with differential, thyroid, cholestorol, B12, Vitamin D, Calcium, Potassium. Everything was normal, with the exception of a slightly elevated calcium level, which they did not even mention to me, and only saw when I obtained a copy for my PCP.

Just an FYI: In 2009 I was also diagnosed with a multinodular goiter, and I get an ultrasound every two years to make sure there is no excessive growth to the nodules. My thyroid levels have never come back abnormal.  

So he orders a 30 day monitor. I am now on day 14.


Here are my questions.

1.) My PCP (not my cardio) seemed confused about my EKG changes. He said it was weird for me to have non-specific t-wave changes, return to normal and then back to abnormal. Also, this is a new finding in my EKGs. When I started getting palps 16 years ago, I would get periodic EKGs (over the course of about 4 years) and I never had this finding.

What conclusions can I make of this? I DO suffer from a great deal of anxiety. Could anxiety, alone, account for this type of EKG abnormality? It's very concerning. My cardio really felt that my electrolytes would be off when he saw the abnormality, again, but they weren't (aside from the slightly elevated calcium). So, again, what conclusions can I draw from this, and should I pursue more testing? Like I said earlier, I had a clean echo and echo stress test 8 months ago (but an abnormal nuclear test, attributed to my breast implants).
And just to emphasize, the cardio said that **if** I did, I'm fact, have the moderate blockage that the nuclear test said I have, I never would have had the level of endurance I had on the treadmill, and felt that I most definitely would have been symptomatic.  

2.) Are couplet and triplet PACs dangerous? Do you think it's an anxiety response?

3.) Do you have ANY insight or recommendations as to what I should do from here? I'm currently wearing the monitor, but so far, nothing "dangerous" is appearing. I haven't had any triplets, but probably 1-2 couplets per day (based on the preliminary monitor results).

Help me, PLEASE!!

LATEST LABS: (where my EKG was abnormal with "non-specific T-wave abnormality)

Lipid Panel (drawn on 1-30-13)
Trig: 67 (20-160)
Chol: 154
HDL: 55 (40-80)
LDL Direct: 95

On the same day, my potassium was a low-normal: 3.7 (3.5-5.1), calcium was slightly elevated: 10.3 (8.4-10.2)

Magnesium: 2.1 (1.6-2.6)
Bilirubin: .4 (.2-1.2)
Bilirubin Direct: .1 (0.0-.5)
Alkaline Phosphate: 77 (40-150)
Aspartate Amino Transferase: 17 (5-34)
Alanine Amintransferase: 20 (5-55)
Total Protein: 8 (6.4-8.3)
Albumin: 4.4 (3.5-5.0)
Globin, Calc: 3.6 (2.0-3.8)
Albumin/Globin Ratio: 1.2 (1.0-202)

T4: 7.6 (4.9-11.7
T3: 30.4 (22-32)
TSH: .94 (.35-4.94)

Okay, I've read your posting and concerns.

Firstly, the overall clinical picture provided by the test results and declaration of your medical symptoms would suggest a healthy heart and cardiovascular system.

The variability in test results, although not entirely uncommon, could be suggestive of metabolic influence. Of particular note would be parathyroid function and the presence of very mild, but nevertheless elevated calcium level. The presence of a goiter, while not necessarily affecting the thyroid gland, has been known to induce parathyroid irregularities due to the space-occupancy that the goiter maintains and whether it imparts any influence upon parathyroid gland function.

Relative to ECG, it should be noted that in some instances, hypercalcemia sometimes produces a high takeoff of the ST segment in leads V1 and V2 and can simulate acute ischemia. In other words, mild ST-T changes could be the result of serum calcium levels and elevated calcium could be the result of irregularity or variability in parathyroid function. It should be noted, however, that your calcium level is hardly remarkable and rests just above the clinical norm. It should also be stated here that reference values are different between clinical laboratories.

I do not see evidence to warrant serious concern regarding CAD and although the calcium level is again, hardly remarkable, it might be contributory in the presence of a goiter that may or may not be inducing irregularities of the parathyroid. Otherwise, the test results reveal a healthy heart.  

Best regards,

Rutheford Rane, MD (ret.)

Okay, the presence of classified arrhythmias such as bigeminy or trigeminy must be established strictly by documented ECG. Many times patients who are vigilant to their heart's rhythm begin detecting what they propose to be couplets and triplets and this is not actually possible by simply monitoring your pulse. The sensations you experience are not altogether identical to the established electrical impulses being generated to which the heart muscle responds.

Patients often try to verbally described these perceived patterns in the context similar to "thump - thump - normal beat - thump - thump - normal beat, or in the case of what is thought to be trigeminy, thump, thump, thump - normal beat, and so on. The true nature of these characteristic arrhythmias is actually the presentation of these patterns without interruption. It is the transformation of normal sinus rhythm to one where constant couplets, triplets or quadruple heart beats occur. The classification of such an arrhythmia is not established by the intermittent perception of this kind of pattern. Thus, these clinical terms are most often misrepresented.

Furthermore, these events arise in the presence of certain conditions and are not diagnostic within the realm of vagus nerve-induced palpitation events, which despite beliefs to the contrary, are not represented in the context of bigeminy or more complex arrhythmia.

It's important to realize that the type of palpitations you are experiencing do not originate from within the heart and do not constitute a constitutional sign of cardiovascular disease or cardiac abnormality. The heart muscle is simply responding to wayward stimulation by evoked potentials which travel along the vagus nerve.

The events are not capable of inducing transformation of the heart's pacers to some dangerous arrhythmia, nor cause any type of cardiac event. It is more akin to a muscle twitch than arrhythmia. To be fearful of their capacity is likened to experiencing a muscle twitch of an eyelid with overwhelming concern and apprehension that it's going to result in blindness. With respect to heart palpitations, it is the unbridled fear of catastrophic outcome which unsettles patients to such a degree and not the events themselves. It is the erroneously established belief that danger of imminent proportions are associated with the palpitations and this is entirely inaccurate.

You'll be fine. I see nothing of your description or test results that would warrant serious concern at all.

Best regards,


Rutheford Rane, MD (ret.)