Palpitations during sleep wake transition

[wxci]

I'm a 44 yo male, in generally excellent health but with some chronic anxiety issues. I have been taking 30 mg/day propranolol for a couple years. A few weeks ago I had some stressful life events and began having ectopic heartbeats at night, sometimes in strings of 3 to 6 in a row. They would occur as I drift off to sleep, and also wake me up during REM sleep. Even if I don't lt them worry me, they are still pretty vigorous and wake me up. Many nights I get very little sleep. My doctor had me double my dose of propranolol to 60 mg which helps some but didn't eliminate the palpitations. During an ECG it looked like these might be PVCs, but I have not yet done a holter monitoring. I also did an echocardiogram, which the doctor said was "essentially normal." Even though my life stressors have diminished considerably, the palpitations continue and have now gotten to the point that they occur during waking hours whenever I stand or roll over onto my side abruptly. My questions:

1) Any insight into why palpitations might occur so dramatically during sleep-wake or wake-sleep transitions? Also, why do they occur when I stand or roll over?

2) Does long term taking of beta-blockers like propranolol cause an up-regulation of beta receptors, making my heart even more "touchy" and likely to have PVCs? Have I developed a "dependence" on propranolol so to speak?

3) Do people in my situation (and others in this forum) ever find that their propensity to have PVCs go away entirely with stress reduction and exercise?

I have long ago quit all caffeine, etc. Thanks for your help!!

[Cleveland Clinic]

wxci,

thanks for the post.

1) Any insight into why palpitations might occur so dramatically during sleep-wake or wake-sleep transitions? Also, why do they occur when I stand or roll over?

Some postulate that change in body positions can change the anatomic position of the heart or the filling pattern of the ventricles leading to an increased symptoms.  There are also variations in hormonal levels like epinepherine and cortisol that happen on a cyclic basis which some feel can effect palpitations. These of course are pure conjecture.

2) Does long term taking of beta-blockers like propranolol cause an up-regulation of beta receptors, making my heart even more "touchy" and likely to have PVCs? Have I developed a "dependence" on propranolol so to speak?

Yes they can lead to upregulation even in the short term.  But again, we dont typically see this too much clinically.

3) Do people in my situation (and others in this forum) ever find that their propensity to have PVCs go away entirely with stress reduction and exercise?

Some have had dramatic effects.  I would look into what is exactly causing your rhythm, then proceed from there. There are alot of coping mechanisms people have listed in the prior post.



good luck

[Gaspipe]

IN regards to your last question I,d say that stress reduction and exercise are helpful but PVC's can come and go no matter what you do in my long term experience. Certainly a complete work up is needed a Holter is probably the ticket to diagnois the problem. And many times its the patient who has to decide their ability to tolerate the arrthymia provided it's not life threatening . If it's not tolerable then more aggressive meds and even ablation can be considered. I've tolerated mine for years sometimes it's easy sometimes it just plain *****.But I really want to avoid the more potent meds if possible.So rest assured you are not alone and once you find out your problem is "benign" keep on pluggin away.

[Gaspipe]

Sorry comment is to wxci

[Momto3]

Just curious.....what is meant by "up regulation of beta receptors?"  

I also took Inderal for many years (off/on) and eventually they seemed to work better on an "as needed" basis.  When I took them for a long period of time (everyday), they seemed to lose their effectiveness in controlling the pvcs...Is that what you are referring to?

[arcee]

Positional PVCs  ---   In my case, you bet.   For a few years, I have not been able to turn on my right side in bed without causing arhythmia -- even during times when I had none otherwise.   I have wondered if perhaps I had a valve problem that was aggravated by that position.  I simply quit sleeping on my right side.  - - - -  Also, when first lying prone at night, I sometimes must sit up again and then lower slowly to eliminate irregular beating.  - - - - In this Forum, I have read of a number of comments by people who also experience some postional onset of PVCs.

[arcee]

I continue to wonder if the vagus nerve msy be somehow related to the whole problem of irregular heart beats.  I just did a search on vagus nerve & found that its name means "wanderer" which is fitting because of its connections with so many organs and bodily functions -- including heart and digestion/elimination.  This, then, might explain some of the "positional" experiences.

[bama jane]

I can't sleep on my left side without having heart palps.  Also have to recline slowly at night to sleep to avoid them. I usually sleep on two pillows, if it is bad 3 pillows.  Did I understand the doctor  correctly in saying that beta blockers can increase palps in some people? I never noticed extra beats until I was started on beta blockers for tachycardia. They  contiued even while I was off them for 6 months but so did episodes of tachycardia (PAT) and sinus tach so went back on.  Have these extra beats throughout the day every day of my life.  My father just died of congestive heart failure from chronic atrial fib, which started as svt at the same age I got it.  His heart was originally normal structually and so is mine.  At the end he had other contributing issues.  Wonder how much heredity plays a part in this as my nephew at 34 just started having extra beats and some heart racing. Have some docs tell me can be inherited and some probably not, but not the definite no one would hope to hear.

[uptowngirl]

Hi,this is my first time posting a comment, female in my 30's.  I have also encountered the same sort of palps during sleep/wake times, as well as a fast resting rate.  I had been on indural also for a short time, however, I still had alot of "breakthrough" (cardiologist's term).  He suggested we try another beta blocker. We did try Tenormin, which worked MUCH better.  I've been on that since 1998, and recently my rate started to esculate again, so I went back to Duke and they diagnosed me with IST (inappropriate sinus tachycardia).  The EP, who was excellent said that different beta blockers can be tried until one gets a suitable "fit".  The EP has now put me on ToprolXL  which is working wonderfully.  All that to say that, perhaps another beta blocker would give you the coverage you need to get you through. It sure has helped me.  Thanks, and all the best!

[wxci]

First, to everyone thanks so much for your kind posts. The information is very helpful!

to momto3, "upregulation of receptors" refers to a general biological mechanism. There are receptor molecules on cells (often cell surfaces) that act as "antennas" for specific signal molecules. Some molecules with a particular shape will fit the shape of a receptor (like plug and socket), activating it and sending a cascade of signals into the cell. In a way, receptors are like eyes and ears for the cell. Sometimes when the concentration of the signaling molecules goes down, or if they are blocked, the cell responds by increasing the number of receptors. Thus, cells may become "more sensitive" to a signal once the signaling molecule concentration comes back to normal or is no longer blocked. My concern is that if beta blockers are used, the cells respond by increasing the number of beta receptors...when you take propranolol away abruptly (in my case) the heart temporarily becomes even more excitable until the beta receptors downregulate to normal. But theory can be overly simplistic, so it's very important to know the actual clinical experience of people. Particularly, if up and down regulation of beta receptors happens quickly (within a few days) as the doctor said, then I'm much less concerned.

Your comments are very much appreciated!! You guys are great, thanks!

[Momto3]

WOW!!

Thanks for the very imformative post!  I never fail to learn something new on this board.  Prior to ablations, I had bizillions of pvcs and tried a number of beta blockers for symptomatic relief.  Eventually, it was as though my body built up an immunity to the daily dose and an "as needed" pill seems to be more effective.  After I began to experience too many breakthroughs and other problems, I was put on antiarrythmics. They helped a great deal, but I had a tough time with the side effects.  Your explanation offers me some greater insight into why the B-blockers wained in their effectiveness over time (especially, since I was on/off).  Thanks again!!

connie

[Momto3]

Hi Pluto!!

I'm not real sure about how BB's works, but I do agree that they slow down the HR. In my case, I did not have high blood pressure, but only took BB's for symptomatic relief of palps. Initially, they worked GREAT. After a few years, I was switched to Inderal 80LA (long acting) and it really helped. A few more years passed, and eventually they just weren't as effective. I think I was off of the daily dose for a few years. During that time, I pretty much managed to "deal with" the pvcs, but on really, really bad days, I would take a 20mg tablet for symptomatic relief. I absolutely agree that taking ANY kind of prescription medicine should ONLY be done under doctor's orders.

Seems as though you are dealing with a similar situation. Like you, I eventually, experienced MORE pvcs on BB's.  Hmmmm....Keep us posted as to what the change in dosage brings about.  Doesn't reducing the dose affect your BP?

[Momto3]

Hi Hank!!

NO WAY!! A lower B/P on lower dosages!!  WOW!  Now, that's great news!  That's terrific that you are making it a point to walk each morning -- I'm still trying to push myself -- just seems that by the time I have time, I just want to rest...haha!  I tried resistance training for 3 months, but when "life" got in the way, I caved.  I really need to get back to some form of regular exercise...new goal!!

Don't know whether the medicine change or the walking is responsible for your drop in B/P, but in either case -- HOORAY!!
I agree, if you have same results on lower dosage - go for it! During my last two visits to the EP, my B/P was a bit elevated (142/84 and 138/80). I have been keeping an eye on it at home and now it is low. I'm trying to figure out if that's why I have been more tired than usual. Waiting a few weeks to test the hypothesis : )

Lifestyle changes that result in positive health are great! There's no better way to maintain good health than getting your body used to fitness, healthy choices, etc. Keep up the great work Hank!

PVCs are still insignificant.  I get 'em, but no big deal. I'll see what the EP says in August.  As for being PVC-free...I'd have to say I'm cruisin' at PVC-less!! LOL!! I will probably be scheduled for an echo in the next few months and it will be interesting to see if things are still improving. I have been a bit more tired in the last couple of weeks, but I think it's "life."  When I can get a B/P reading it is generally about 100-110/55-62; pulse steady around 60-64. I'm hoping B/P change is not because of valve trouble???  I'm just a bit paranoid...Overall, I still think I am doing much better than one year ago!!  

[Momto3]

Oops....Thanks so much for asking!

[mrbh]

This was really interesting to me, as I am presently wrestling with a beta blocker issue and have had my thinking changed quite a bit. Much of what you folks are discussing here is part of that change.

I have been on Inderal since 1998, starting with 10mg 3x a day then 20mg 3x or 4x a day. Presently taking a 10-10-20 dose schedule. In the past 8 months, there is a definite connection between the Inderal and my PVC's and my more frequent episodes of sinus tach. It doesn't seem to help any more while still ripping and slashing at my digestion. My gastric misery was FAR worse during my trial of Toprol XL about a year ago. Yikes!

I also share the shaky job of effectively coping with palps when trying to go to bed at night. Just trying to stretch out in bed can be quite an experience, so I have great feeling for what some of you are going through.

The upregulation of beta receptors was a fascinating concept and I find myself in agreement with it. It might be revealing to note that my PVC's arrived when I was dosed on 80mg of Inderal LA in 2002. As I decrease the dose gradually, everything is worse, more frequent and more distressing. So, the upregulation theory makes even more sense to me. As dosage decreases, symptoms increase...almost a rebound effect.

Yes, my symptoms have all been checked out by an internist and my cardiologist. Doesn't make things any easier though.

Standard caveat: Never mess with your meds without consulting your doctor.

[SARA-M]

I am a 37 year old female. about 18 months ago I was short of breath, had palpitations, chest pain and a sore throat.
My GP did thryroid blood test(I have a multinodular thyroid), EKG and Holter monitor test.
Thyroid hormones were in normal range, EKG showed something and 24 hour holter monitor showed sinus arrhythmia with frequent isolated PAC's (2.5% of total heart beats). my doctor put me on 50-100 mg Atelonol. I did not help at all. the throat and chest and back pain is still there. I dont have those "thumps" anymore, but my heart is quivering all the time. I can feel something like a electicity stream in my heart all the time.

I saw a cardiologist a few days ago. A new EKG showed nothing. He recommended an echocardiogram and a thalium stress test. I have sever palpitations in bed, at night and in the morning.

Has Atenolol caused this heart quivering. should stop taking it?
I have laready reduced the dosage to 25 per day.

[feeling crazy 2]

i had anxiety attacks since i was 16 ys old they went away a few yrs ago.(self treated)im now 36 and i find  that when im sleeping mostly i will get heart palpitations so hard and fast it wakes me up and i try to keep myself calm and breathe slowly in my nose out my mouth this lasts id say 45seconds to a min.it scares the living **** out of me and i dont have a clue whats wrong with me.MEGA STRESS???maybe but i dont know,but i dont think DR.'s know either.

[feeling crazy 2]

i had anxiety attacks since i was 16 ys old they went away a few yrs ago.(self treated)im now 36 and i find  that when im sleeping mostly i will get heart palpitations so hard and fast it wakes me up and i try to keep myself calm and breathe slowly in my nose out my mouth this lasts id say 45seconds to a min.it scares the living **** out of me and i dont have a clue whats wrong with me.MEGA STRESS???maybe but i dont know,but i dont think DR.'s know either.

[NurseKagome]

I have woke up many times at night with a racing hart beat (often weridly enough also it happens to me in my dream if I'm dreaming at the time)or woke up with palps. I HATE IT!! It sux! So I definatly understand what your all feeling!

[andez]

A related discussion, Chest Jolt while sleeping on side (either) was started.