Post Exercise Elevated Heart Rate

I am a 51 year old man.  I have no discomfort or inability to aerobically exercise.  From my early 20's to late 30's I was VERY active in aerobic sports and ran an average of 6-8 miles per day.  My resting pulse is now from 68 to 72 and BP is good for my age.  My problem is that after a session of aerobic exercise my pulse will not return to normal for many hours.  This effect is dependent on the pulse rate I maintained during exercise and the duration.  I can experience resting rates of 120+ for up to 4 hours after a strenuous hike.  The rate will then very gradually drop and not return to normal for up to 8-12 hours. Lately I have noticed that eating a meal will elevate my resting pulse to about 100 for several hours. This has been my condition for many years and has dramatically altered my life.  I exercise now in the range of 95 to 105 and have little elevation of rate.  Any higher and I have extended periods of high rate.  This condition has caused depression and anxiety to a point that I cannot psychologically tolerate the effects of vigorous exercise.  One doctor wants me to take atenolol 25 mg per day for symptoms-another 50 mg but neither has any explanation of the cause.  I've had echos, treadmill, ecg's, holter....all normal except for minor aortic and pulmonary insufficiency they discovered and say is unrelated and minor.  I would like to have my life back.  Should I take the medication and try to ignore the fact that the doctors do not know the cause ( bothers me a great deal )?  The elevated pulse after exercise is described to me as normal sinus rhythm.  Some years ago some PVT's were detected on the stress treadmill test but they told me they were not dangerous.  Thank you

[CCF-M.D.-CRC]

Dear j,

I too am at somewhat of a loss as to what would be causing the extended elevation of your heart rate.  Is it possible you are becoming dehydrated during your exercise?  A low volume status may elevate heart rates.  I would probably check a 24-hour Holter monitor test that includes a period of vigerous exercise to document the extent of the situation.  If the Holter revealed only sinus tach it is possible you have inappropriate sinus tachycardia. This can be treated with beta-blockers or ablation but does not always need treatment.

[RFC]

I have a similar story regarding excersise. I am 52, active, male. My latest job is administrative, out of my house. I do not get the excersise I believe I need. I joined a gym in Jan. I had a vigorous program of cardio and weight training alternating 5-6 times weekly. My diet is healthy, weight normal, some daily alcohol(2 beers), no smoking. After two weeks of excersise I began to get extended bouts of arrythemia, 4-12 hours. ( I have been aware of isloated periods of arrythemia in the past typically brought on by lack of sleep or excess alcohol)
I went to the ER after my first long incidence and was given cumetin and atenolol. I continued the excersise. The bouts of arrythemia continued. Stress test and echo normal. I am getting two extended bouts a week now (6-18hrs)I am on 50 mg of Atenolol,25 ea morning and evening. I have stopped all alcohol. (just in the last week) I have 1-2 cups of decafe coffee.
I am also very depressed about this condition. It's effecting my work. I have trouble consentrating and completing tasks. I appear confused. This is not me. I have no interest in the next more powerful drug Sotalol. The side effects are too risky. I have been reluctant to give up all alcohol and excersise and real coffee but now the alternative is not good. I am hoping that this new regimine keeps my heart beating more regularly so I can get off the atenolol. I believe it contributes to the depression and confusion.

[arthur]

Get to a cardiologist/electrophysiologist(ep) asap.  

I am 53 and have been athletic all my life.  I have had numerous bouts with atrial fibrillation, an arrythmia which would be triggered by vigorous exercise. Needless to say, I too experienced a combination of depression and panic. You need to have the arrhythmia identified (for example, with a Holter monitor) and treated (drugs are not the only option).  In my case, a rf ablation successfully removed the arrhythmia.  The meds your doc has you on are typically given to avoid clotting and get you less sensitive to adrenline (due to exercise)...but they do not address the underlying cause...something an ep could ascertain.  I found that once I knew exactly what was causing my problem, I felt much better and could set about planning the counter attack.

[RFC]

Thanks for your response. I am going to the cardiologist today and will bring up those issues. So far the doctor talks like the cause of the arrythmia is a mystery that we may never know. I have gone 4 days w/o an occurance so I am feeling pretty happy.
I have been fortunate to be very healthy my whole life to date and now I am falling apart.

[arthur]

Hang in there.

I felt exactly the same.  There is a cause for everything.

If your are having occasional atrial fibrillation, kicked off by excessive exercise (or anything that gives you an adrenaline rush...for me this included cold drinks, sudden change of posture, even nightmares) it is possible (and even probable) that they are being caused by "foci" located at or near the pulmonary vein entrances to the back of the atria.  Your cardiologist may not be aware of this connection and may deem to treat the symptoms and not the cause.  In most cases these are CURABLE assuming that there are not too many "foci" and they are accessible by a catheter ablation technique.  I have attached a summary of the latest findings re. AF and its treatment for your information (it was originally posted in this forum back in November 2000).  I had AF (paroxysmal..ie, kicked off occassionally) which started up about two years ago and made my life a living hell...it was diagnosed as being caused by these pulmonary vein foci (apparently as the result of the wonderful combination of age and athleticism which "stretches" the PVs and can lead to "foci"), and the focus responsible for my AF was removed (ablated) with a radio-frequency energy pulse using a specially designed catheter.  This technology is new...ie, it only began to be practiced in the last 5 years.

You may find the attached summary re. AF and approaches to its treatment of interest (it was originally posted by one of the Cleveland Clinic's cardios back in Nov 10, 00).
Again, good luck to you...go to an EP if the Cardio is clueless.


ATRIAL FIBRILLATION ABLATION, WHICH APPROACH IS BEST - LINEAR, FOCAL, SEGMENTAL OR
     CIRCUMFERENTIAL?
     Christopher R. Cole,M.D. Andrea Natale, M.D.
     Cleveland Clinic Foundation, Cleveland, Ohio, USA

     Introduction
     Over the past 5 years there has been a paradigm shift in the treatment of atrial fibrillation
     (AF). Advances in the understanding of the initiating triggers of AF and in ablation technique
     have changed the treatment of AF from one of chronic control to acute cure. The question of
     the ability to cure AF has been answered; what remains to be answered is what technique is
     best suited to achieve this end.

     There are currently 3 main approaches to AF ablation: atrial linear lesions to interrupt AF
     wavelet propagation, focal ablation of foci that trigger AF, and circumferential ablation of the
     pulmonary vein ostium to achieve electrical isolation of triggering foci. We will explore the
     advantages and disadvantages of each of these 3 techniques and discuss potential future
     directions of AF ablation.

     Background
     The magnitude of the problem of AF is well known. By age 65 upwards of 5% of the population
     have had an episode of AF and over a third of hospitalizations for arrhythmias are due to AF.
     It is a major cause of morbidity, with over 200,000 strokes a year attributed to AF. In the
     United States the cost to treat AF is $3.6 billion annually of which $400 million is for drugs
     alone (1, 2).

     Until recently, pharmacotherapy with antiarrhythmic drugs or rate control agents with
     anticoagulation was the only treatment option for patients with AF. Although better than
     placebo at maintaining sinus rhythm (3) antiarrhythmic drugs are relatively ineffective over the
     long run. The retention rate for SR at 6 months after cardioversion is only 60% in patients on
     antiarrhythmic therapy (4). In addition, antiarrhythmic drugs confer a small but added
     pro-arrhythmic risk to the patient, particularly those with structural heart disease. For these
     reasons investigators have been looking for better treatment options for AF including ablation.

     Overview of the Approaches to Atrial Fibrillation Ablation
     As the understanding of the mechanisms of arrhythmias progresses, so does the ability to
     treat arrhythmias with catheter-based interventions (5). As we have seen in the past few
     years, each change in the mechanistic understanding of AF corresponded to advancement in
     the treatment options.

     The hypothesis of a critical mass needed to sustain atrial fibrillation (6, 7) and the multiple
     wavelet theory of atrial fibrillation (8-10) led to the development of the surgical maze
     procedure (11, 12). By making multiple linear scars in the atrium, the atrial chambers are
     compartmentalized in smaller regions unable to sustain AF. This technique, although
     successful, requires general anesthesia and open heart surgery. These important limitations
     have fueled interest in the development of catheter-based ablation procedures.

     The idea that atrial fibrillation could be triggered from a rapidly firing single focus was first
     suggested by Scherf in the 1940's (13). However, it was not until recently that this idea was
     more fully explored. It is now believed that in addition to the substrate needed for multiple
     wavelets, AF is triggered by a rapidly firing focus in the majority, if not all, cases. The
     recognition of this mechanism is based on the pioneering work of Haissaguerre et. al. (14, 15)
     who first demonstrated that atrial ectopic beats within the pulmonary veins are responsible for
     the initiation of spontaneous paroxysms of AF. This finding paved the way to different
     catheter-based treatment approaches. Focal ablation of the ectopic focus was initially
     considered. However, since detailed mapping and ablation within the pulmonary veins is
     technically challenging and carries the risks of pulmonary vein stenosis, circumferential lesions
     to electrically isolate the pulmonary vein from the atrium has been considered more recently.

     Patient Selection
     As with any procedure one of the keys to success is proper patient selection. In a patient
     who has planned open-heart surgery for another reason the surgical maze procedure may be
     the best approach. If the patient has infrequent episodes of AF and infrequent APCs, a focal
     AF ablation may be difficult to perform.

     While there are no hard age cutpoints, a younger individual with paroxysmal AF and no other
     serious health problems would be a more ideal candidate for ablation than an older individual
     with chronic AF and other major illnesses. Generally a trial of at least 2 antiarrhythmic drugs is
     given before proceeding to ablation. If the left atrium is greatly enlarged (>4.5cm) on
     transthoracic echocardiogram, ablation may be less likely to succeed. Currently patients with
     a low EF (<40%) are excluded from ablation procedures; As the field progresses, the exclusion
     criteria will probably change.

     Linear Lesions (Atrial Segmentation, Maze Procedure)
     The first catheter-based approach to ablation of AF was designed to mimic the surgical maze
     procedure (11). The catheter-based maze has been performed by using a variety of catheters
     to make linear lesions in the atrium and interrupt the propagation of the wavelets of AF
     (16-20). Several different approaches have been used including epicardial linear lesions
     generated by hand-held probes (21), the creation of right sided only linear lesions (17, 20, 22,
     23), both right and left sided linear lesions (16, 18, 19), and the use of different proprietary
     catheters (24). The use of three-dimensional electroanatomical mapping has been suggested
     to facilitate line placement and to insure continuity of the lesions as well (25, 26).

     In a pioneering work, Swartz created 3 right atrial linear lesions, 4 left atrial linear lesions and
     one septal linear lesion using standard 7F ablation catheters and specialized coaxial long
     sheaths (16). All 30 of his patients required both right and left sided lesions for termination of
     fibrillation and there was an 80% success rate. There were two strokes following left-sided
     ablation in his series.

     Due to the stroke risk of left-sided ablation right-sided only ablation appeared more appealing
     (17, 20, 22, 23). Haissaguerre et. al. described the first successful right-sided ablation case
     report (17). Using specially designed catheters with closely spaced ring electrodes the
     investigators made two geometric linear lesions in the right atrium with successful cure of AF.

     Natale et. al. performed right-sided only linear ablations in 18 patients with a 22 month
     success rate of 50% (20). Of those who remained in sinus rhythm, 5 subjects did not require
     medication and 4 subjects responded to antiarrhythmic drugs that were previously ineffective.
     Garg had a similar success rate in a series of 12 patients (23). Interestingly, although right
     atrial lesions may decrease the atrial defibrillation thresholds they seem to create the
     substrate for more incessant arrhythmias.

     Subsequently Haissaguerre et. al. explored the addition of left-sided linear lesions for patients
     who failed right-sided only lesions in a series of 45 patients (18). Patients were divided into 3
     groups of 15 subjects with a different right-sided ablation pattern used in each group. Those
     who failed right-sided ablation only proceeded on to left-sided ablation. The success rate of
     the right-sided only approach was low- only a success rate of 13% without drugs to 40% with
     medications. The addition of left-sided linear lesions in 10 patients increased the success rate
     with medication to 60% and decreased the number of episodes of AF in 70% of the patients.
     Complications included 3 sinus node dysfunctions and 1 case of hemopericardium.

     Expanding on this work, Jais and colleagues used biatrial linear lesions in 44 patients (19).
     Using two right-atrial lines (1 septal and 1 cavotricuspid) and 3-4 left-atrial lines they were
     able to achieve a success rate of 57% with medications. There were improvements in an
     additional 27% of the patients and 16% were considered treatment failures. There were 5
     pericardial effusions and 1 each of a pulmonary embolism, inferior myocardial infarction and a
     reversible cerebral ischemic event. An average of 2.7

[RFC]

I stupidly left my notes at home for my appointment today. I brought up the RF Ablation question. My doctor responded that I would then be forced to have a pacemaker. I read that this is the result of the AV node being ablated. From my limited understanding of your forwarded article, none of the proceedures required a pacemaker. None were overwhelmingly sucessfull with rates of about 50% common. I guess those are still pretty good odds. He's recommending Amiodaione if my new "no stimulant program"does not work. I haven't looked up the side effects but I can guess.  Are drugs necessary for you, post ablation?
I have the option of seeing an EP at a Boston Hospital which I will take advantage of to learn more about my particular condition before taking the toxin.
Thank you for your research and encouragement. RFC

[arthur]

Ablation conducted in the PVs for treatment of atrial fibrillation is about 60% curative on the average...the technique is improving as we discuss this (including methods employing other energy sources and even cryoablation).  There is NO need for a pacemaker, as the ablation site is completely distinct from any natural pacemaker center in the heart.  I was left with a couple of unablated PV foci that cause some atrial premature beats at times, so I take a low dose of tambacor to make my atria less sensistive to outside influences (if I wasn't such a soccer fanatic, I wouldn't even need this med since even the skips disappear if I avoid strenuous exercise). It all depends on what the EP examination reveals...that is, how many foci, where are they located, can they be ablated, etc.  If you have symptoms that the EP feels are stemming from a PV focus, then it's normally a two stage process: (1) a dry run wherein they try to induce the arrythmia with stimulants given IV, and if successful, (2) the ablation procedure wherein they repeat the stimulant protocol and zap the buggers responsible for all those skips.

There are risks associated with the procedure since it is invasive (catheters up the groin and into the heart), and you should discuss those risks with your doctor.  My choice was clear, since I simply could not tolerate the absence of exercise in my life.

Good luck with your adventure.

[RFC]

After a pretty good week I wake up this morning to find myself in arrrythmia again. I have not slept well the whole week waking up at 3:30 either as the result of the attenolol or the worry. I find that the lack of sleep contributes to the onset. I have had bouts of apnia (apnea) which I also believe contribute to heart problems.
In any event I am discouraged that I have not been able to controll the onset with abstinence from coffee etc. I tried a xanax this morning in hopes that this might convert me to no avail. The side effects of the proposed Amiodaione are rediculous.  I am making my appointment with the ep today in hopes he sees an alternative treatment.

[arthur]

You are going through what I and many others in this forum have gone through.  The first reaction is that there must be a way I can control the onset of the arrhythmia...maybe it's something I'm eating, maybe it's the lack of sleep... maybe it's caffeine, chocolate, coke...maybe it's my anxiety...maybe it's a tumor...maybe it's GERD...

It can actually be any of the above and more.  Some people claim to achieve some control using meds, herbs, magnesium, bananas, etc.  This simply avoids the issue.

The bottom line is that there is something wrong now that was fine before.  That a host of stimuli will set this thing off and it's almost impossible to prevent it by "watching" yourself.

I think you are doing the right thing...check it out with an expert and decide on a plan of action.  Believe me, once you discover exactly what's wrong and develop a plan of action, you'll feel 100% better.  Hang in there.

[RFC]

An interesting site. http://www.yourhealthbase.com/atrial_fibrillation.html

The more I read about Amiodarone the more convinced I am that I can not take this toxic drug. I get a sense that we are close to knowing more and finding better ways of dealing with afib. I don't want the current cure to kill me before then. I just converted from a nearly 30 hr afib. My reading indicates that stroke in not a big concern in an otherwise healthy heart. I am on 7.5mg of coumatin. The above site refers to an Italian doctor with a sucessful ablation technique. I need to find the best guy in the Boston area or outside if necessary. I hear about Cleveland, Oklahoma, Utah, Italy!!!

[RFC]

An interesting site. http://www.yourhealthbase.com/atrial_fibrillation.html

The more I read about Amiodarone the more convinced I am that I can not take this toxic drug. I get a sense that we are close to knowing more and finding better ways of dealing with afib. I don't want the current cure to kill me before then. I just converted from a nearly 30 hr afib. My reading indicates that stroke in not a big concern in an otherwise healthy heart. I am on 7.5mg of coumatin. The above site refers to an Italian doctor with a sucessful ablation technique. I need to find the best guy in the Boston area or outside if necessary. I hear about Cleveland, Oklahoma, Utah, Italy!!!

[RFC]

An interesting site. http://www.yourhealthbase.com/atrial_fibrillation.html

The more I read about Amiodarone the more convinced I am that I can not take this toxic drug. I get a sense that we are close to knowing more and finding better ways of dealing with afib. I don't want the current cure to kill me before then. I just converted from a nearly 30 hr afib. My reading indicates that stroke in not a big concern in an otherwise healthy heart. I am on 7.5mg of coumatin. The above site refers to an Italian doctor with a sucessful ablation technique. I need to find the best guy in the Boston area or outside if necessary. I hear about Cleveland, Oklahoma, Utah, Italy!!!

[RFC]

Sunday morning research: Italian Breakthrough? http://www.med-edu.com/HyperNews/patient/get/arrhythmias/afib-regulars/22/2/1.html

Best Regards,
RFC

[RFC]

Sorry for the multiple posts????. I am going to try some of the minerals, potasium, magnesium and i carditine (sp?)for the arrythmia. I found a brisk walk worked to forstall an episode last evening.

[arthur]

If you are considering an ablation I would recommend any of the major heart centers...I am sure that Mass General in Boston is good.  I myself went to the Univ of Penn (Philadelphia) and would highly recommend Dr. Francis Marchlinski ... extremely prudent and experienced.

The ablation of PV initiated AF has been in vogue now for about 5 years with a wealth of experience to back it up.  Even newer techniques are surfacing which include cryoablation which sounds somewhat safer that the rf version.  

It all boils down to what you have (as determined by a real electrophysiologist) and what can be done about it...you need to do the research.  Good luck.

[jdm]

Since posting this question I have finally taken my doctor's advice and begun, about a week ago, 25 mg. Atenolol once a day.  The change was immediate and VERY dramatic.  I no longer have the pronounced rate increase after meals ( to 96 to 105 every time I eat  from 68 to 70 prior ).  I am able to exercise ( still at a very moderate level of about 100 pulse rate ) but will work it up ) and see my rate go back to normal IMMEDIATELY. Just like I was a normal person in reasonable shape. There is NO prolongation of high rate.  NONE.  My heart is behaving the way it did years ago and the effect was immediate!  I will slowly work up my exercise level to determine if the Atenolol will counter the elevated rate when I am exercising at  increased rates.  My ( HMO ) doctors never diagnosed the cause.  They simply told me that my fast rate was "not dangerous".  Perhaps I suffer from the extopic foci that some have mentioned near the pulmonary artery that get irritated by or other factors exercise. I was always told that my heart was in normal rhythm in spite of a high rate. My resting pulse is a bit lower now than prior to starting the drug but I apparently have adequate blood pressure as I am not dizzy etc. It is now about  about 60 to 64. I simply cannot believe the change after so many years.  I will keep using it and keep my spirits up that it will continue to control the condition as I slowly increase my training intensity.  I don't want to overdo it too soon etc.  The drug also shows promise of finally breaking the cycle of panic and anxiety that I was in due to obsession with my symptoms.  No matter what happens in my future each day is one more free from this curse. I am awed by the genius that could come up with such a powerful and specific drug as this.   Thanks to all of you for the information.

[RFC]

My primary care physician made me aware of a new proceedure by Dr. Wechsler @ MCP-Hahneman University in Phil. The Maze-III, minimally invasive procedure is " unquestionably superior" to bundle ablation. At six months 92% of the patients were in normal sinus rhythm. The article states that they continue to work to simplify the proceedure. My hope is that this kind of breakthrough will eliminate the need for the very toxic anti arrhythmic drugs.
   I also read about an athelete who has had good luck stopping his afib episodes with 1000-1200 mgs of liquid potassium. (www.med-edu.com/HyperNews/patient/get/arrhythmias/afib-regulars/7/1/1/2.html) I tried it on Sunday and found that my afib stopped in about 45 min.
   My EP says that there in no danger to me with an otherwise healthy heart to continue to take my 25 Atenolol and Cumetin and try some of these nutritional remedies before moving up to the more serious drugs. I continue to have one or two episodes of afib a week but my sense is that they are getting less severe.
I am also starting to take I carnitine,coenzyme Q10 and fish oil.
If some combo of these vitamins does not work I will have to take another hard look at an ablation technique.