Re: palpitations

Posted By CCF Cardio MD-SGM on March 21, 1998 at 13:17:41:

In Reply to: palpitations posted by jeanette on March 12, 1998 at 01:20:21:







: This is long. Please bear with me.
I am a 39 year old mother of 5. I am overweight and have hypertension
for which I take 25mg. of atenolol daily. I was diagnosed with Hashimoto's
thyroiditis 15 years ago just a few months after the birth of my first
child. The endocrinologist I was sent to at the time put me on replacement
thyroid at the first visit because he said I would eventually become
hypothyroid.
Shortly after beginning replacement, I went to the emergency
room with an irregular heartbeat, I was sent to an internist who did a
24 hr.Holter, told me I had PACs and PVCs and was out of shape because
my heart rate was too fast. My weight at that time was 50 lbs. lighter
than presently and I was moderately active. I tried very hard to correct
this "defect" by trying to be less stressed, exercise,etc. I was not
consuming stimulants and avoided medication because I was breast feeding.

During the next nine years I had four more kids and off and on irregular beats,
including episodes of tachycardia and premature beats (as well as frightening
episodes in which I felt as if my heart and a large vein below it were "shuddering"),
angina-like chest and arm pain, and a subjective bruit in my right ear in
certain postures, for which I had consultations with cardiologists and one
neurologist (for the bruit because I also have migraines) who ordered one
more Holter, 2 treadmills,  2 echocardiograms and recommended a thallium scan
(not done due to nursing another child), as well as a CAT scan and
carotid ultrasound for the bruit. I was told I had no evident heart disease.
I still had the scary palpitations, no confirmation as to their origin, and,
despite several successful attempts to increase my cardiovascular fitness,
no response to being in better condition. There was concern that I had MVP,
but the echos, both done 5+ years ago, supposedly indicated I did not have
a prolapse (one of the techs who did one echo indicated he thought I did and
one of my family doctors thought I did as well because he was sure he had heard
a "click"? when listening to my heart - he had sent me for the echo).
After a scary final birth almost six years ago, during which I hemorrhaged
heavily, I once again had more palpitations, and developed mild hypertension
about 3 years ago (due I'm sure to my persistent overweight and genetics).
I got fed up with all of it and requested my original thyroid labs from
many years previous. I was not surprised to learn that my initial tests
indicated that I was HYPERthyroid (which I was never told and for which I did not
receive any symptomatic treatment) and that my thyroid levels over the years had
occasionally indicated too much suppression (the kind I had read was associated with
bone loss). I asked my family doctor to let me wean off the thyroid and, lo and
behold, my levels were normal and have stayed that way for five years (I was
tested as recently as two months ago). I still have evidence of antithyroid
antibodies and imagine I will become hypothyroid eventually.
Despite going off the thyroid meds, and going on atenolol for hypertension 5 months ago,
I continue to have these irregular beats. I have not noted a single pattern,
except that they can be triggered or made worse by stimulants, ovulation and
mensruation, emotional stress, allergy (when I have hives or at certain times of the year),
and certain postures. I have recently
had several weeks of increasing palpitations - the worst I've had in years -
and I am once again frightened. I would like someone to help me find the
cause and get the palpitations to go away.
My questions: Can an episode of untreated hyperthyroidism damage the heart?
Would this damage be apparent in subsequent cardiac tests?
Can the heart be stimulated by a thyroid "leaking" hormone due to antibodies
even if the thyroid tests show normal levels?
On the atenolol, I get no relief - my palpitations just happen
in "slower motion". Does this lack of response by my heart indicate an
electrical problem?
I haven't had an echo or treadmill in 5 years, a chest x-ray in 3 (ie; no tests except a 5 minute
EKG strip since I became hypertensive) and never a thallium scan - should these
be repeated?
My new family doctor suggested switching from atenolol to verapamil-
should I request certain tests before making that change?
Is a test of my heart's electrophysiology a good idea?

Unrelated to the thyroid, can a hiatal hernia or esophogeal spasm or
reflux trigger arrythmias?
I have reflux when laying down or bending at the waist and have had a sensation of something being
in my chest when I lay on my left side at night for the past year and I
wonder if my stomach is pressing upward?
Could this cause sharp pain in the heart synchronous with each beat?
(I've had 3 such episodes standing and reclining) No one has looked
into whether or not I have a hernia.
Finally, I have some concern that I have sleep apnea since my weight has
risen this past year. I have palpitations at night and terrible chest
"rushes" that waken me when I have nightmares - weird pain that runs from
my chest down both arms and has left an odd lingering pain for as much as a
day subsequent. Would testing for apnea be a good idea (I know weight
loss would!) In addition to these "weird" pains I have angina-like pain
- sometimes when upset, sometimes when I ingest stimulants (I've had them
a few times at rest and also a couple of times when getting painkillers
at the dentist -the dentist told me the shots have a stimulant effect) -
this happens less often since I've been on the atenolol.
Thank you for your time.




  _
Dear Jeanette,
From your question, I gather that your most significant complaint is palpitations.  I will attempt to address this issue and provide some recommendations and reassurance.  Palpitations, as you know, often represent premature or "extra" heart beats that arise from the ventricles (PVC's) or the atria (PAC's).  In the presence of a structurally normal heart (i.e. no history of ventricular dysfunction or significant coronary artery disease)  these irregular beats are benign.  I want to reiterate this, because I think it's a crucial point:    If a heart is normal, palpitations pose no risk to the patient.  I hope that this is reassuring.
Many factors such as increased thyroid hormone levels (possibly exacerbated by therapy you were receiving)  caffeine, alcohol, cigarettes and other stimulants can increase the incidence of PVC's and PAC's.  Often, treatment with beta-blocking medications such as atenolol or possibly calcium channel blockers such as verapamil can reduce the frequency and symptoms of palpitations.    Hyperthyroidism can exacerbate or cause palpitations and irregular heart rhythms (arrhythmias), however its effects are not permanent, and tend to resolve when thyroid hormone levels return to normal.  In regards to esophageal reflux,  sometimes this can produce palpitations by irritating the atrial chambers of the heart, which lie adjacent to the esophagus.  Therapy for reflux includes antacids, H-2 blocking and other drugs like Pepcid or Tagamet, weight loss, and possibly surgical therapy for resistant cases.   Sleep apnea can sometimes cause heart rhythm abnormalities, and can produce other complications such as pulmonary hypertension (high blood pressure in the lungs).  If you have a history of loud snoring or have been witnessed to stop  breathing for intermittent periods during sleep, you may wish to be evaluated for this condition with a sleep study.  
It appears that you've undergone extensive testing of the heart.  I don't believe that repetition of these tests would yield any additional information.    One consideration is performing recordings of your palpitations with an event recorder which you could turn on when you're experiencing the problem.  This would identify whether you have PVC's or alternatively suffer from an arrhythmia.  In either case, an electrophysiologic study of the heart may be helpful.  This procedure can sometimes be used to cure arrhythmias, and in some cases can also remove the source of PVC's.   Something to consider.
Hope I've been of help. Information in the Heart Forum is for general purposes only. Specific diagnoses and therapies can only be provided by your physician.