Cardiophobia or legit concerns?

[cb23243]

So I am a 23 year old medical student. For the past 4 months ive been experiencing random episodes of sinus tach as well as several panic attacks. Now the reason i differentiate between the 2 is because the latter seems to be preceded by cognitions (fear), sensations, and what you might call "cues" that trigger anxiety attacks. The former seems to come out of the blue, sometimes waking me up. Ive checked my pulse during these episodes on a pulse oximeter and it can get as high as 190bpm for very short periods of time, then gradually slowing back to NSR (does respond to valsalva and like maneauvers).

Ive had several resting ECGs following these incidents which are unremarkable. Ive had an unremarkable stress echocardiogram (54% EF incr. to 68% upon exertion) with no exercise-induced dysrhythmia, dyspnea or chest pain. Ive had a normal 24-hr Holter study with 0 PVCs and PACs. My TSH level is normal, as are my basic electrolytes + magnesium (immediately following episodes). 24-hour urinary metanephrine study unremarkable. Chest x-ray normal.

My blood pressure is normal in/around 120/70 at rest. During episodes it can be as high as 160/100 for very brief periods, usually normalizing within an hour after acute on-set. My resting heart rate varies wildly im guessing because i am 23, but usually 60s-80s depending on time of day. Like i stated during the episodes, my HR can push 180 for very short period esp. If im paying attention to my pulse. Also, i am constantly aware of my heart beat following these episodes and during high anxiety days (bounding carotid pulse, can also see in the mirror) though BP seems normal. I am currently seeing Dr. Mohammed Khan, a CC-trained EP at Alexian Brothers Medical Center.

My event monitor captured one of these episodes. Sinus tachycardia btw. 170-110. This was just one episode, though.

My major fear is that there is something other than anxiety, as i didnt think your own catecholamines could cause such a high HR, brief as it may be. Also wondering if prior to event monitoring i could be experiencing some SVT runs, although ive been told SVT wouldnt gradually dissipate back to NSR, but would come on very quickly and terminate very quickly. The in and out sensation of being aware of my heart beat has also caused me to become neurotic about sudden cardiac death. Should i be concerned about this? I am adopted so I have no family history.

Am i missing something? Anything? Or could this really be just harmless panic attacks?

[nurse0702]

i am currently experiencing anxiety and have been captured up to 169 on holter monitor in sinus tachy. dem doctors state anxiety can not cause a hr above 145 but as my psychologist reminded me...the mind is extrememly powerful, people can hypnotise themselves so they dont even require an anasethic prior to surgery- without proof how can they tell you your mind isnt capable of increasing your heart rate above 145

[cb23243]

Thanks for the replies. Yeah my event monitor captured a few mre of these and its always been sinus tach.

[achillea]

Considering your age, the results of your tests indicating a healthy heart, and your own awareness of the possible (likely) relationship with some kind of panic disorder, I would strongly recommend a nice visit with a shrink specializing in anxiety.

Having spent years mucking around on my own, trying to dope out the chicken or egg problem of whether the awareness of my own heartbeat is the cause or effect of an adrenalin surge, I have found that the shortest way to a solution is to put yourself into a head-specialist's capable hands, once most reasonable physical causes are ruled out.

BTW, don't fear the SSRI approach:  You might find you are very quickly no longer preoccupied by your internal goings-on, and are much more free to enjoy stuff that is going on around you.

[is_something_wrong]

It seems your only concern/problem is sinus tachycardia?

Also, you're doing a very common mistake regarding the relationship between sinus tachycardia and SVT. Tachycardias that instantly start and stop are by far the most common SVT's but you may also have SVT's that warm up and cool down. If the SVT is caused by a reentry phenomenon (extra pathway in the heart) it will instantly start and stop. If it's caused by other phenomena (like so-called increased automaticity, the most common other explaination) it can warm up and cool down. But the specific tachycardia "AVNRT" is the most common supraventricular tachycardia and is caused by AV node reentry. This would show up on EKG with very specific changes (no P wave or P wave after QRS) and can't be interpreted as sinus tachycardia. Obviously you don't have that.

The differential diagnosis is possibly atrial tachycardia, but this would usually show inverted P waves or P waves different from sinus P waves. The exception is atrial tachycardia that origin close to the sinus node, but that's not common. If you had SVT you would likely at least have some PACs during 24 hours.

I've experienced anxiety attacks with a heart rate of 200 or above, so that's completely possible.

Because you are a med student you should know this better than me ;) I would guess you have cardiophobia, did this occur after cardiology class? :)

[MichelleP_3811]

First off considering all the testing you have had done it sounds like your heart and lungs are structurally fine so you need not worry about sudden death.  You are correct about svt, they start and stop abruptly and will not ramp up or down in any significant fashion  So you can likely rule that out as well. It also sounds like you had an event monitor beyond the holter and caught one of the episodes. If the doctor is not concerned by it then you likely have nothing to worry about.  The only other thing I can think of is possible sleep apnea.  If your oxygen is being cut off while you sleep it could be causing your heart to over compensate and beat fast.  Or you could be having an anxious dream that raises your heart rate as well.  I have to imagine going to medical school puts a lot of pressure on you.  So try to take some time to find some way to release your stress.  And when an episode does come on do your best to remain calm so you don't make the situation worse.  And finally your other option is to go on anti-anxiety medicine but I would try to manage it first before going that route.  Best of luck getting this under control and best of luck with your studies.