Ectopic SVT or sinus tachycardia?

[is_something_wrong]

To all my friends here :) I have a little puzzle that I need to solve.

Saturday night (after some truly stressful events earlier the day, fight with my girlfriend and parents almost got divorced, etc), I went out with some friends to get a couple of beers and get something else than arguing on my mind.

I tend to get irregular heart rhythm during walking and other exercise if my stress level is high (this is monitored on Holter and it's just PACs - nothing to worry about). Anyway, I keep worrying a little, especially when I'm far from home.

We were about to leave, and go out (after 4-5 beers), and suddenly I felt something "weird" in my chest (PACs). I checked my pulse and it was just fluttering, I don't know how fast it was, but it must have been over 200 (at least that's what it felt like). It was regular, with an occational skip now and then (PAC I guess). After a couple of deep breaths, it started to slow, to a still "quite elevated" level, maybe 160. It kept going up and down a bit, until it settled at about 90-100 (that is not uncommon after some beers).

I sometimes get this phenomenon when I exercise alone and get a bit panicky over my heart rate. It seems I get a PAC (or several PACs) and my heart rate tends to hit the sky AFTER the (non)compensatory pause.

How high can sinus tachycardia get in the setting of exertion, alcohol and extreme stress/anxiety? During my stress test I got my HR close to 210 (sinus), and it would be no problem to keep going (but according to my doctor it wasn't necessary). Can sinus tachy get far up in the 200s if you are anxious enough?

What do you guys think? Extreme sinus tachycardia or SVT? :)

[dfoxworth86]

How do you live with it??? When my heart goes that fast I get extremely anxious and my stomach and chest starts burning. I'm not able to function at all for days, unable to eat or sleep. Exhausted all the time.

[LivingInHope]

I think you would have to be off your beta blocker to get a true picture with the standing plasma norepinephrine (of course asking the doc's permission on that).  Even if you have some POTS, low iron can make tachy worse (it has done it to me), so definitely worth checking into.  My doc says ferritin (iron stores) is the best indicator for iron deficiency.

is_something_wrong- Glad there seems to have been a simple solution for that nasty tachy!  Did they also tell you to avoid caffeine and chocolate?  I have a brother-in-law who had SVT and that's what they told him.

[is_something_wrong]

Oh well, I went to a doctor today (after another 220-260 bpm event yesterday), and answers were as follows:

1) You do not have ventricular tachycardia. I'm 100% certain.
2) You do have a supraventricular tachycardia.
3) It's not possible to say if it's accelerated sinus tachycardia or ectopic atrial tachycardia.
4) Try a beta blocker.

I did try a beta blocker (like 10-15 mg propanolol) this morning and it's a bit funny, no matter how hard I try, jogging, running, playing football, walking, running backwards, anything, I'm completely unable to provoke SVT and I don't even get a PAC. I get some PACs or PVCs at rest, though, because my HR is a bit slower, but I guess I can live with that. My doctor told me to change to Metoprolol (Toprol) though.

That easy. Problem solved for now :)

[Nurse2b1982]

My heart rate also drops in small incriments, I was told this was normal and that for adults, ours takes much longer to return to normal than in a child. There is a rule after excercising about how much your HR should drop in a certain amount of time, unfortunately, I don't remember the exact amount of time or the HR. You may be able to research and find out though. I can't remember where I read it at.  I also notice that if I take my pulse in my wrist it is always light when I have tachy but I can usually feel it pounding out of my chest so I don't worry about that. Once a month or so ago, I woke up in the middle of the night and it felt like my heart was going fast and fluttering, and I freaked but it went away. I thought for sure it was VTach but who knows cause it hasn't happened since? I will say that my last holter showed around 300 couplets and 9 triplets and I cannot recall ever feeling any different than I normally do with the regular PVCs....the only time I feel diffrent is when Im getting like 300+ Pvcs an hour, then I get short of Breath, so if I were to have VTach, IDK if I would even feel it unless I passed out or something.
Oh I know, I shoudl practice what I preach too:) It's hard when it's YOU:)

[Nurse2b1982]

Thanks and I will mention that to the neuro doctor when I see him next week. I don't get tachycardia but maybe once or twice a month now because I am on the beta blockers but if I stop the BB, about three days later, it will return with a vengance! Will the standing plasma norepi test work if I'm on a BB? I have seen a ENT and I has a ENG done, which was normal. I will have to check my iron and ferritin cause I'm not sure about those. I have been racking my brain to figure out what my problem is! I even had the doctor draw a vitamin b12 level to make sure I didnt have pernicious anemia(I saw a lacy w/ similar sx as mine and thought it was worth a shot) Thanks for your help!

[LivingInHope]

I think mine tends to be strong- but I don't get up that high- my holtor only went as high as 152 and 148 when I got it last year and that with standing without sitting on the edge of the bed first.  But you may want to get a nuclear medicine test and see if there is/are and area(s) of your heart demonstrating ischemia (lack of oxygen) if you haven't gotten that test done.  Also, hasn't the doctor given you any medications to try to slow your heart rate?  

[LivingInHope]

If you want to verify about your POTS (like I haven't gotten done- just had abnormal numbers here and there), the thing to do is get a standing plasma norephinephrine test, preferrably during the time when your tachy is the worst for you & see if it's over 600, a criteria mentioned in an article by Dr. Raj from Vanderbilt University.  (See PM for more info.)  If the neurologist can't find anything, you might take a trip to an ear, nose and throat specialist and ask for some vestibular testing!  Is your iron and ferritin normal?

[is_something_wrong]

Thanks for a lot of great answers here:)

No, it's really not a big deal, and it resolves by itself if I just relax some seconds. That makes me believe it's just sinus tachycardia. I don't think I've got a heart (structural) disease.

However, some things are frightening me. Especially the fact that my heart rate seems so "weak" or "light" when it's maxed, of course I know (from all the cardiology I've read) this is caused by anxiety constricting blood vessels in your hands, the blood is sent to my muscles, and the fact that a quick heart rate reduces the blood pumped out in each beat. Anyway, I start to worry about VT, though it's extremely unlikely (and if it was, it would have been benign). It's something about being able to practice what you preach :)

I felt my heart rate dropped gradually / slowly, but kind of "in levels" like, say 210 - 180 - 160 - 140 and so on. It was just on the highest level my rate felt really "light".

Do you have similar symptoms with your sinus tach?

[Nurse2b1982]

I have researched POTs and I too, beleive that I may have the hyperadrenic type. I have had my catecholines checked and they all came back normal so phenochromocytoma is not my problem apparantly, I a Big mystery to a lot of doctors:( I'm headed to a neuro doctor next week because I'm a lot CONSTANTLY dizzy and no one knows why:( So maybe I'll get some answers there.

[Nurse2b1982]

No u are definenitly not alone! I understand completely, believe me! It's hard to not get scared when ur HR goes that high but as long as it comes down on it's own, it's okay:) I know a girl who has SVT and she was told not to go to the ER unless it would not break on it's own within 30 mins or unless she had symptoms(like passing out):)

[chuparosa]

Wish I could give you a great answer since you have been so helpful and kind to many on this site but I can't.

Sorry to hear you had such a rough night. Stress is the only for sure trigger for me. When I am very upset or tense, or even playing a hard level on xbox, I will always get the flip flop beats. And I refuse to give up drinking. I love a delicious beer or an ice cold margarita in the summer. You gotta enjoy some of life's simple pleasures.

[LivingInHope]

Premature atrial contractions I just found out according to a medical website is what PACs stand for (didn't realize) & it says they're normal variations as are PVCs.  Learned something new!  I was diagnosed with IST (inappropriate sinus tachycardia) prior to the tilt table test, where I was diagnosed with POTS.  

My epinephrine and norepinephrine and their inactive metabolites, metanephrine and normetanephrine have all come back at one time or another outside the normal range, but not far enough for the doctor to look for a pheochromocytoma, a rare tumor usually found on an adrenal gland which can cause high catecholamines during active times, while they can be silent other times and catecholamines can be normal.  

If you are also getting spikes in blood pressure, you may want to get pheochromocytoma ruled out with a fasting blood test called plasma free metanephrines, which is supposed to be the best there is for detecting that type of tumor.  You'd want to try to get it done when you recently had been having a particularly bad episode and hopefully, when you hadn't taken tylenol for about 72 hours, because that can interfere, I've read with assaying the levels.

I invite you both, if you have not already taken a look, to come to medhelp's dysautonomia forum (dysautonomia=dysfunction of the autonomic nervous system), where there a number of active community members, such as myself, who suffer from IST and various forms of orthostatic intolerance and other symptoms of dysautonomia.  I believe I likely have, due to certain labs, the hyperadrenergic form of POTS (postural orthostatic tachycardia syndrome).  Here's a link to the forum:
http://www.medhelp.org/forums/Dysautonomia-Autonomic-Dysfunction/show/266

[is_something_wrong]

Hi, thanks for a wonderful reply:)

I know it's not easy to say when no P waves are found, and I know the "160 limit" for sinus tachycardia. It's ridiculous! Every time I exercise I'm a living proof that sinus tachy can get far above 160 :)

Anyway, when I see 200 I'm getting a bit more uncertain. But I'm very sensitive to my adrenaline too I think, my HR can easily get to the 150s just if someone scare me :) It's good to know I'm not alone :)

[is_something_wrong]

Thanks for replies:)

SurgiMenopause:
I know, I need an EKG to find out (and I would likely not find out anyway, because at high rates (and no visible P wave) it's not easy to find out anyway). But as it only lasted for seconds at that high heart rate, it's impossible to get an EKG done :(

I usually rarely drink at all, so it's kind of hard to cut back on drinking, but I'll try to just go out for 2-3 beers if I'm going out anytime soon.

My Holter only showed some PACs (15 or so) no couplets, no PVCs, no SVT.

I get tachycardia only when I'm exercising / walking AND are anxious. I can get sinus tach with panic attacks, but they are rare. I can get mild sinus tach with stress, but never higher than 120s-130s. My Hb is 16,8 (upper normal) my ferritine is 280 (upper normal) my K+ Ca++ and Na+ are all in upper normal range. FT3, FT4 and TSH normal. SaO2 99-100%.

I get quite elevated heart rate when standing up, though only when I'm stressed or anxious. My cardiologist said it's normal.

Thanks for your replies and support, both of you:)

[LivingInHope]

Oops- I meant might not mibht and levels, not levles.

[LivingInHope]

I believe the only way to tell sinus tachycardia from SVT (supraventriculare tachycardia) is by EKG.  But you didn't say that any SVT showed up on your holtor- I think maybe you meant to say PVC or premature ventricular complexes?  If you don't ever have this rapid heart rate ever while sitting or laying, you may want to see about getting a tilt table test from a cardiologist or more specifically, an electrophysiologist to see if you might be suffering from postural orthostatic tachycardia syndrome (POTS).  

And if drinking that much brings on more rapid of heart rate, you might try cutting back and see if that helps.  Also, low iron can bring on tachycardia, so you mibht want to get your ferritin (iron stores) and blod iron levles checked.

[JerseyGirlNB]

I have an undiagnosed arrhythmia. On the holter they found several PACs and triplet beats, but they have not named the condition. The important thing i want to point out however is that almost always, my flutters coincide with drinking (either during or the morning after). I have cut back significantly on alcohol consumption because of this. I'm afraid of the stuff. I had two mixed drinks the other night and 2 days after my heart was a mess. My doc gave me some toprol (anti-arrhythmia) for when i experience sympotms, but I also have low blood pressure... so I have to be careful when taking toprol. I just wish they knew what this was and what causes it... i'm only 29 years old and healthy!