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Exercise Induced PAC's - Many - Help
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Exercise Induced PAC's - Many - Help

Hi All,

I have posted here before, but I wanted to get your advice and see if anyone knows what I may not know. I have recently been getting what feels like a Bigeminy PAC's. I say PAC's because on my treadmill test and event monitor they all came from the Atrium.

Recently I have had a bit more heart activity, a non sustained tachycardia run the other day, and now when I hit the bike at the gym I notice at around 80-90% of MHR my heart will start to feel tired, it will jump a few BPM's and then wham, I get hit with what feels like a extra beat. It actually feels like a flip flop, or gurgle, then a normal beat or two and a less intense flip flop. This can happen 2-5 PAC's. It makes me automatically stop and cough and scares me quite bad. Besides the anxiety I dont really feel much different, maybe dry mouth or a little short of breath or more winded from anxiety. I don't get what others describe as a compensatory pause or thump, just the flip flop extra beat feeling.

Also, I notice when I obsess about my heart all day, and then hit the GYM, I get more PAC's.

Has anyone experienced this or have a theory. I have two right now. The more sinister one is that I have a blockage and my heart is not getting the blood it needs so it tries to speed up. The other theory is that adrenaline is released when I notice my heart rate feeling weak, and it causes a string of PAC;s.

I have panic disorder, so this whole heart thing is the worst type of happening, and this is ruining my quality of life, always expecting to drop at any second, or at least irrationally worrying about it. Any ideas of whats going on? As an FYI, I have a normal echo, stress test showing PAC's, normal event monitor with occasional tachy and pac's, and bloodwork is all optimum. 33 male fit.
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1402011_tn?1291415382
Also, I get PAC's randomly though the day, they feel light and fluffy and dont really bother me. But why would they be so hard and aggressive while working out?
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503607_tn?1275675179
My opinion would be its adrenaline causing your pac's,  I can have a good day and then I think about my heart and boom a pvc.  When we excercise we release extra adrenaline when your heart is sensative to the adrenaline your going to get more palpitations and then anxiety, its a vicious cycle.   I was placed on Atenolol to block my adrenaline rush and slow things down.  It also keeps my palpitations at bay.  If you can work through them while excercising that is a great thing.  If they prevent you from doing things then you need to look into opinions to control your anxiety or the pac's.

Good Luck!
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1402011_tn?1291415382
Thanks Debbier. That option is looking more promising. Supposedly Premature atrial impulses arise from irritable automaticity foci in the heart PAC's and are very sensitive to Catecholamines, or fight or flight hormones, which my body is rich with having PA. It may be that during exercise I get anxious from all of the stress and anxiety of worrying about my heart and  to many Catecholamines are released irritating an already irritated heart causing multiple PAC's. This might also be why the first ones are so strong, and then they seem to tail off as the hormones are burned.

If anyone else has theories I would love to here them. I think this post is useful for anyone in the same category as me now or in the future.
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1124887_tn?1313758491
Hello.

I'll try to answer this - and I hope this is a good answer.

Your symptoms are as I would have described mine. Exactly.

It is correct that premature beats during exercise CAN be caused by blockages in the coronary arteries, this is why they are more of a concern to doctors than the premature beats happening during rest. But, it's very important to know, this mainly concerns PVCs and not PACs. And in your setting it's almost not an option (CAD when you are 33 years old is really uncommon and often caused by the combination of smoking, extremely high BP and cholesterol, and a massive family history of CAD)

The higher up in your heart, the more likely are the cells to respond to adrenaline, which is the reason PACs in this setting are fairly normal. And yes - they can feel violent, almost as atrial fibrillation on a bad day. As long as you have monitored an event, and you know this is "only" PACs and not A-fib or multifocal atrial tachycardia (A-fib "light"), you have nothing to worry about.

And still we do, don't we? :)

You describe this very correctly, the "jump" in BPM followed by PACs is a response to adrenaline. First your sinus node get activated by the adrenaline and your heart rate increases, then atrial cells are affected and you get PACs.

My solution was 10 mg of propranolol (non-selective beta blocker) twice a day. It wiped away the PACs during exercise (I can still get a PAC now and then during exercise, I climbed a mountain last weekend and I think I felt 3 of them, mainly when I got a "stretch" in the body when reaching out to climb - this is due to changes in the pulmonary veins which often causes PACs) but I don't get the irregular heart rate I had before. The beta blocker wiped away my panic attacks too, by the way. You should ask your doctor if this is something you can benefit from.

In addition, you should try to accept your adrenaline theory.

PACs may or may not cause a compensatory pause (or noncompensatory as the correct word is when dealing with PACs). It depends on if the PAC resets the sinus node or not and when in the heart beat cycle the PAC fires off. It can be described as a "skipped" beat, a double beat or a "triple" beat if the PAC fires off in the exact middle between 2 ordinary beats. The feeling of a complete "skipped" beat usually favors a PVC.

You mention "occasional tachycardia". Is this ordinary sinus tachycardia due to anxiety?

Anyway, I hope you manage to deal with your anxiety, and that you accept that PACs during exercise in your case is triggered by adrenaline and isn't dangerous. If you learn to accept this, they are likely to go away with time, but if you don't, beta blockers can be of great help during the process.

Good luck :)
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995271_tn?1312416925
HI  sgately11, there's only one study that I'm aware of that showed any sort of relationship to ectopic beats and blockages (CAD).  But it might not apply to what you have.  It was done for PVCs, not PACs.  

What the study showed was that people with "recovery" PVCs had a higher incidence of cardiac mortality.  Recovery meaning after you are done exercise.  I used to get recovery PVCs during my 20s and 30s, I don't anymore.   I don't know why.  I had a cardiac MRI done last year and there was no CAD detected, there was 0% blockages in all of my arteries.

I don't know how this would extrapolate to PACs.  I know a lot about PVCs, not too much about PACs as I don't suffer from those.

I think your idea on adrenaline is good.  Just to give you some idea about how much adrenaline influences your heart rate when you exercise I will use my father as an example.  He had a massive MI when he was 42.  This was back in 1987.  He eventually required a heart transplant.  Post-transplant he took great care of himself and recovered wonderfully, he's still with us today after 22 years.  What always struck me was how his exercise tolerance was so high.  All the nerves to the heart were cut, I though most of the heart's reaction to exercise came from the nerves heading to the heart from the brain (called the autonomic nervous system).  Well I was wrong.  We produce adrenaline immediately during exercise and the heart reacts quickly to it.  My father's pulse reacts just as quickly to exercise as it always has.

Ectopics of the benign variety are usually caused by something called "enhanced automaticity".  Any cell in the heart is capable of becoming a pacer.  ectopics are caused by those hyper little bastards :-).  Adrenaline can make them more hyper and you release a lot of adrenaline during exercise...  I think this is your best theory.
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1402011_tn?1291415382
Hi Gentlemen and Lady,

Thank You for the feedback. If I had to take a poll it would look like the adrenaline theory is 3-0 over CAD, which would make sense if I really think about it.

Your answers have really helped and taken the edge off of the arrhythmia.

Is_something_wrong

To answer your questions I assume the beats are PAC’s. During my stress test I had two at peak exercise ectopics that were confirmed PAC’s, and an event monitor concluded atrium arrhythmias by an electro physiologist.  Now these exercise induced could be different (during the event monitor I rarely exercised due to anxiety) but I doubt they are AFIB. The reason I doubt this is that my pulse stays normal; it just feels like someone slips in a half heartbeat between beats during exercise. The feeling is one of shock at first because it feels like a flip flop going a thousand miles an hour. No Pause, No skip. No thump, Just that gurgle flip flop feeling, then normal beat or two, then gurgle flip flop. Rinse, wash, repeat.

I have had two episodes of tachy. One at the gym during curls where my heart rate shot to 150 and stayed elevated for 15 minutes and then came down gradually, which sparked this whole cardiac situation.  I have to take some blame because I was losing weight and not eating or drinking fluids properly, just a bottle of green tea all morning. I had been on paxil, gained 50 pounds and had higher BP 140-160 /85-95 for a few years and needed that to come down, so I lost a bunch of weight over 9 months or so quit paxil and abruptly klonopin (bad combo). My bp is 110/70 now, no family history of early CAD or HA, just some late life 65+ and alcohol related heart issues (Uncle was a severe alcoholic).

My second tachy happened the other night, had two beers, and woke up in the middle of the night to carry my daughter to bed. Heart rate jumped to 150 or so, heard my heartbeat in my ears, stayed elevated for a few minutes, and then declined quickly. My normal heart rate recovery is typically 50-70 in the first minute, so the sticking tachy feels weird.
I did notice extra beats before, they run in the family (mom, uncle, both benign), but they were never concerning, usually during high stress, and I just moved on.

The only problem I have now is I get panicky to push my heart, for fear of extra beats. I do know when my heart rate climbs I get anxious which proceeds the extra beats, so this whole adrenaline thing really makes sense. My goal now is to move past the fear I have created, which really is a living hell, and try to get back to normal.
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Avatar_n_tn
Interesting, just posted a question on this site for almost the same thing. 66 year old male runs 3 mile/day and recently had stress test at 17.5 mets and ejection fraction of 63%. Have a history of sporadic A Fib which converts with 25 mg topolol. Recently began to have extra/skipped beats when running or lifting weights..especially when heart was ramping up to 140 bpm during run...very disconcerting. These irregular beats did not impact my endurance, so I wasn't concerned about CAD i.e. no chest pains, shortness of breath etc. Tried taking the topolol about two hrs before a run two days ago and the irregular beats basically dissipated to being undetectable, although couldn't get my heart rate above 120 bpm.

I also sent the same question to my cardiologist and he responded almost immediately. He said they were definitely adrenalin induced PAC . They become more prominent with age  and the fact that the irregular beats responded to the beta blocker was conclusive that they were benign and of no medical consequence.

This sounds precisely what you are experiencing and if it responds to one of the many beta blockers on the market, that would be conclusive.

Good Luck
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