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Inappropriate Heart Rate Increase in Athlete
Hello and thanks so much for all of your help! I am an 18 year old female college soccer player. I recently developed heart palpitations. These are very predictable, and come on when I minimally exert like climb the stairs or do a slight jog (it goes from 70 to 150 and higher with this) . I had a stress echo which revealed that the PR interval did the wrong thing as exercise increased (it either got longer or shorter..whichever is not normal, sorry I forgot!). Long story short, I eventually had an ablation for AVNRT which the doctor said was very easily inducible. He said it got up to 220 during the procedure. After three months since the procedure, I have felt absolutely no improvement. Sorry for all of that information, but my question is; what could this possibly be? He has eliminated adrenaline tumors, thyroid problems, anemia, a PFO, cardiomyopathy, and POTS with a tilt table test. How likely is it that he missed an accessory pathway? Also, he thought it could be IST, but my resting heart rate is only 60 to 70. Any ideas would be soooooooooo appreciated!!!! Thanks again!!!
Haha, no, my doctor didn't go to med school in the Carribean thank God! I knew UPenn was a great school, but I wasn't sure if they had a good EP program. I guess that's kind of stupid, if it's a good school, then all of their programs are probably pretty high quality. Sorry, I really wasn't thinking haha!
You're right that I'm lucky it's not a life threatening condition or that it doesn't even put me at a higher risk for heart disease, and I am definitely grateful for that. However, I feel that, because it's not dangerous in those respects, my doctors kind of shrug me off. This makes sense because I know that soccer isn't life, but I am receiving a large scholarship and I feel like I have so much more to prove before my "career" ends. But even beyond that, I have to rest while putting groceries in my car. This condition is making me more fatigued than I've ever been, and some days it takes all of my will to get out of bed. I struggle to make it up more than two flights of stairs. I guess it's a minor issue in the whole scheme of things, but I really just feel so yucky all of the time with it, and it's just such a pain as you know first hand! I will check with my mom about her access to medical articles online, and then email you if I want more information. That's so kind of you to offer. I just wanted to thank you for taking so much time to help me, I can't tell you how much I appreciate it! Good luck with you heart!
You're right that I'm lucky it's not a life threatening condition or that it doesn't even put me at a higher risk for heart disease, and I am definitely grateful for that. However, I feel that, because it's not dangerous in those respects, my doctors kind of shrug me off. This makes sense because I know that soccer isn't life, but I am receiving a large scholarship and I feel like I have so much more to prove before my "career" ends. But even beyond that, I have to rest while putting groceries in my car. This condition is making me more fatigued than I've ever been, and some days it takes all of my will to get out of bed. I struggle to make it up more than two flights of stairs. I guess it's a minor issue in the whole scheme of things, but I really just feel so yucky all of the time with it, and it's just such a pain as you know first hand! I will check with my mom about her access to medical articles online, and then email you if I want more information. That's so kind of you to offer. I just wanted to thank you for taking so much time to help me, I can't tell you how much I appreciate it! Good luck with you heart!
Hi Erin,
Yes, mine are not spontaneous either. They happen about 1 out of 20 times I run up stairs and almost always happen (with the pause....fast burst...pause....fast burst) in the reovery phase of exercise.
It sound like your doc is very good: UPenn is a fantastic program. I just wanted to make sure you didn't live in a one-cow town with a doc from a Carribean med school (where the entry exam requires you to have a pulse and be able to read Sam-I-Am). I'm sure he's on top of it. At least he is open with you and wants to do more tests.
I don't have any materials on regeneration of pathway tissue but have heard it can happen. Perhaps your mother has a login to a medical resource library.
I have access to medical resource library from my graduate work and can give you a login off-line if you'd like so you can snoop around ([email protected]).
I think your questions are now above my head and you are best to keep working with your EP to do as many workups as you can have done. If they can replicate it in the lab, they should be able to figure out what is going on. It could very well be an SA node problem. I had one doc that has had 3 ablations and is still symptomatic without explaination. The body is complicated and doesn't seem to want to give up it's secrets. I hope you can find a solution. But at least it's not dangerous, right?
Yes, mine are not spontaneous either. They happen about 1 out of 20 times I run up stairs and almost always happen (with the pause....fast burst...pause....fast burst) in the reovery phase of exercise.
It sound like your doc is very good: UPenn is a fantastic program. I just wanted to make sure you didn't live in a one-cow town with a doc from a Carribean med school (where the entry exam requires you to have a pulse and be able to read Sam-I-Am). I'm sure he's on top of it. At least he is open with you and wants to do more tests.
I don't have any materials on regeneration of pathway tissue but have heard it can happen. Perhaps your mother has a login to a medical resource library.
I have access to medical resource library from my graduate work and can give you a login off-line if you'd like so you can snoop around ([email protected]).
I think your questions are now above my head and you are best to keep working with your EP to do as many workups as you can have done. If they can replicate it in the lab, they should be able to figure out what is going on. It could very well be an SA node problem. I had one doc that has had 3 ablations and is still symptomatic without explaination. The body is complicated and doesn't seem to want to give up it's secrets. I hope you can find a solution. But at least it's not dangerous, right?
Adam, thanks again! I live in Denver, and I completely understand what you're saying about the quality of doctors. I have heard that there is an excellent EP at another hospital with whom I am considering scheduling an appointment. If this gets to be a much bigger problem, I suppose I could fly out to Boston or some other city to see a specialized specialist :) My doctor went to the University of Pennsylvania for all of his schooling and training, and I know he also received specialized training in catheter ablations of abnormal rhythms such as a fib and avnrt. I guess I don't know much about the quality of their program, do you? I like him. He seems to care about helping me and seems very knowledgeable. He just seems slightly stumped because he was so positive I would be cured after that ablation. He says there's a 1% chance that the AVNRT was not properly ablated or that he missed something, but from everything I am reading, it seems that may be what could have happened.
This is a continuing process. I just had a stress echo with bubbles to rule out a hole in my heart, and while they told me they couldn't see any hole, they have yet to tell me how my heart responded to the exercise and how it compared with my other echo that was before the ablation. My mom (a doctor) said I might need to swallow a camera of some sort that takes pictures of the heart behind it because the echo can miss those sometimes I guess. My doctor thinks the problem could be with the SA node, but he isn't sure because he said that looked fine during the EP study. He also is extremely hesitant to even modify my SA node because he is so worried about me needing a pacemaker.
So, to answer your question, he's really not sure what to think, but he suspects possibly IST or some other problem with the AV node. I personally suspect and hope that it is still AVNRT that was missed during the ablation. You said a new pathway can grow after an ablation. Is that true? Could you tell me more about that? My resting is only 70 or 80, which is atypical of IST though. Do you know anything about IST? He thinks the shortness of breath is due to whatever my problem, like IST or the AVNRT. Did you not get winded with the AVNRT you had? And the other thing about me is that, this isn't spontaneous at all. If I start jogging, I am 100% sure that my heart will start acting like this, and I know that it will start on that second or third step. Also, if I start walking up a hill, it will start on that second or third step again; it doesn't just randomly double like yours. Yeah, the shortness of breath is what makes this unbearable, not the palpitations, although the palpitations are no fun either. Thanks for all of you help!!!!!!!
This is a continuing process. I just had a stress echo with bubbles to rule out a hole in my heart, and while they told me they couldn't see any hole, they have yet to tell me how my heart responded to the exercise and how it compared with my other echo that was before the ablation. My mom (a doctor) said I might need to swallow a camera of some sort that takes pictures of the heart behind it because the echo can miss those sometimes I guess. My doctor thinks the problem could be with the SA node, but he isn't sure because he said that looked fine during the EP study. He also is extremely hesitant to even modify my SA node because he is so worried about me needing a pacemaker.
So, to answer your question, he's really not sure what to think, but he suspects possibly IST or some other problem with the AV node. I personally suspect and hope that it is still AVNRT that was missed during the ablation. You said a new pathway can grow after an ablation. Is that true? Could you tell me more about that? My resting is only 70 or 80, which is atypical of IST though. Do you know anything about IST? He thinks the shortness of breath is due to whatever my problem, like IST or the AVNRT. Did you not get winded with the AVNRT you had? And the other thing about me is that, this isn't spontaneous at all. If I start jogging, I am 100% sure that my heart will start acting like this, and I know that it will start on that second or third step. Also, if I start walking up a hill, it will start on that second or third step again; it doesn't just randomly double like yours. Yeah, the shortness of breath is what makes this unbearable, not the palpitations, although the palpitations are no fun either. Thanks for all of you help!!!!!!!
Hi Erin,
I don't think your problem has much at all to do with your psyche, I just wanted to put forward the possiblity that you might get caught up in that circuitous loop if the worry gets intense.
My block does show up on an ECG but only during the EP study, not under normal conditions. If you had/have AVNRT, you feel your hear beat really fast, right? I would be walking up a hill and suddenly my heart would go from 90bpm to 180bpm (doubling) in a one beat transition (as opposed to ramping up naturally) and then snap back to regular pace after 30 seconds or so. That hasn't happend for a while so perhaps that is gone for me.
But I still cannot do strenuous exercise (even though the doc says its ok) because I get those long pauses and then bunched up beats. Can you feel yours or do you just get winded?
Do you have an electrophysiologist? Where do you live? Not to say great doctors can't be provincial but one benefit of living in Manhattan is that I have access to so many top specialists who are out of not only the best schools but more importantly out of the best and most up to date residencies and fellowship programs in the world. The electrical activity of the heart is such a specialized thing! Imagine when a doctor doesn't know enough about it so he sends you to a cardiologist who studies only the heart...but he doesn't know enough about it so he sends you to an electrophysiologist who may in turn send you to someone that specializes in your particular problem. I have a feeling that many many doctors don't really know exactly how to deal with problems like ours. It's no fault of their own: they're every bit a smart and dilligent but picture the difference: Doc 1 goes to Harvard Med and then back to his home town in Minesota. 90% of his patients are fat and old and he only sees maybe 30 young people a year, each with different problems. He goes to an annual conference and perhaps sits in on one 90 minute presentation called "Differentiating atrial flutter from atrial fibrillation in adolesents with blue eyes between the ages of 13 and 14" or some rediculously narrow topic. (S)he doesn't get the same practice as doctor 2 who also goes to Harvard but then goes to be a fellow at a leading electrophysiology department of a top hospital in Chicago and finds a nich in researching and treating patients with XYZ. Doc 2 might see 100 young people a year and has 20 years of doing specific types of ablations etc. I'd advise you do some homework on the anatomy and physiology of the heart so that you can talk to the doctors about your condition and try to understand it. Perhaps a second opinion is in order.
What does your doc say about getting winded? That must be annoying. Try to get a diagnosis from your doc as to exactly what you have now and I'll be better prepared to address your questions.
I think, when it comes down to it, the heart is such a complex thing with so many symptoms and observations straddling several different diagnoses that cause becomes ambiguous. I'm sorry to say that there is a decent chance that this is it for you: that you'll never find a cure and that you'll have to be a jogger who just enjoys life and fitness but can't really go after it any more. The good news is that it seems like it is a totally benign thing and you can be greatful for that. But don't let that discourage you, especially if you think you can pay for college with your talents.
-Adam
I don't think your problem has much at all to do with your psyche, I just wanted to put forward the possiblity that you might get caught up in that circuitous loop if the worry gets intense.
My block does show up on an ECG but only during the EP study, not under normal conditions. If you had/have AVNRT, you feel your hear beat really fast, right? I would be walking up a hill and suddenly my heart would go from 90bpm to 180bpm (doubling) in a one beat transition (as opposed to ramping up naturally) and then snap back to regular pace after 30 seconds or so. That hasn't happend for a while so perhaps that is gone for me.
But I still cannot do strenuous exercise (even though the doc says its ok) because I get those long pauses and then bunched up beats. Can you feel yours or do you just get winded?
Do you have an electrophysiologist? Where do you live? Not to say great doctors can't be provincial but one benefit of living in Manhattan is that I have access to so many top specialists who are out of not only the best schools but more importantly out of the best and most up to date residencies and fellowship programs in the world. The electrical activity of the heart is such a specialized thing! Imagine when a doctor doesn't know enough about it so he sends you to a cardiologist who studies only the heart...but he doesn't know enough about it so he sends you to an electrophysiologist who may in turn send you to someone that specializes in your particular problem. I have a feeling that many many doctors don't really know exactly how to deal with problems like ours. It's no fault of their own: they're every bit a smart and dilligent but picture the difference: Doc 1 goes to Harvard Med and then back to his home town in Minesota. 90% of his patients are fat and old and he only sees maybe 30 young people a year, each with different problems. He goes to an annual conference and perhaps sits in on one 90 minute presentation called "Differentiating atrial flutter from atrial fibrillation in adolesents with blue eyes between the ages of 13 and 14" or some rediculously narrow topic. (S)he doesn't get the same practice as doctor 2 who also goes to Harvard but then goes to be a fellow at a leading electrophysiology department of a top hospital in Chicago and finds a nich in researching and treating patients with XYZ. Doc 2 might see 100 young people a year and has 20 years of doing specific types of ablations etc. I'd advise you do some homework on the anatomy and physiology of the heart so that you can talk to the doctors about your condition and try to understand it. Perhaps a second opinion is in order.
What does your doc say about getting winded? That must be annoying. Try to get a diagnosis from your doc as to exactly what you have now and I'll be better prepared to address your questions.
I think, when it comes down to it, the heart is such a complex thing with so many symptoms and observations straddling several different diagnoses that cause becomes ambiguous. I'm sorry to say that there is a decent chance that this is it for you: that you'll never find a cure and that you'll have to be a jogger who just enjoys life and fitness but can't really go after it any more. The good news is that it seems like it is a totally benign thing and you can be greatful for that. But don't let that discourage you, especially if you think you can pay for college with your talents.
-Adam
Adam, I am so impressed with all of your knowledge of this situation! I was hoping that I could find some people who had similar problems. I get short of breath as soon as I start any type of activity, and the palpitations come as soon as the shortness of breath. I feel it the most, though, when I stop. If I lay down or sit immediately after exercise, I feel like I can't possibly get enough air, and so I have to walk around for a few seconds after or I breathe incredibly hard. Is that how it is with you? I play soccer, and this is probably one of the worst sports to have this in, although it ***** in any sport, I'm sure! I don't ever feel pauses or skipped beats, just such an exaggerated response to any activity whatsoever. It's ridiculous! I really don't know what I'd do if this couldn't be fixed, it's so miserable as you know. I have been on antidepressants for anxiety long before this started, and I really don't think this is mental, but I guess a psychiatrist could never hurt. Soccer is my escape from everything, and it hurts so much that I can barely do it anymore. I read that an AV block can be seen on an EKG, but my EKGs have always been normal. Does yours show up on an EKG? What are you doing to relieve symptoms? I have tried bystolic, a beta-blocker, but it did not help. Do you have any more recommendations? Again, thanks so much!
Hi Erin,
Dito for me. I'm a 28yo former D1 athlete and had an AVNRT ablation to fix the slow pathway last summer. The procedure did not help. I too get onset of palipitations when climb stairs or lift heavy thing.
What are your palpitations like? For me, it's usually in the recovery period, just 30 seconds after coming down from exercise that I get a longggg pause and then a cluster of rapid beats and then a longggg pause and then a cluster etc. Do you feel like you will pass out?
What your doctor is probably referring to in the increasing PR interval is that hearts like ours tend to have an increasing amount of time between when the SA node fires (P) and when the AV node releases/translates that pulse to the Ventricles (up and down of R) as a percentage of the overall cycle (that is to say that the interval would not be getting shorter in an absolute basis when your heart rate is increasing but it would be getting RELATIVELY longer). This is a classic symptom of a Second Degree Type 1 (Mobitz I or Wenchebach block) block of the electrical system. Wenchebach is what I have and the mortality rates associated with it in the absense of structural heart problems is supposedly no higher than for the general population. The block can come in two forms: 70% of Mobitz I blocks are located in the AV node while 30% are in the His-Perkenje bundle. Blocks in the AV node have proven to give no predisposition to degeneration into more-dangerous Second Degree Type 2 or Third Degree heart blocks. However blocks in the His-Perkenje bundle seem to want to become more serious blocks as time progresses. I don't know the mechanism for this degeneration but do know that almost all of the His-Perkenje located blocks are due to either structural heart problems or tissue damage after heart attack. Therefore, you should rest assured that there is a very low chance that the cycle lengthening is anything more than a horrible inconvenience.
I wish I had answers to why exactly this is happening to you (and to me too) but the study of electrophysiology, while becoming very good at detecting and flagging high risk persons and providing treatments for them, falls short of being able to explain exactly why some things happen. It is very possible that a new pathway grew. The heart is a pretty amazing organ (as are most of the organs) in that it really wants to find a way to keep beating. Look at all the posters on this site who complain of a range of palpitations ranging from mild PVCs to chronic flutters and tachycardias. And 99.999% of them will die of something other than an problem with the electrical system of the heart. I'm not an MD and certainly your electrophysiologist can explain thing better than me.
Having been an athlete, I know that it will be very frustrating for you to not be as active in sports. Additionally, even though I have learned about my problem and have the doctors OK that everything is benign with me, when the events happen it is very very traumatic. At a point it can become more of a psychological battle than a physiological malady. You may want to eventually consider talking to a psychiatrist. There is a misconseption that crazy people go to psychiatrists when in fact there is a real service they can provide for people who have certain physiological conditions, the stress from which can lead to a feedback loop of: symptom> worry > makes symptoms worse > worry more > makes symptoms even worse > worry even more etc. For me, having just a few chill pills to take as needed (perhaps 3 times a month) gives me not only the parachute out of a panic situation when I get bad palpitations (and for me the panic is a result of, not a cause of the palpitations which is very difficult to articulate to non-MD medical service providers) but also gives me the comfort that there is that chord to pull if I get in a jam. I'm not sure that you are at this point but if your symptoms continue and you start to get very nervous about them, psychiatric treatment might do you good.
I hope I've been able to shed some light on the reentry tachy that you have and why, unfortunatly there may never be a cure. But on the bright side, it sounds like you have somthing that, while rare, is a lot more common and benign than you may think.
Best of luck and please come back with any question that you have.
-Adam
Dito for me. I'm a 28yo former D1 athlete and had an AVNRT ablation to fix the slow pathway last summer. The procedure did not help. I too get onset of palipitations when climb stairs or lift heavy thing.
What are your palpitations like? For me, it's usually in the recovery period, just 30 seconds after coming down from exercise that I get a longggg pause and then a cluster of rapid beats and then a longggg pause and then a cluster etc. Do you feel like you will pass out?
What your doctor is probably referring to in the increasing PR interval is that hearts like ours tend to have an increasing amount of time between when the SA node fires (P) and when the AV node releases/translates that pulse to the Ventricles (up and down of R) as a percentage of the overall cycle (that is to say that the interval would not be getting shorter in an absolute basis when your heart rate is increasing but it would be getting RELATIVELY longer). This is a classic symptom of a Second Degree Type 1 (Mobitz I or Wenchebach block) block of the electrical system. Wenchebach is what I have and the mortality rates associated with it in the absense of structural heart problems is supposedly no higher than for the general population. The block can come in two forms: 70% of Mobitz I blocks are located in the AV node while 30% are in the His-Perkenje bundle. Blocks in the AV node have proven to give no predisposition to degeneration into more-dangerous Second Degree Type 2 or Third Degree heart blocks. However blocks in the His-Perkenje bundle seem to want to become more serious blocks as time progresses. I don't know the mechanism for this degeneration but do know that almost all of the His-Perkenje located blocks are due to either structural heart problems or tissue damage after heart attack. Therefore, you should rest assured that there is a very low chance that the cycle lengthening is anything more than a horrible inconvenience.
I wish I had answers to why exactly this is happening to you (and to me too) but the study of electrophysiology, while becoming very good at detecting and flagging high risk persons and providing treatments for them, falls short of being able to explain exactly why some things happen. It is very possible that a new pathway grew. The heart is a pretty amazing organ (as are most of the organs) in that it really wants to find a way to keep beating. Look at all the posters on this site who complain of a range of palpitations ranging from mild PVCs to chronic flutters and tachycardias. And 99.999% of them will die of something other than an problem with the electrical system of the heart. I'm not an MD and certainly your electrophysiologist can explain thing better than me.
Having been an athlete, I know that it will be very frustrating for you to not be as active in sports. Additionally, even though I have learned about my problem and have the doctors OK that everything is benign with me, when the events happen it is very very traumatic. At a point it can become more of a psychological battle than a physiological malady. You may want to eventually consider talking to a psychiatrist. There is a misconseption that crazy people go to psychiatrists when in fact there is a real service they can provide for people who have certain physiological conditions, the stress from which can lead to a feedback loop of: symptom> worry > makes symptoms worse > worry more > makes symptoms even worse > worry even more etc. For me, having just a few chill pills to take as needed (perhaps 3 times a month) gives me not only the parachute out of a panic situation when I get bad palpitations (and for me the panic is a result of, not a cause of the palpitations which is very difficult to articulate to non-MD medical service providers) but also gives me the comfort that there is that chord to pull if I get in a jam. I'm not sure that you are at this point but if your symptoms continue and you start to get very nervous about them, psychiatric treatment might do you good.
I hope I've been able to shed some light on the reentry tachy that you have and why, unfortunatly there may never be a cure. But on the bright side, it sounds like you have somthing that, while rare, is a lot more common and benign than you may think.
Best of luck and please come back with any question that you have.
-Adam
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