PACs. What did just happen? How to cope?

[is_something_wrong]

So, I went of beta blockers (25 mg metoprolol) one and a half month ago, because I didn't have any fear of heart disease anymore. Big mistake. Three days later, the PACs came back with a vengeance. After some time, I visited my cardiologist and he did an echo (completely normal) and an EKG (also textbook normal). He told me to restart Metoprolol and increase the dose to 50 mg/day, which I did. It didn't have any immediate effect, but two-three days later, the PACs were more or less gone (back to just a few daily). So far, so good.

The problem is, I've gained 20 kgs as a side effect of my anti-anxiety meds, which I'm now fighting very hard to get rid of. A couple of weeks later I decided to start a low carb diet, to lose some more weight before summer season.

I don't really know what happened, but three days later I had a major flare up of PACs. The first day I had maybe 50 of them. Next day 500. The third day, I was going away for the weekend, to my cabin, along with my girlfriend, far from doctors (which made me anxious because I had so much palpitations). I swear, on the way there I had at least 1000 PACs during three hours, some of them in trigeminy and bigeminy. I had no symptoms except for the palpitations and anxiety. On the way there, I stopped at an emergency room, and had an EKG done (which was normal, they observed my EKG for about 15 minutes, I think I had one PAC or so). But the rest of the day, I felt like I was losing my mind. I had thousands of PACs, the only time they went away was when I was jogging (which the doctor encouraged me to do). The PACs appeared non-stop, and worsened with positional changes (like standing, sitting, walking). When going to sleep, they went away.

Next day, I was doing some (fairly heavy) gardening and I felt no PACs. Later that afternoon they came back, but far less than the day before. Next day after that, I only felt a few PACs and for 4 days now, they have stayed away, more or less.

I should mention that I immediately stopped my low carb diet when the PACs were at the worst. I also tried to take some rapidly acting beta blockers (propranolol) which had always been effective in the past. It didn't help.

I keep having this nagging fear that my PACs will return, because 1) I have no idea what really triggered them, and 2) beta blockers did not help. Or rather than fear of PACs (I'm fairly skilled in cardiology so deep down I know they are not dangerous) it's more the fear of fear of PACs, if that made any sense. It's causing so much anxiety, I almost fear losing my mind. I fear that I will never get rid of them, that they will just turn up out of nothing, I fear it will compromise my life quality, fear it will getting me depressed (which never has happened), fear that I will lose my interest in living (which has never happened), etc.

Beta blockers have always been helpful in the past. Why didn't they work this time?
Could the low-carb (and ketosis) trigger PACs? I think my potassium was fine (even though the ER EKG did reveal a slightly longer QT than usual, 415 msec vs 380 which I normally have)
How do you cope with premature beats and the uncertainty they represent?

[MichelleP_3811]

Besides for taking the meds are you doing any cognitive work to learn how to deal with anxiety?  The most important thing when you sense you are starting to spiral into anxiety is to first not deny it.  Do not try to push it away, acknowledge it. Then take steps to calm yourself.  Deep breathing for as long and as often as necessary.  Finally talk yourself off the ledge.  You have lived with these issues for a long time and your heart is evaluated as normal so it is simply fear getting in your way.  So try and give yourself a pep talk as you would a friend.  I will say things like, "it's ok, everything is fine, no need to worry"  Do that as well for as long and as often as necessary.  Our reactions to life are really learned behaviors so it is important for us to try and unlearn the behaviors that hold us back replacing them with empowering responses.  This may take time so whatever you do just keep at it and be gentle with yourself.  You have a good handle on understanding your heart now spend some time getting a good handle on understanding and working through your anxiety.  It isn't an impossible feat.  Take care and stay strong.

[is_something_wrong]

Thank you for your replies!

I can refer the note from my cardiologist, by the way (just the results):

EKG: Normal.
Echocardiography: Normal sized left ventricle with good contractility (EF >60%). No septal or posterior wall hypertrophy, normal atriums, normal valve functions and normal blood streams on Doppler.

Dx: Benign ectopic beats. No treatment necessary, but Holter monitoring will be considered if the ectopic beats persist for a long time.


I'll just have to learn how to NOT let these ectopics affect me and my life quality. I'm already on SSRI for my anxiety.

[pvctom]

so sorry to hear of your ectopic beats. I am on 25 mg of lopressor, and had had these pvcs, pacs for longer than i want to think about. they are annoying, and sometimes scary. but as you have probably read, these PVCs and PACs are very common and I might add very annoying and uncomfortable. the best way to cope with them is just to get checked out really well by your doctor and cardiologist. i was told years ago, by my late cardiologist, god bless him, that my PVCs were a benign 'random phenomena'.

wish you the best. this is a very good site to be, with these annoying beats.

[achillea]

I know what you're talking about, because I have been through some of it courtesy of PVCs rather than PACs.  

Weight gain on some antianxiety medications can be a big and tiresome deal, and stopping the meds does not always cause the weight to come off easily.  I've seen quite a few doctors' accounts of how frustrating this phenomenon can be, for them as well as their patients.

And then there is the fact that the cause of most PACs and other benign arrhythmias in *normal* hearts is simply not understood.  Without understanding, there is no treatment that is both rational and reliable--and, alas, there is certainly no cure.

However, you, given your understanding of the physiology involved, know that these ectopics are not dangerous.  The real trouble is that (1) some people feel them more than others do; (2) the sensations can often cause intense fear;  (3) anticipating more ectopics causes adrenaline to be released, which finally--oh, joy--(4) generates what in fact is often referred to as 'the fear of the fear.'

You say, quite understandably, that “I keep having this nagging fear that my PACs will return, because 1) I have no idea what really triggered them, and 2) beta blockers did not help. Or rather than fear of PACs (I'm fairly skilled in cardiology so deep down I know they are not dangerous) it's more the fear of fear of PACs, if that made any sense. It's causing so much anxiety, I almost fear losing my mind. I fear that I will never get rid of them, that they will just turn up out of nothing, I fear it will compromise my life quality, fear it will getting me depressed (which never has happened), fear that I will lose my interest in living (which has never happened), etc. “

So, given that there is no reliable medical treatment for PACs, what to do next?  I think that it must be treatment of the fear.  You are already taking some anti-anxiety medication, but it is not totally effective, for when this approach does work (as Zoloft—after trials of many other SSRIs—does for me), the awareness of the ectopics fades, which lets the patient get some rest and regain optimism.

If I were in your situation, I am pretty sure I would return to the doctor who is treating my anxiety and discuss two things with him/her:

1. Change of medication to something that both minimizes weight gain and calms the mind.  This balance can be difficult to find, but through trial and error and generous amounts of exercise and diet, something approaching it can be found.  If it's any comfort (ask me how I know), it's more difficult with women than men.  :-P

2.   Trial of a combination of medication and cognitive-behavioral therapy.  I don’t remember reading that you have tried this approach (and if you have, forgive me), but time and time again, I have read that this two-pronged attack is far more effective than either medication or analysis alone.

Good luck, and do keep us apprised.

[Artaud]

Actually, in a healthy heart, there's not much uncertainty. A point many people miss is that a lot of people experience them, but not everyone feels them. The important thing is that you have been examined and everything is OK.

The following article is about the Gastro-Intestinal tract causing rhythm issues, profound rhythm issues, and in this case, it's not the type of food being eaten, just food period. We also have receptors in the Aortic Arch and neck arteries, all trying to tweak the heart rate for some changing circumstance. Then Catecholamines alter the rhythm, and the more fearful we are, the more Catecholamines circulate, we get more ectopics, then more Catecholamines, then more ectopics, etc.

http://bjcardio.co.uk/2009/07/cardiac-manifestations-and-sequelae-of-gastrointestinal-disorders/