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Please help with possible PAC
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Please help with possible PAC

I have anxiety and have been in the hospital a bunch on my own to get tests on my heart which is what my anxiety revolves around. I have had an echocardiogram, bruce stress test, 24 hour monitor, two week event monitor, advanced cholesteral tests and ekg's where the doctors have raised no concerns and told me there is no need to follow up.

1. Having palpitations during stressful and at times non stressful times. I would describe the beat as being fast around 110 bpm being constant and then having two slow heavy beats within 10 seconds. It goes like beat..beat..beat..Beat......beat..beat..beat..Beat........beat etc. Are these considered PAC heartbeats?

2. Also when I do get stressed or notice a high heart rate it usually lasts for the day and is difficult to calm it down. Does this mean anything or is there a way to manually lower it through an exercise?

Loop Monitor;

"The rhythm was sinus" "The single event of the presumed sinus tachycardia showed a rapid and regular supraventricular tachycardia and without a run up to the heart rate the likely sinus tachycardia, it is hard to exclude another form of supraventricular tachycardia"  

Cardiac Dimensions:
Right Ventricle 28 normal = <30mm
Aorta (base) 32 normal = <37mm
LA 35 normal = <40mm
LVend diast 47 normal = 35-57mm
LVend syst 29 normal = 25-40mm
Septum 09 normal = <11mm
Post Wall 10 normal = <11mm
Diastolic Function:
E (cm/sec) 80 E:A 1.29
A (cm/sec) 62
IVRT: (msec)
DT: (msec)
S:D
PulmD (cm/sec)
Pulm AR
LV MAS Index Height 72 (inc) Weight 180 (lbs)
Systolic Function:
Aortic Valve:
Regurgitation: No
Peak Grad 4.3 (mmHg)
Valve Area (cm2)
Max Vel V2 (m/sec)
LVOTvel V1 (m/sec)
LVOT Diam. (cm)
Doppler Quantitation
Mitral Valve:
Regurgitation: Trace
Mean Grad (mmHg)
Valve Area (cm2)
Pulmonic Valve:
Regurgitation: No
Peak Grad (mmHg)
Tricuspid Valve:
Regurgitation: Trace
RVSP (mmHg)
Est RAP (mmHg)
PAT (n. 100msec)
PAP (mmHg)
4610897_tn?1393869202
Thank you for your question.

The symptoms you are describing are called palpitations (forceful or bothersome contractions of the heart), and are an extremely common reason for office visits from patients.

The goals of evaluating palpitations is to provide a rhythm (i.e. electrical rhythm of the heart)-symptom correlation. That is, the goal is to see what electrical rhythm you are in when the symptoms are occurring. When I am evaluating these symptoms in my patients, I am trying to determine if there is any dangerous rhythm that could kill or hurt my patient or if there is a benign (not dangerous) rhythm that I can treat with medicines. Finally, if the symptoms occur with a normal “sinus” rhythm I can reassure my patient that their palpitations are noncardiac in nature.

Depending on how frequent the palpitations are determine what kind of monitor I have the patient wear. If the symptoms are rare, I have them wear an Event or Holter monitor for a longer period (2-4 weeks). If they are very frequent, 24 hours of monitor should capture their electrical rhythm when the symptoms occur.
Reviewing your test results, I see that you have a structurally normal heart from the echocardiogram. In addition, the summary from the Holter monitor showed 1 episode of a fast heartbeat that was regular. The interpreter believed it was likely sinus tachycardia (a normal, but fast rhythm) but based on the rate and the way it sped up they could not exclude other fast rhythms (which is often the case). There is no mention of whether you were having symptoms at the time that you recorded.

Now to answer your questions:
1. PAC’s are premature atrial contractions. They are not based on symptom description. They are a diagnosis made on ECG. What you are describing can only be called palpitations, your perception of early or forceful contractions. To call them PAC’s would require confirmation by a Holter or Event monitor (some kind of ECG monitoring device).

2. You are describing a fast heart rate when you become stressed. This is likely physiological based on your individual stress response.  Your heart rate at rest can be mediated by exercise, as conditioned athletes are often observed to have slow heart rates at rest. However, that is no guarantee that you cannot prevent your heart rate from shooting up when you become stressed. Exercise is important in stress reduction, which is where I believe you should focus your efforts. Exercise, stress reduction techniques like yoga/Tai/Chi, avoidance of stimulants/caffeine, and getting adequate and restful sleep might yield reduction in the symptoms you are describing. You may also want to speak to a counselor or psychiatrist about methods to reduce stress (that may or may not involve anxiety medication).
The good news is that with a structurally normal heart and no evidence of ECG abnormalities on multiple tests your prognosis is excellent and matches that of the general population. The symptoms are not in danger of killing you, but clearly they are bothersome. My advice would be to try and tackle the problem from a stress reduction angle at this time now that organic disease has been excluded.
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