confusing symptoms for my mother

Hello Doctor,

My 80 year old active mother has had many problems with numerous PVCs for about the past two years. She feels every one and can tell you with accuracy on EKG when each happens. The constant pounding in her chest really affected her quality of life. She tried many beta blockers without success, and found success w/sotalol as the fifth or so medication tried. She has been taking it for nearly a year (40 mg twice daily) and it has controlled the palps quite well. She initially started on 80 mg bid but was cut back to the current dose because it made her too tired. As I mentioned, this lower dose has been doing great controlling her symptoms.

She also had a stent placed last year in the LAD, unrelated to the palps. She has had at least 3 caths during this time because of a variety of chest related symptoms (which turned out not to be cardiac) and her heart is functioning well.

About two weeks ago she had a big increase in palpitations, without any noticeable change in routine, exercise, or meds. It sent her to the ER once because they happened so frequently in a 12 hour period and she started to get very worried. They only noted PVC's and sent her home with no treatment. She then had a 24 hour holter monitor, The nurse from the cardiologist's office told her today she definitely has PVC's, but they cannot increase her sotalol because her heart rate is too low. She will get a call from the doc next week to "decide what to do." Here's the conundrum: For about the past five days her palps are all but gone and she feels pretty much back to normal!  Now she's uncertain what to do.

Questions:
1. What could cause a sudden increase, then diminshing of the palps?  She has a big problem with chronic constipation. Might this exacerbate? The constipation is currently ongoing but the heart symptoms are gone.

2. What might be a treatment option if she can't increase sotalol?

3. If the palps are now essentially gone, would it be reasonable to do nothing and only change the protocol if and when they increase again?

4. If the patient were your mother, what would you advise her to do in this case?

Thanks so much!  

[Michael J. McWilliams, M.D.]

1. What could cause a sudden increase, then diminshing of the palps?  She has a big problem with chronic constipation. Might this exacerbate? The constipation is currently ongoing but the heart symptoms are gone.

I do not know of a relationship between constipation and PVCs.  PVCs do what they want to do.  We can't explain why they come and go but we do know that they do it.  They will come in spurts, torment you for a few weeks to months and then disappear.  You will not find a satisfying answer as to why the happen.


2. What might be a treatment option if she can't increase sotalol?

There aren't a lot of options.  Beta blockers, calcium channel blockers (both slow down heart rate), sotalol and tikosyn.  There is another class of medications that can be helpful but her coronary artery disease makes her not a candidate.



3. If the palps are now essentially gone, would it be reasonable to do nothing and only change the protocol if and when they increase again?

Yes.  I would do absolutely nothing.  The problem is even if they palps were still there, there are not a lot of options.


4. If the patient were your mother, what would you advise her to do in this case?

I would do my best to have her deal with the palpitations without taking any medications other than a beta blocker or calcium channel blocker.  Sotalol is ok, especially in low doses like 40 mg twice per day.  Some PVCs can be ablated depending on where they come from in the heart, but I would not want my 80 year old mother to have that procedure unless she absolutely couldn't take it.  the risk would be too high.

I hope this answers your question.  Thanks for posting.