Abnormal Vagal activity

[PVC]

Hello and I appreciate the opportunity to ask a question on this busy forum.  My story is one of heart arrthythmia that I believe results from increased vagal tone.  I am only 38, male and in otherwise perfect health except for this atrial arrhythmia.  You may be wondering why I am bothering to ask questions in a neurology forum but I have exhausted the cardiology testing including a trip to the Mayo clinic where some peculiar results were found.  First of all I am the only person that apparently has the connection between swallowing and a heart arrhythmia.  My heart will beat normally until I swallow.  Everytime I swallow there seems to be a short pause followed by a burst of atrial tachycardia.  This has on several occassions degenerated into afib.  All the cardiologists have never heard of such a strong correlation with swallowing.  I understand that the vagus nerve passes behind the esophagus and is responsible for many things in our body.  Vagal stimulation exhibits a parasympathetic effect on the SA node of the heart.  When I swallow it seems that the heart beat pauses and then becomes arrythmic for a few seconds.  If I do not swallow nothing goes wrong - the correlation is perfect.  When I run my heart rate will be 140 bpm with no problem until I finally swallow.  I have seen the heart rate jump to 239 bpm right after the swallow.  So to sum up I have done all the cardiac investigations including an EP study, which showed nothing abnormal.  I apparently am the only person that shows the swallowing trigger caused by the vagus nerve I believe.  Can you help me understand why this happening.  I appreciate the cardiac angle completely.  But the cardiologists are baffled as to my swallowing trigger.  At first they didn't beleive it - called it a coincedence.  They now recognize it as something unique but really don't know where to go with it so I am treated as all other afib patients.  An electrophyisologist recommended I try scopolamine to see if by inhibiting the vagal effect I could minimize or eliminate the problem.  I have not done this yet but did notice that during a recent cold my resting heart rate went from 50 (normal for me) to 70.  During the days with this higher resting rate the swallow trigger disappeared.  Are there medications that can do this on a permanent basis?  Are there procedures that can correct a hyper active vagus nerve.  Or is there another possible explanation for all of this.  
Sorry for the long response but details are important.  
I appreciate any ideas you may have.
Peter

[CCF Neuro[P] MD, RPS]

Dear Peter:

Sounds too interesting to be true.  I guess you could just stop swllowing but that would be too easy.  I have one problem with your theory.  It sounds very convincing.  However, the vagus does more than just swallow.  Since this does not happen when you have a bowel movement (a classic valsalva maneover) should do the same thing and evidently it doesn't.  This would also produce a parasympathetic output.  I might just give a trial of what the EP specialist suggested.  If it controls your problem then you are in luck and they have a publication.

Sincerely,

CCF Neuro MD

[Peter]

Thank you for your thoughts.  I wasn't sure if you would laugh me off or see this as an interesting and unique case.  Your observation regarding the bowel movement is accurate, however is it not possible that the specific fibres being stimulated by the action of swallowing could create  the problem?  I did not mention before that because of this connection I asked for a barium swallow to see how the esophagus looked.  They found significant acid reflux which was then treated.  The problem seemed to go away for a while and then return.  I thought that was the answer - chronic irritation of the esophagus had finally affected the vagus nerve, which upon swallowing, did its thing to the heart rhythm.  Unfortunately even while on the reflux meds it returned.  I guess the problem for me is the fact that the empirical evidence is conclusive - I swallow I get a momentary arrhythmia that unfortunately can degenerate into afib. Every test on the heart is completely normal, which is of no surprise in that I have run marathons, climbed mountains and kayaked at 5 whitewater nationals.  The fact that even the cardiologists can't explain this and that they actually have never heard of this but see that it is happening, makes me all the more convinced of finding a solution.  I believe that, although I have been cast into the pit with all other heart patients that in my particular case something else is the cause and that if it could be idenfified perhaps I wouldn't need to suffer years of trial and error medications etc.
I guess it is my hope that someone will eventually either recognize something or become interested enough to pursue this - I guess I can join the club on this line of thought.
Any other ideas, suggestions?? Perhaps from the neurologic point of view there could be test, medication worth trying?  As for the scopolamine what do you know of this drug? I believe it is taken for motion sickness for a few days only.  Is there a drug out there that could do the same thing but indefinitely?
Always searching!
Peter

[CCF Neuro[P] MD, RPS]

Dear Peter:
It is always possible that there is segmental vagal dysfunction but the overwhelming evidence of the literature would be against it.  However, your symptoms are not your everyday ones either.  Reflux really has not too much to due to vagal nerve innervation of the anatomical spincter of the eosphagus.  The vagus can cause too much acid secretion and subsequent gastric ulcers.  However, you would certainly know this as this is a very serious entity that needs surgery to clip the vagus.  What doesn't sound right to me is that an acute brady would induce tachycardia.  Sinus tachycardia that is narrow wave (SVT-like) is actually treated with vagal stim.  It is also treated by adenosine which actually stops electrical transmission (the ultimate brady) for a brief moment to kick the heart out of SVT.  So you are really a paradox.  I am sorry I can't help.

Sincerely,

CCF Neuro MD

[Peter]

Your observations are appreciated.  With regards to the acid reflux, how about the idea that esophagitis could in fact irritate the vagus nerve enough to cause the vagal brady upon swallowing.  Such a momentary effect could initiate the SVT and ultimately afib.  Cardiologists due recognize that a sinus pause can trigger such events.  So in closing I would first like to say thankyou for you time and thoughts.  I would also ask - at this point in time it would appear that such ideas are not supported in modern medical thought so I suppose I am confined to pursue this from the cardiac viewpoint.  If I were in a hospital such as yours would there be testing and possible treatment from a neurological point of view?
Peter

[Peter]

One other symptom worth mentioning - it seems that prior to the onset off heart beat problems (ie. swallowing trigger) I experience a fair amount of muscle twitching especially in the left Pectoralis muscle group.  I sometimes wonder if the twitches are in fact skeletal or cardiac in origin.  There is no disruption to the beat so I suspect it is skeletal.  Could this entire scenario be part of a neuromuscular disorder of some sort?
Peter

[CCF Neuro[P] MD, RPS]

Dear Peter:

The right vagal nerve control heart rate, so left pec twitching will not be involved.  In addition, the pec nerve comes off the brachial plexus and not the vagal nerve.  Yes, severe irriation of the eosphogus can cause neurological symptoms: Sandifer's syndrome.  However, the irritation is severe and one would see seizures in this disorder.  I think that cardiology would be the ones working you up for this, but the answer is yes.  Why don't you contact the cardiology site on this service as they are from the Cleveland Clinic.

CCF Neuro MD

[brian]

HI Peter -

I also suffer from PVC's PAC's (I feel these every day - some days only a few and some days hundreds). I have also had several episodes of atrial fibrillation that lasted for hours. In addition, I have frequent episodes of elevated heart rate. I have had multiple echos and  stress EKGs and all tests are normal.  Doctors say not to worry and just to live life.

Although I have never noticed symtoms when I swallow, I have noticed a strong correlation between eating/indigestion and "skipped beats".  My doctor doesnt understand this, but nearly every time I have gone into afib (about 5 of 7 times), I was drinking/eating something very cold. I have also noticed syptoms (symptoms) are reduced when I take an antacid or Prilosec for my stomach. These are definite correlations and ones I am not imagining.

I too have a lot of (what feels like) muscle twitching in my chest (in the muscles over my rib cage). Muscle twitches are common elsewhere (legs, feet) too.

So you are not alone.

Brian

[CCF Neuro[P] MD, RPS]

Dear Brian:

What you are experiencing with eating or swallowing something cold is a vagal response.  This is a technique we use to stop someone in SVT.  What happens is that the cold solution induces stimulation of the vagal nerve by causing a sudden change in the breathing and circulatory pattern.  This causes the heart to brady down due to increased parasympthetic tone.  The key is the cold.  Swallowing alone does not induce this activity.  The sudden cold is what is the trigger.  I would bet that if you had physiological testing of your heart, they would find the source of your problem.

Sincerely,

CCF Neuro MD

[sue]

I have excessive sinus tach due to autonomic malregulation.  My vagal restraint is malfunctioning which causes my heart to beat over 200 bpm.  

The cardiologist states "Susan was tilted to +60 degrees for 10 minutes.  At rest her heart rate was 108 / min and bloood pressure 113/68 mmHg.  During the tilt, her blood pressure was well maintained.  The lowest value recorded was at the 10 minute mart 113/70 mmHg with a heart rate of 113/min.  The highest value recorded was at the 9 minute mart 129/69 mmHg with a heart rate of 115/min.  During the tilt, there were prominent fluctuations in beat to beat heart rate (reflective of prominent Mayer waves).

A Valsalva strain accelerated the resting siuus rate from 110/min to 145/min and following release of strain there was an abrupt and dramatic slowing down to 90/min with gradual acceleration over a space of one minute to the resting sinus tach range.

Susan exercised for 12 min completing stage 4 of the Bruce protocol.  The heart rate rose from 120 to 201/min and blood pressure rose from 118/80 to 144/69 mg.  There were no ST-T wave changes.

The Valsalve maneuver suggests that vagal tone can be recruited provided there is a sufficient stimulus.  On the strength of thie, I am prescribing digoxin .25 mg daily because of its ability to enhance vagal tone."

Another holtor monitor was done after a 2 week period and that indicated the pills didn't work.  He has now prescribed Diltiaz but is not sure it will work either.  The next step he would like to do is to cut the nerve that goes into my heart so my heart won't race like this.  Unfortunately he says it is experimental and is unsure whether it will work.

Can you provide information to me as to what these nerves do and what side effects I will have if he does this procedure?  Can you let me know if there are better ways to fix my problem.

[sue]

I have excessive sinus tach due to autonomic malregulation.  My vagal restraint is malfunctioning which causes my heart to beat over 200 bpm.  

The cardiologist states "Susan was tilted to +60 degrees for 10 minutes.  At rest her heart rate was 108 / min and bloood pressure 113/68 mmHg.  During the tilt, her blood pressure was well maintained.  The lowest value recorded was at the 10 minute mart 113/70 mmHg with a heart rate of 113/min.  The highest value recorded was at the 9 minute mart 129/69 mmHg with a heart rate of 115/min.  During the tilt, there were prominent fluctuations in beat to beat heart rate (reflective of prominent Mayer waves).

A Valsalva strain accelerated the resting siuus rate from 110/min to 145/min and following release of strain there was an abrupt and dramatic slowing down to 90/min with gradual acceleration over a space of one minute to the resting sinus tach range.

Susan exercised for 12 min completing stage 4 of the Bruce protocol.  The heart rate rose from 120 to 201/min and blood pressure rose from 118/80 to 144/69 mg.  There were no ST-T wave changes.

The Valsalve maneuver suggests that vagal tone can be recruited provided there is a sufficient stimulus.  On the strength of thie, I am prescribing digoxin .25 mg daily because of its ability to enhance vagal tone."

Another holtor monitor was done after a 2 week period and that indicated the pills didn't work.  He has now prescribed Diltiaz but is not sure it will work either.  The next step he would like to do is to cut the nerve that goes into my heart so my heart won't race like this.  Unfortunately he says it is experimental and is unsure whether it will work.

Can you provide information to me as to what these nerves do and what side effects I will have if he does this procedure?  Can you let me know if there are better ways to fix my problem.

[Mike]

I also have the symptoms first described by Peter.

One November after a severe cold, I realized that my heart was skipping or pausing a beat sometimes.   It took awhile to make the connection to swallowing, but there was no doubt that there was a correlation.  

Scared by the sensation of heart stoppage, I went to doctor after doctor but there were no answers.  Eventually I insisted on a 24 hour Holter monitor.    After the EKG was analyzed, they told me there were "no abnormalities".   One doctor did note that the episodes seemed to coincide with occurrences of "Ventricular Ectopies" (I may have that spelled wrong?).    He told me these were "normal" and happened to everyone but that it was rare that I could actually sense them.  

He was even more astonished when I demonstrated my ability to skip a beat by swallowing.   As someone else mentioned, the only advice I was ultimately given was to "ignore it".

Besides the swallowing-skip symptoms, I don't have any of the other things mentioned here- reflux, muscle twitching, etc.
Before stumbling onto this forum, I had pretty much given up on finding more information about this unique condition - let alone others that had it!  Thanks!

Mike
***@****

[Ida]

I'm so happy to have stumbled upon this site. You may be able to answer my question. I had a severe adverse reaction to a drug almost 3 years ago.(edema,convulsive shaking,sweatty palms/soles of feet,stiff neck, tight throat,fast eye movements,weak left arm,thick tongue)(At ER I had high BP,low sodium, high glucose) Since then I've had a sensation in the left side of my neck. (Not real pain...just tenderness or it felt like something was lodged in there someplace). I've had (or have) many other disorders, including malignant/essential hypertension accompanied by bradycardia, panic disorder, episodes of various other endocrine problems & odd sensations. Not until recently my family doctor told me that I may have vagal neuritis. (He prescibed Lamictal but I haven't taken it yet.I confess..I'm afraid of new pills. I have to think about it and check it out first)
Tests revealed that I have (or had) first degree AV block and a trace of mitral regurgitation. These tests were never discussed with  me so I had to research on my  own. What I am finding is scaring me. If my vagus nerve is not functioning properly what will happen? Could it improve? I can't seem to get a doctor to explain to me what happened to me. What does this sound like to you? Please let me know. Thank You, Ida

[Dennis]

Brian,
I too have similar symptoms.  My heart "pauses" when/after eating.  I also have muscle twitching in legs, arms, trunk etc...
Have you received a diagnosis from your doctor?

[Michael J.]

I am a 44-year old male that has a history of high blood pressure for fifteen years.  I exercise frequently by jogging, walking and biking.  I had no problems up until November of 1997.
In the evening, about 7:30, I suffered my first experience with vasal-vagal syncope.  I knew I was starting to feel bad with the "normal" symptoms of lightheadedness and rapid heartbeat.  I passed out and quit breathing for approximately fifteen seconds.  After lying down, I began to come around which is normal for this episode.  I was taken to St. Louis University Hospital and kept overnight.  No abnormalities were found, but I did have attrial fib (sic). Fast forward to October of 1999 and at the same time of night, I had another episode and this time I knew what was happening to me, but I stayed upright and had my wife rush me to the hospital.  The doctors decided to send me to Springfield Memorial Hospital in central Illinois and the doctor on call in the cardiac unit just happened to be a rhythm specialist who ordered catheterization and an electrophysiology test. I was told I have the arteries of an 18 year old with no electrophysiological problems.  I was told I do suffer from vaso-vagal syncope. I take diovan 160 mg., metoprolol 2Xday, Norvasc 5 mg. 2Xday, baby aspirin, potassium and buspar 15 mg. 2Xday. There are times I feel my heart flutter and it worries me.  Many times when I stand after sitting a while, my ears feel like they "fill up" and I can't hear very well.  I can't drink alcohol at all with these medications and I can't even smoke a cigar once in a while, though I have done neither to any extent at all.  Do you have any answers to this problem?  I noticed a couple of years ago that with certain foods, it became difficult to swallow the food.  These items were meat that became dry or white beans.  Was this acid reflux and was it a symptom of things to come with the vasal-vagal?  I am determined and I will keep hunting until I find an answer to this perplexing problem! Thank you for your time!

[suffering]

Peter and all others who suffer from vagus nerve problems.  Two years ago I had my gallbladder removed.  I was suffering from extreme bloat.  I had my gallbladder removed and still suffering from bloat.  Now my heart acts up when I wake up from sleeping.  It races and I get out of breath for hours.  I believe it stems from the vagal nerve control.  I was diagnosed w/gastroparesis: definition: stomach paralysis...caused by vagus nerve.  I bloat and now have heart problems upon awakening.  The vagus nerve is part of the human anatomy but it seems like doctors shy away from talking about it and possibly not knowing a whole lot about it.  Gastroparesis is very uncommon, 3 out of 1,000 has it.  Basically it is caused by vagus nerve damage thru diabetes. I'm not diabetic.  I had an upper/lower GI nothing showed.  I believe it is that nerve line.  I had an EKG, an echocardiogram. the the echo showed slight mitral valve leak.  When I get startled my heart gives a learch big time and I have had angina attacks from loud noises especially if woken up.  Never had any of this til I had gastroparesis. I have had this condition for almost 3 years.  I'm sick of it.  I'm on propulsid to help empty my stomach and on xanax to relax my nerves and tremors (I believe my tremors are from the vagus nerve also)  epilepsy can be caused by a bad vagus nerve, tremors are a form of that.  The xanax helps to relieve my stomach tightness also which relieves my breathing to my diaphram.  The bloat rises to my chest which gives me heart pressure.  The cardiologist states the bloat won't hurt my heart. I disagree cause constant pressure can't be good for it.  I'm planning to go to Mayo Clinc..it's my last ditch effort.  Then I guess it's suffering for the remainder of my life. I spoke to the cardiologist about the vagus nerve...he had no comment.  Spoke to my primary care physician...passed it off.  It's like no one wants to speak about it...like they did'nt hear you.  The vagus nerve is real, it's the 10th cranial nerve in the body, the second brain...it's real, it controls the digestive function, heart function and keeps seizures at bay. Doctors, people...let's get this important nerve out in the open!  It took me a long time to finally figure out what was wrong after everything physically checked out, outside of my stomach not emptying.  World let's not hide the vagus nerve problems.!!!

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