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Vagus Nerve Role In Sinus Tachycardia
by asaria, Feb 24, 2009 11:15PM
This is in follow-up to the posts by PVC and others in the now-closed topic "Abnormal Vagal activity."
I started having very distressing runs of sinus tachycardia in the range of 200bpm a couple of years ago. I was referred to a cardiologist who did very thorough investigations, including 24hr and 14day Holter, stress thallium, stress echo (twice), etc. I have not required an EP study so far.
Unfortunately, this cardiologist was not much on history-taking, preferring to emit only a grunt before moving on to a cursory physical exam and to order the investigations noted above. This is a pity, since I now believe I had the diagnosis with me when I walked in his door: I tried to tell him that my sinus tach was inevitably triggered by eating something (particularly if sweet) on an empty stomach (particularly while sitting down or reclining). He dismissed this with another grunt and a shrug.
Had he done any history at all, he would have found out that I have intermittent gastro-esophageal reflux as well. I did not mention it, because it did not occur to me at the time that it could be related. When all the tests (except the Holters) were negative, he put it down to 'one of those things', scheduled follow-up (which has been normal) and prescribed propranolol 10mg PRN for the symptoms.
The propranolol has worked to get me back down to a normal rate, though it usually takes 30-40 minutes, sometimes requiring a second dose. I've had a couple of trips to the ER when my rate was heading up toward 300, but fortunately I haven't popped into atrial fibrillation (that I know of). It is very distressing, though.
A little while ago, I was watching "House, MD." I like it because I am an ER physician and I love to see House say some of the things that I would never dare to vocalize. When Hugh Laurie's character tossed off something about the connection between the vagus nerve, reflux and arrythmia, it got me thinking about my own sinus tach.
Consequently, I got a script from my family doc for Losec. I have tried it for a while now in two circumstances: when I have noticeable reflux, and when I notice the irregular beats after eating that are the harbingers of a full-blown episode of sinus tach. It appears to have worked more quickly and effectively that the propranolol, to the extent that I have not needed the propranolol at all.
I have no idea if the Losec is truly effective (a study population of one is an anecdote), but I have a few thoughts on the matter:
(1) The vagus nerve carries afferent, as well as parasympathetic efferent, neurons that innervate the areas that are affected by gastroesophageal reflux.
(2) Decreased vagal tone can certainly precipitate a tachyarrythmia.
(3) It is not a ridiculous idea, therefore, that excess gastric or esophageal acidity might inhibit the vagus, possibly resulting in decreased vagal tone in the SA node or elsewhere in the heart.
(4) I feel a lot better after taking one Losec than two propranolols. Something in me appears to 'return to normal', as opposed to the treatment with propranolol that slows my heart but still leaves me with a funny feeling of 'jerkiness' or irritation somewhere in the thoracic region that I can't localize very well. This may be what some people here have described as "muscle twitches".
(5) The Valsalva and coughing never helped (and I tried them a lot, believe me, on my way to ER at 0200H with my rate heading up toward 300 and starting to feel woozy). What seemed to help a bit was a 'reverse valsalva': forced inhalation (rather than exhalation) against a closed glottis.
(6) Sometimes, the patients are smarter than the doctors. When someone says they get a tachyarrythmia when they swallow, why not believe them? Could they really make something like that up?
(7) Even with all our wonderful advances in technology, the medical history remains the most important part of any patient evaluation. Most times, the answer lies locked inside the patient's brain, waiting to be teased out by a knowledgeable clinician. That it why I shall try to be strong and walk out on any physican who cannot be bothered to take one; she's wasting her time and mine.
(8) "House, MD" is, after all, just a television show (by my own rules, I would have to dump him because he never takes a history), but thinking and talking about medical matters without constraint can, sometimes, spark an idea that leads to a diagnosis.
asaria
This discussion is related to Abnormal Vagal activity.
I started having very distressing runs of sinus tachycardia in the range of 200bpm a couple of years ago. I was referred to a cardiologist who did very thorough investigations, including 24hr and 14day Holter, stress thallium, stress echo (twice), etc. I have not required an EP study so far.
Unfortunately, this cardiologist was not much on history-taking, preferring to emit only a grunt before moving on to a cursory physical exam and to order the investigations noted above. This is a pity, since I now believe I had the diagnosis with me when I walked in his door: I tried to tell him that my sinus tach was inevitably triggered by eating something (particularly if sweet) on an empty stomach (particularly while sitting down or reclining). He dismissed this with another grunt and a shrug.
Had he done any history at all, he would have found out that I have intermittent gastro-esophageal reflux as well. I did not mention it, because it did not occur to me at the time that it could be related. When all the tests (except the Holters) were negative, he put it down to 'one of those things', scheduled follow-up (which has been normal) and prescribed propranolol 10mg PRN for the symptoms.
The propranolol has worked to get me back down to a normal rate, though it usually takes 30-40 minutes, sometimes requiring a second dose. I've had a couple of trips to the ER when my rate was heading up toward 300, but fortunately I haven't popped into atrial fibrillation (that I know of). It is very distressing, though.
A little while ago, I was watching "House, MD." I like it because I am an ER physician and I love to see House say some of the things that I would never dare to vocalize. When Hugh Laurie's character tossed off something about the connection between the vagus nerve, reflux and arrythmia, it got me thinking about my own sinus tach.
Consequently, I got a script from my family doc for Losec. I have tried it for a while now in two circumstances: when I have noticeable reflux, and when I notice the irregular beats after eating that are the harbingers of a full-blown episode of sinus tach. It appears to have worked more quickly and effectively that the propranolol, to the extent that I have not needed the propranolol at all.
I have no idea if the Losec is truly effective (a study population of one is an anecdote), but I have a few thoughts on the matter:
(1) The vagus nerve carries afferent, as well as parasympathetic efferent, neurons that innervate the areas that are affected by gastroesophageal reflux.
(2) Decreased vagal tone can certainly precipitate a tachyarrythmia.
(3) It is not a ridiculous idea, therefore, that excess gastric or esophageal acidity might inhibit the vagus, possibly resulting in decreased vagal tone in the SA node or elsewhere in the heart.
(4) I feel a lot better after taking one Losec than two propranolols. Something in me appears to 'return to normal', as opposed to the treatment with propranolol that slows my heart but still leaves me with a funny feeling of 'jerkiness' or irritation somewhere in the thoracic region that I can't localize very well. This may be what some people here have described as "muscle twitches".
(5) The Valsalva and coughing never helped (and I tried them a lot, believe me, on my way to ER at 0200H with my rate heading up toward 300 and starting to feel woozy). What seemed to help a bit was a 'reverse valsalva': forced inhalation (rather than exhalation) against a closed glottis.
(6) Sometimes, the patients are smarter than the doctors. When someone says they get a tachyarrythmia when they swallow, why not believe them? Could they really make something like that up?
(7) Even with all our wonderful advances in technology, the medical history remains the most important part of any patient evaluation. Most times, the answer lies locked inside the patient's brain, waiting to be teased out by a knowledgeable clinician. That it why I shall try to be strong and walk out on any physican who cannot be bothered to take one; she's wasting her time and mine.
(8) "House, MD" is, after all, just a television show (by my own rules, I would have to dump him because he never takes a history), but thinking and talking about medical matters without constraint can, sometimes, spark an idea that leads to a diagnosis.
asaria
This discussion is related to Abnormal Vagal activity.
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