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Rapid Heart Rate in middle of night

Had stress induced heart attack 5 months ago.  Doctor now thinks it was acute cardiomyopathy instead as there was only evidence of damage in a number of small locations. Two stents placed in my RCA, although this artery played no role in the attack.  On effient, aspirin, coreg (6.25 mg  2x/d), and just switched from 5 mg lipitor to 10 mg pravastatin.  About 8 weeks ago I started noticing a flutter or rapid heart rate when I woke. I haven't sleep well in several years so it has been common for me to rise around 3am with 4 to 5 hours sleep, and the time I have this rapid heart rate only occurs on waking.   I do not feel any other symptoms.

My blood pressure has generally been running around 120/75.  sometime lower sometime higher.  My diastolic is normally below 80 and rarely gets over 80.  On occasion my systolic goes above 130, but not often.  My heart rate varies from low 50s to low 60s.    this morning it was 124/75 with a HR of 54 not long after rising at 3am.

I am a 58 yo male.  normal weight.   Before & after the heart attack I was exercising - 1 mile of brisk walking and 10 minutes of light dumb-bell weights almost every day.  I have no problem walking a couple of miles at a good pace.  On occasion I have felt dizzy when rising from a squatting position but I understand this might be a symptom of coreg.  

I currently take a magnesium supplement.  Also during last 5 months I went to a totally plant based diet - lots of brown rice and various beans and greens and some fruits,   Am drinking two glasses of wine per day.  not a smoker.

Echo showed heart valves were working OK.  mildly decreased LV ejection.  LV diastolic function - impaired relaxation.  frequent PVCs  

Treadmill test (Bruce protocol) indicated  appropriate heart rate response.  rare PACs, normal sinus pre-test, normal ST/T waves, sinus tachycardia at peak of test.

What is likely going on?  
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4610897 tn?1393869202
Hello, thank you for your question.

The symptoms you are describing are called palpitations, and could be due to a number of different types of abnormal electrical rhythms of the heart; this is called arrhythmia. It is difficult to tell from the description of symptoms (the history), physical exam, and even a resting ECG (which only records a 6 second strip of what is going on electrically with your heart) usually. From the information you already shared though, you have what is called an ischemic cardiomyopathy, which is a weakened heart muscle presumably from coronary artery disease (blockages of the arteries that supplied your heart). This is inferred from the results of your echocardiogram, which showed depressed LV function. The presence of structural heart disease like a cardiomyopathy and coronary artery disease places you at risk for a number of different arrhythmias.

The rhythm strip (the ECG was hooked up to you during the ECHO to allow for certain measurements) demonstrated premature ventricular contractions (PVC’s). They are a common cause of palpitations in patients, and are relatively benign (not particularly dangerous) unless they occur more than approximately 10% of time, are strung together in groups of 3 or more (this is called ventricular tachycardia which can be lethal if it persists long enough), or unless the symptoms are disabling. The treatment is beta-blockers (like Coreg and other beta-blockers) or can be ablated with radiofrequency waves if severe enough.

However, that assumption cannot be made. You should ask your physician for a Holter or Event monitor (preferable). These are ECG monitors that are worn for 24 hours up until a few weeks. This will demonstrate your electrical rhythm exactly when you are having the symptoms, which is what required to make a definitive diagnosis. This is because while it appears you already get PVC’s, the symptoms that occur in the AM may be due to any number of arrhythmias (atrial fibrillation, atrial flutter, supraventricular tachycardia, atrial tachycardia, premature atrial contractions) and the only way of knowing is to be recorded on an ECG precisely when you get the symptoms.

Another avenue to explore is obstructive sleep apnea. Ask your physician about considering this diagnosis especially due to your poor sleep at this time. This is explored with a polysomnogram (PSG) or sleep study.
Also, explore stress reduction techniques (massage, yoga tai-chi), and moderate amounts of caffeine and alcohol. Try and maintain 30+ minutes of exercise at least 5 times per week. Congratulations on the dietary modifications you have made thus far!

So in summary, ask your physician about:
1. A Holter or Event ECG monitor
2. A PSG, or sleep study

Dr. S
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