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Feeling irregular heartbeat and tightness in chest. EKG and blood test normal. Any suggestion?

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Practicing since : 1966
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I went to the emergency room two weeks ago for palpitations, They did EKG and blood work, all was great. I don't smoke, given up regular coffee and hard alcohol. i get plenty of exercise. Just lost 20 pounds, I am in my 50's. Doctor said, he didn't know what it was. Said I am in good shape. I do feel a dip in my heartbeat occasionally, than it goes away, and do feel a tightness in my chest every day. I started taking baby aspirin and potassium. I do need my gall bladder taken out. I do have horible acid some nights. Life is good other wise, new job, new home. My family is mobving to join me soon, so a little lonely, but very busy. I miss the wife.
Can you tell me some suggestions and courses of actions.
Thank you.
Posted Thu, 20 Dec 2012 in Heart Rate and Rhythm Disorders
Answered by Dr. Anantharamakrishnan 2 hours later
Welcome to Health Care Magic
You have missed beats, often / and fast rate, occasionally...

     Feeling of ‘dip’ points to missed (ECTOPIC) beats. Irregular heart beats need to be documented by ElectroCardioGram (ECG / EKG). Ectopic beats can be from ventricle (lower chamber - Ventricular Ectopic; VPC) or Atrium (upper chamber - Atrial Ectopic; APC). APC are generally harmless. Even VPCs are often harmless – ‘benign’. If they are frequent (More than 5 per hour, 2 or more coming in succession –they need investigations further.

Tachycardia is a heart rate above 100/minute.

     Anxiety / Alcohol / Tobacco (smoking, chewing) / Caffeine (too much coffee, cola) are common causes.
     Medicines may be responsible – like phenylephrine, pseudo-ephedrine used for ‘cold’ / Salbutamol, salmeterol used for asthma. Occasionally, there are abnormal nerve paths (bypass tracts) in the heart.
     Since you have eliminated most of these, probably bypass tract is the case with you and anxiety is contributing.
Though they could be normal in many, it is advisable to investigate.
A thorough history and physical examination is the first step -
     Routine 12-lead Electrocardiogram (ECG) is part of clinical examination.
     If a routine ECG does not show, 24 to 48 hour AMBULATORY MONITORING (Holter) is done to analyse and plan for further management
     ECHOcardiogram is necessary to see the heart valves (Mitral Valve Prolapse) / heart muscle (Cardiomyopathy) and heart function (Ejection fraction, wall motion abnormality).
     Treadmill exercise ECG (TMT) is done to exclude Ischemia (reduced blood flow).
     Laboratory work-up is routine - like blood counts, sugar, urea, electrolytes (potassium in particular – why are you taking without documented deficiency!?), thyroid (over active) etc. Your internist will suggest based on the situation.
     If there are no clues and if you are still bothered by it to the extent of interfering with life style - there are more tests – advanced techniques of investigations of increasing complexity (some of them invasive), depending on need. Your cardiologist may suggest them based on the situation > like Electro Physiological Studies (EPS) – it is the gold standard / it resembles angio / a catheter is put inside the heart, electrical activity recorded, stimulation and suppression tests are carried out, suitable medicine tested and so on. The test is invasive, has a minimal risk and is not generally done unless there are compelling indications. He is called ELECTRO-PHYSIOLOGIST.

     These ectopic beats could be normal in some persons. The feeling depends on individual sensitivity. Some do not feel them at all / some may feel every beat.
     A specific treatment for the beats may often not be necessary.
     The first line medicine is generally beta blockers, like Metoprolol – slow release and small dose. It will benefit both anxiety and missed beats. Your doctor will give proper prescription and follow up.
     If they are not effective and if the problem is severe, several other classes of drugs are available - acting by different mechanisms - the specialist will decide tailored to your need / they may have side effects and need regular follow up.
There are other advanced treatment modalities - like RF ablation / invasive and done with EPS.

     Your ‘horrible acid in the night’ will need upper GI endoscopy to exclude Hiatus Hernia or Peptic Ulcer. In the mean time, you may benefit from PPI (Proton Pump Inhibitors) like Omeperazole.
     With the investigations completed and stabilised on a standard medication, your 'gall bladder can come out.’ – A multi-speciality Tertiary Care hospital will be ideal.
     Rather a long essay?! Too many suggestions? Relax! The only course of action you need to do - is of course is to be in touch with your doctor. It is a question of time and you will be well. Medicine is well advanced nowadays – management is possible for almost all situations...

Take care
Wishing speedy recovery
God bless
Good luck
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