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Have GAD, panic, heart palpitations, distended abdomen. Normal tests. Turned vegan. May have GERD or celiac disease

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Cardiologist, Interventional
Practicing since : 1998
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Hi there -
40 year old male, 6 feet (183cm), 192lbs (87kg), former competitive athlete. Have an anxiety (GAD w/ panic) diagnosis and 'mysterious' heart palpitations (not tachy, nor skipping beats or double beats, etc. heart just beating _harder_) that are hence assumed to be caused by the anxiety alone, but they occur without any anxiety and are mechanically reproducable, and I have an extreme amount of gas/trapped air so I think I either have GERD, or celiac disease, and/or just a distended abdomen and excessive gas caused by bacteria due to recent diatery changes or magnesium deficiency (proven by blood test) causing slow motility. In any event, the palpitations are often physically triggered and not due to anxiety. I'd like your opinion/possible diagnosis on this please.

2 x EKGs, 2 x blood tests, 2 x urine tests, chest x-ray, ultrasound, manual exam of the heart shows everything normal. Hence, the MD concluded that palpitations are caused by anxiety alone, and/or they subjectively appear to be more than what they are to me b/c I've been sensitized to being more aware of the heart. While both of these assessments are probably true, they do not explain:

- Why I can mechanically reproduce palpitations regardless of state of mind when laying on stomach or sides, putting pressure on abdomen or thorax in certain other ways, vasoconstriction of any kind (from belt tightening to alcohol consumption), eating after many hours on empty stomach, eating too fast or a heavy meal, even slouching/bad posture and bending over, etc.
- Why sometimes during these non-anxiety palpitations while lying down or after dinner, and sometimes during an actual panic attack, I intermittently get chest tightening and chest pains, either on the left or right side, and fear I’m having a heart attack, but the chest pain and the palpitation goes away with repeated burping. I sometimes have to burp for minutes.
- Why I can actually measure a jump of up to 30-35 in systolic pressure only (diastolic remains the same) when the palpitation is happening. Clearly, the heart is contracting much harder, but not beating faster -- I'm not imagining it. Example: Ate a heavier meal a bit too fast tonight, not enough chewing. It also contained grains/gluten. I should mention that I'm on 25mg of Metoprolol extended release beta blocker per day for the past month. My BP is now routinely 120s/80s, even 110s/70s during the day. After the meal, I got the palpitations, and measured systolic BP of 140s-160s while it was happening, while the diastolic remained in the 70s and 80s. Pulse is 60s to 70s while it's happening (in contrast to resting heart rate of about 58), so my heart is not racing, just contracting harder.

This was measured repeatedly while sitting slouched on the bed, where the full abdomen obviously applies some pressure on the thorax and heart. When I sit up straight in a chair and thus relieve the pressure, and especially when I follow the urge to burp repeatedly (many times, sometimes for minutes) during which nothing but trapped air seems to come out, the systolic pressure goes down as much as 20-30 points. In this case, it went from 160 to 140, then to 130, within a minute. Thus, I'm convinced that part is not anxiety.

My theory: I turned vegan overnight 6 months ago and have had tremendous amount of gas since. Obviously the intestinal flora is suffering from the sudden change from a standard American diet. Also, the blood tests found a magnesium deficiency, which may be causing slow motility leading to more gas. I lost a fair amount of weight during the same time period without even trying due to the vegan diet, but appear to still have a distended abdomen. I don't think that's all remaining belly fat. I think a lot it is bowel gas as well as trapped air in stomach. I feel constantly bloated. And burping seems to both alleviate the bloating and regulate the heart rhythm when I have palpitations. Sometimes I can burp for many minutes straight. So my potential self diagnoses are:

(a) The gas is swelling my stomach to the point it is pressing against my diaphragm. This is making it difficult to breathe as the expanding chest allows the swelling to push into the thorax rather than creating a larger place for the lungs. This is also the cause of the palpitations.
OR: (b) Trapped gas/air is backing into esophagus, irritating the vagus nerve.
OR: (c) I may have GERD b/c the palpitations are happening after meals, and I've also had chronic cough and sinus infections as per GERD. However, this still appears unlikely b/c I almost never have heartburn/acid reflux.
OR (d) Hiatus hernia. Again, no reflux or regurgitation, but the esophagus would trap gas when the hernia slides into the chest cavity. The trapped gas presses on the vagus nerve and causes heart palpitations. (c) and (d) are consistent b/c repeated burping and orthostatic repositioning seems to regulate the heart rhythm and make the palpitations go away. Orthostatic vitals were done but were not clinically significant. However, they weren't done while I was having the palpitations and I was thus not able to demonstrate that I'm able to relieve the palpitations orthostatically and by burping.
AND/OR: (e) I have celiac disease and developed gluten sensitivity since turning vegan.

Does this make sense? What do you think is going on, what's more vs. less likely, and what should I do about it? The palpitations are very disruptive. Sometimes they go on for a long time and when they happen at night, I end up losing much sleep. Many thanks in advance.
Posted Tue, 22 May 2012 in Digestion and Bowels
Answered by Dr. Prabhakar C Koregol 9 hours later

Thanks for writing such an exhaustive account as well your own concerns and theory.

I would like to make few things clearer. First of all your symptoms are not attributable to one single problem, probably you have more than one issue and major one being GERD and second being anxiety.

The situations in which you get palpitation there is nothing abnormal about it.
In these postures and situations every person would experience the normal heart beating and eventually most of the people become accustomed to it. So you just need to ignore them.

Blood Pressure raise by 10-20mmHg is acceptable and usual but in your case because of added anxiety or worry about the possible disease the magnitude could be a little more, which again I would stress should be said normal.
Your explanation for symptoms are quite plausible except may be your comment on the intestinal flora which doesn't generally happen.
At the end you need to learn to ignore these palpitations by not worrying about them and manage stress and diet to reduce your gastrointestinal symptoms.

Hope this information helps relieve you of your anxiety. Please accept the answer if you have no further questions.

Wishing you good health.

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