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Stomach pulse with palpitations, back pain, high BP, no chest or abdominal pain. Worried about abdominal aortic aneurysm

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Cardiologist, Interventional
Practicing since : 1996
Answered : 192 Questions
Hi there -
I've asked a related question to a cardiologist here 2 weeks ago. Have seen a GP and got tests done since. So now I have a new question.
I'm 40, male, 6 feet, 190lbs, no history of health issues, former competitive athlete. Under a lot of chronic stress last couple of years, and in recent months started suffering from a lot of anxiety. One episode took me to ER which I feared was heart related, but turned out to be an especially bad panic attack. I was given Ativan on a one-time basis after manual and stethoscope exams, ECG, blood and urine were all normal. My BP was high. Was measured 170s/110s at ER, but also 140s/90s same day at ER, few hours later. Then I went to see a GP who did their own blood and urine tests and chest X-rays. No pheochromocytoma. ECG so normal that they don't even think the left wall of my heart has thickened, as it happens to athletes, or if it had, it's not that way now. No electrolyte or thyroid issues. No anemia, no kidney or liver issues. Stethoscope (both heart, lungs and abdomen) and manual (pressure) exam shows no murmurs, gallop or anything unusual. Resting heart rate 60. Total cholesterol under 200. I can walk 8-10 miles very briskly, getting my heart up to 115-120 and keeping it there for 2-3 hours, no issues. No shortness of breath, no chest pain. When I sprint and stop, the recovery factor (the number by which your heart rate goes down in 60 seconds once it starts going down again after exertion) is between 30 and 40 every time I measure. I was given a selective, slow release beta blocker (metoprolol), only 25mg, and within 10 days of beta blocker + taking up some breathing exercises and meditation again, my BP is now consistently down to 120s/80s. So I was inclided to consider this my "medical clearance", agree that there isn't any underlying medical cause, and go deal w/ the anxiety and the external stressors / life issues.

However, throughout this entire time (last few weeks), I've also been having an abdominal sensitivity. I've always slept on my stomach, and all of a sudden, I can't, b/c laying on stomach or the sides causes heart palpitations within seconds. By palpitations I mean the heart beats "hard", not racing (measures 70s, low 80s max), nor skipping beats or extra beats. It just feels like it has to beat "hard" to push against something. That is what would wake me up, and I suspect trigger a panic attack. My BP is now down to normal now, and I don't think it's just my "tuning into" it more and being more aware of the sensation/presence of my heart beating. In fact, when it beats hard, the BP goes up by 10-15 points (though that's not scientific b/c I can't measure the BP while laying on my stomach. By the time I sit up again and strap myself on, who knows if it's up b/c of the heart palpitation of b/c of the anxiety?) There is of course a strong possibility that subconscious thoughts and fears are triggering the palpitations when they happen on its own (wakes me up at night, or happens during day while standing, sitting, laying on back, etc.). Chronic activation of the amygdala is even known to cause permanent changes in the somatosensory cortex, and I know whatever you pay attention to can create a feedback loop and people seem to be able to "bring on" symptoms they fear. But, I'm concerned b/c I can reproduce this at will _mechanically_, regardless of my state of mind, by simply:
- laying on stomach or sides
- any vasoconstriction (morning after any alcohol consumption in sleeping in dry room, or tightening belt)
- eating a lot on empty stomach or eating fast while leaning forward
- forcing very XXXXXXX breaths inhale/exhale slowly, like 4 cycles or less per minute. This is the opposite of hyperventilating, these are XXXXXXX slow, diapgragm breaths into the abdomen and sides and back and should slow the pulse down, not speed it up
- manually pressing hard on region below solar plexus

In short, I'm really worried about AAA (abdominal aortic aneurysm) b/c I sometimes also get a stomach pulse w/ the palpitations. I also do have some lower back pain, but it has v. good alternative explanations, goes away when I stretch, and does not radiate. Aside from the higher BP, I have no other risk factors for this. Never smoked, no family history, no chest or abdominal pain of any kind. I should also mention that I went vegan overnight 6 months ago after a lifetime of standard American diet, and have been losing weight in a healthy, slow way naturally since, like most people who go vegetarian. I cut out all animal products, and now supplement vitamin B12. I'm almost down to my ideal weight of 187lbs (forget the BMI, I carry a fair amount of muscle still and have broad shoulders, so I'm pretty lean at this weight), but still have somewhat of a distended abdomen b/c belly fat is the last to go, b/c I haven't been doing any resistence/isometric training and b/c I'm likely "marinating" in cortisol due to the work stress.

I'm really worried about AAA. Is there a less ominous explanation for the stomach pulse? How about the palpitations when laying on stomach or increasing abdominal/thoracic pressure? I realize that the vagus nerve extends up when laying in that position and left lobe of lung, heart and stomach get compressed, so vagus nerve may be understimulated and cause palpitations. The GP advanced a vague theory re: the vagus nerve. I realize that when pulse or BP go down, receptors in your carotid may speed it up again, etc. etc. But why is all this happening now, why won't it go away for weeks though my BP is now normal, and why is it mechanically reproducable at will? Do I need to get an ultrasound? In your view, what's the likelihood that I have AAA? And what's your alternative explanation? Many thanks in advance.
Posted Wed, 18 Apr 2012 in Heart Attack
Answered by Dr. Raja Sekhar Varma 18 hours later

Thank you for the query.

I remember the details from your previous posts.

Since there is no abnormal increase in the heart rate and since there is no arrhythmia, what you are feeling is the most likely an apical impulse of the heart when your chest is pressed against the bed.

The change in the location of the apical impulse may be due to the change in posture and the effect of such change on the diaphragm and the heart.

Though the ECG and clinical examination are normal, I would still get an echo done to know if there is left ventricular hypertrophy. Echo is more sensitive than ECG to pick up any increase in ventricular mass and wall thickness.

I would put Abdominal Aorta Aneurysm as unlikely. Again, if the worry over its possible presence is disturbing you, it can be easily solved by doing an ultrasonography of the abdomen and visualizing the entire abdominal aorta. "Seeing is believing".

I hope this answers your query.

With regards,
Dr RS Varma
Above answer was peer-reviewed by
Follow-up: Stomach pulse with palpitations, back pain, high BP, no chest or abdominal pain. Worried about abdominal aortic aneurysm 1 hour later
Hi Dr Varma -

Good to hear from you again. Like I said, the chest x-ray, new blood tests, and everything else done so far since we last corresponded looks good/clean. No pheochromocytoma. No thyroid issues, electrolytes, anemia, etc. Just some vitamin/minerals that are low that may be associated w/ anxiety - particularly vitamin D and magnesium. Slow release beta blocker (metoprolol) is working great despite low dosage (25mg). My BP is now consistently 120s/80s.

And I will get the ultrasound done, b/c like you said, seeing is believing, but given the doctor's schedule, that looks like it's 2 weeks out. That's a long time to be worried about something as serious as AAA, so I'm just looking to get some reassurance. Why do you say it's unlikely? Does it happen often to people who are only 40? I don't have any other risk factors, but I might have had high BP for a few years w/o knowing. I have no abdominal pain, but I'm really worried b/c all Internet search about a "stomach pulse" or high abdominal sensitivity seems to lead to AAA.

As far as the echo, I will try to convince the GP to refer me to a cardiologist to get that done. He was resistant b/c he says if there was left ventricular hyperthrophy, the wave in the ECG would not look the way it does. Though it's not made specifically to measure that, he says it's sensitive enough that the output would look different. The idea is that if the ECG is clean and the stethoscope is not detecting any heart issues and I don't have chest pains, etc., then the other tests (echo, Holter, etc.) will be clean as well. I know this also has to do w/ the business end of things. Insurance here doesn't like to pay for things that don't appear to have a medical justification -- a negative test triggering another test in the same area. What are your thoughts?

As far as the explanation for the symptoms, you were talking about the vagus nerve before, now you seem to be favoring the apical impulse. If this is the case, why would I start feeling it now? Could it have anything to do w/ anxiety? And as far as posture change, I'm not laying down any differently. The only thing that changed is that I've lost a bunch of weight due to turning vegan over the past several months, so I'm visibly leaner, but still have kind of a distended abdomen b/c (a) belly fat is the last to go in men, (b) I have only been doing cardio exercise, not interval training or resistance that digs into the long-term fat reserves, (c) there is excess cortisol resulting from chronic stress which tends to make it very hard to to burn off the belly fat b/c the body thinks it's winter and it's starving, hence the stress. If it is the apical impulse, combined by a temporary rise in diastolic pressure which makes me feel it, what is the remedy? What will make it go away? Sometimes it also happens when I'm lying on my back w/ the arms raised over my head, but most other times, this position is fine. But while lying on stomach, the palpitations happen every single time.
Answered by Dr. Raja Sekhar Varma 1 hour later
Thanks for the reply.

Yeah, i do feel that it is unlikely to be AAA.

You had talked about an increase in heart rate which is why I thought that was a reflex response . Now you appear very clear that there is no abnormal increase in heart rate.

So, the only logical conclusion is that you are just feeling the transmitted pulsation of your own heart beat when your chest is pressed against the bed. Anxiety and stress probably serve to increase the force of contraction. When you do have a distended abdomen, it is certainly difficult to lie down prone.

But, whatever the explanation, you don't need to worry so much about it since all the tests have turned out to be normal. You would do fine if you were to reduce your stress levels, keep your BP under control and follow your regular diet and exercise regimens. I would also recommend some yoga and other relaxation techniques. Also, it would be nice if you could distract yourself from analyzing so much and worrying about unlikely issues.

Since you now have your BP under control and since the ECG has not shown any changes, even if there were a little hypertrophy of the ventricle, it would regress over a period of time. It is difficult to predict how much time that would take, but I would not worry about it. The important thing is to keep the BP at normal levels, 24 x 7.

I hope this helps you.
With regards,
Dr RS Varma

Above answer was peer-reviewed by
Follow-up: Stomach pulse with palpitations, back pain, high BP, no chest or abdominal pain. Worried about abdominal aortic aneurysm 1 hour later
It does help, thank you. The analytical mind definitely goes into overdrive as there's a notion in the West that medicine is a deterministic science. We all know it is not, but are conditioned to act as if it is, or expect it to be. So the fact that no one can tell me for sure why I'm experiencing these symptoms makes me look for causes, including unlikely ones, which in turn fuel the anxiety in a feedback loop. I understand that as long as one believes that worrying is rationally/logically justified, one will never stop worrying. That's the nature of tier-2 anxiety. Understanding this intellectually does not always lead to behavior modification though :) I would like nothing more than to be told that there's definitely isn't AAA or an XXXXXXX growth/tumor creating compression or circulation problem or anything else organic, so I can move on and deal w/ the anxiety / life in general. I accept that there are many things out there that allopathic medicine does not understand nor is designed to solve, and I'm comfortable w/ that uncertainty, and w/ the idea of following paths such as meditation, pranayama breathing, acupuncture, ayurvedic or homeopathic or osteopathic medicine, etc. I just want to get a XXXXXXX light from the allopaths first, which is difficult when no one can go farther than advance theories on why the symptoms may be occurring. I'm an engineer, among other things, so maybe I'm thinking about all this the wrong way?

Last question / clarification: my heart _does_ beat faster when it palpitates. It's just not racing as I had previously thought and may have written. Now that I've actually measured it multiple times, when palpitating, it goes from a resting heart rate of low 60s to the 70s, or a XXXXXXX of low 80s. So I discovered that the reason it feels so uncomfortable is not b/c of how tachy it is, but b/c of how "hard" it seems to beat, almost as against some obstruction. You can see and feel the pulse on the chest, on stomach, sometimes the brachial. There's an accompanying rise in the BP, by about 10, especially diastolic. I am not short of breath while it's happening, and no chest pains, but a diastolic going from 82 to 95 in seconds and the heart beating hard in my ear seems plenty enough to prevent going back to sleep. My anxiety in the past has always been tied to conscious thoughts, so I could see it coming on and pair the physical symptoms w/ it. I suppose it's possible that I have subconscious fears now that I'm not aware of, which kick off out of the blue and therefore I experience the symptoms as purely physical. That still does not explain the mechanical trigger at will thing though.

The GP is going to take orthostatic vitals -- not sure what he's looking for.

I will follow your advice on distracting myself, which I successfully do, but then days pass and there's no improvement in the symptoms so I get sucked back in again. It is comforting to know that you don't think it can be AAA.
Answered by Dr. Raja Sekhar Varma 18 hours later

Thank you for the reply.

The most logical explanation for your symptoms would be an increased sympathetic drive; increased stress and anxiety; postural changes triggered by pressure over the (distended) abdomen; relative fixity of the diaphragm; accessory muscles of respiration and some physical deconditioning - all leading to an increase in the heart rate (minimal) and in the BP (probably systolic BP increasing more than diastolic BP); a widened pulse pressure or only a diastolic increase in BP leading to a narrow pulse pressure; a postural (or otherwise) change in the location of the apical impulse; increased inotropy with increased force of contraction of the heart - all leading to your symptoms.

Please note that, if you are hearing the heart beat in your ears, it could be a totally different condition known as pulsatile tinnitus. If so, you need evaluation for the various causes of pulsatile tinnitus.

I appreciate your excellent and earnest attempts at understanding and analyzing your symptoms. It is from this understanding and awareness that the best solution to your problem will arise.

It might help to up titrate the dosage of the long acting selective beta-blocker to twice a day. The sympathetic drive and the increased inotropy as also the increased heart rate/BP during stress may be better controlled that way.
Avoidance of the prone position can help.
All efforts should be taken to reduce stress. How about a vacation to India? It would be a pleasure to XXXXXXX you and perhaps, have a chance of examining you in detail. As of now, I am dependent only on your descriptions and am unable to clinically examine you (which is so necessary before confirming a diagnosis).

Hope this helps. I wish you all the best for a speedy recovery.

With regards,
Dr RS Varma
Above answer was peer-reviewed by
Follow-up: Stomach pulse with palpitations, back pain, high BP, no chest or abdominal pain. Worried about abdominal aortic aneurysm 1 hour later
Dr Varma -

Thank you again for your thoughtful reply. I certainly hope you are right and what you're describing is all it is. Unfortunately I will have to wait as long as 2 weeks to find out. In the meantime, I am noticing that simply getting my mind off my body and off this notion of AAA for a few hours makes a noticeable difference in the symptoms, and the palpitation (or my awareness of it) is not so constant. I will avoid the prone position till I have all the tests back, but the temptation is to check if there's improvement, and then get anxious when there isn't. I'd go so far as to say that it's possible the anticipation of palpitations when lying prone may be creating or exaggerating them through anxiety. At least I hope so.

I have in fact thought about visiting India several times recently. I've been all over North XXXXXXX Europe, and parts of Middle East but never to India. Having practiced vipassana meditation and pranayama breathing at different times in my life, I'm motivated to learn yoga at the source for personal development. At the same time, I have no illusions about some of the difficulties your country faces and how the "old culture" is being overrun by the "new culture" in many instances, so locating an authentic program one could pursue over the course of a vacation (7-10 days) is a challenge. I'm not looking for a "guru" or a Westernized yoga technology factory but a place where the authentic knowledge of ancient spiritual practices are not lost. Believe it or not, such places still exist in XXXXXXX today, but you'd have to really know where to find them.

In what part of India do you practice? If I did make that visit for a "spiritual retreat" to reduce stress and get centered, it may be feasible to see you. Also, I'm sure American insurance doesn't cover any medical expenses in India, so can you give me an idea of the dollar-based cost for an office visit, ultrasound/doppler, echo, Holter and similar tests?
Answered by Dr. Raja Sekhar Varma 22 hours later

Thank you for your reply.

I am sure that you are improving with respect to your symptoms. Yes, it does take some time to get control over the mind and the body. All factors have to be taken into account and treated accordingly.

What you have noted about Yoga is very true. You will definitely need to be selective when you choose the teacher and the place.

I am practicing at XXXXXXX Hospitals-DSI, Banashankari, Bangalore in the state of Karnataka, South India. Bangalore does offer ease of connectivity with the US and a pleasant climate during most parts of the year.
An office visit would be between $5 - $10; Ultrasound approximately $30, Echo $20 - 25, Holter $100 approx.

Do let me know if you plan a visit. Meanwhile, I wish you all the best in your endeavors.

Dr RS Varma
Above answer was peer-reviewed by
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