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Suggest treatment for anxiety disorder and POTS

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General & Family Physician
Practicing since : 2005
Answered : 2408 Questions
At the age of 21 (summer 2001), as I was ending my seventh or eight consecutive streetball game (three on three) for the day and preparing to cool down, I suddenly felt an unbearable tachycardia, irregular palpitations that resembled a horse run, followed by an instant cold/warm sweat on my forehead, nausea that spread upwards from my lower abdomen, intense trembling in both my arms and finger tips, a feeling that my legs had been cut from knees to heals, and what was most scary, a severe dyspnea that lasted for days and weeks afterwards at a different level of intensity and made me go to the ER once. Prior to that infamous day, during a ten-year period of semi-professional basketball career, I had had no symptoms at all, except a few of times separated by multiannual intervals (at the age of 12, and then 17-18) when I had experienced some warning signs such as a sudden dyspnea on/after exertion (weigh-lifting) or while in a steam room/hot tab/hot weather, and a sharp, thunder-like chest pain at rest lasting for a second or less. Nonetheless, that hot summer day was "special" - 41 degrees Celsius in a shadow, around 18:00 hours, with me having had an extreme lack of sleep for almost the entire summer because of my intense social life and night-time partying (no active smoking, no drugs, just less than moderate amounts of alcohol, mostly beer). I immediately left the playground and rushed to a private specialist for internal medicine since he was at that time the only one in possession of a 3D Doppler Echo in our small town in eastern Macedonia . That same day I was diagnosed for the first time in my life with MVP, namely a "discreet" [I assume this means mild] prolapse of the left mitral cusp" and a "particularly mobile/dynamic function of the valve apparatus." Although this seemed to be the right diagnosis of my problem, perhaps congenital and never looked into seriously, this doctor bluntly dismissed the seriousness of this "heart condition" (rather than decease) affecting, according to his words, "from 5 to 20%" of the general population." He also told me to calm down, relax a bit, "since many athletes have the same with no serious implications," and gave me some beta blockers that only made my "anxiety" condition worse in the next couple of months. As I would later learn, this downplaying attitude towards MVP is upheld by most of the physicians in the world, particularly those who have been closely involved in my case. In the early days, some cardiologists even recommended that I continue with my strenuous exercise tempo and visit a good psychologist or psychiatrist. Of course, twelve years have past since then and whatever I have done I have only struggled to overcome my nasty symptoms that seem to have become more frequent lately, albeit not more intense. Over the past decade, I was also diagnosed (ECG, 2002-3) with "a right bundle branch block" (recommended diazepam and asked if I do steroids though I deliberately avoid even antibiotics when I am sick), as well as with a sliding hiatus hernia and GERD (2008-9, this is something that I know I have had since teenage years). I have deliberately avoided taking any drugs (diazepam, amoxicillin) and I still do that in line with my principles. In the last two years, (I have been residing in Canada since 2009), however, I have had to call 911 twice as a result of intense MVP/heart attack symptoms that began occurring at rest. I cannot identify a strict pattern of symptoms at rest, although I am certain they are triggered and made more intense by a considerable lack of sleep (sometimes I sleep only 4 hours a day and, since recently, I have also done some night shifts), excessive sugar and fat consumption (e.g. chocolates which I am addicted to), excessive single meals, even a mild dose of alcohol etc. Both times I was recently taken to the emergency room I underwent a longer-than-usual ECG tests but the latter showed nothing but sinus tachycardia (about 120 bpm) and "anxiety." Last weak, the night after I did a couple of strenuous night shifts for the first time in my life, I had guests in my house. As I was preparing food for them, I suddenly felt a sharp, radiating chest pain for a seconds or two, followed by a sense of fear and panic, the well-known sweating on the forehead, trembling, terrible weakness, slower speech, and breathlessness. I was on the edge of calling 911 once again but instead I did what I usually do in this situation: I immediately went out of the house to feel the cold and take a fresh breath for a minute, and I then drank a big glass of natural, home-made lemon juice with honey. This condition is usually preceded and accompanied by a more intense discomfort In the upper back, above and around my left shoulder blade. On the other hand, I cannot strictly relate this discomfort to a cardiac condition, since it has also been muscle-related, occurring ever since my basketball days, especially after exertion, strenuous heavy lifting exercises, prolonged sitting, uneasy sleep, or sleepless nights. Luckily, I am able to describe a recurring patter of symptoms, often involving a near syncope, in the immediate cool down phase of almost every demanding physical exercise that I do (basketball, swimming, heavy lifting). And this pattern has been constant since the very beginning in 2001. This pattern goes as follows: it starts with sudden sensation of nausea radiating from my lower abdomen upwards and has never involved any kind of chest pain on exertion (sharp, burning, heaviness), It is then followed by instant (feeling of) sweating on my forehead, trembling, tachycardia, often including palpitations/extra-systoles, and all that resulting in a progressive dyspnea and a feeling of airflow blockade somewhere around the plexus and diaphragm (I literally gasp for air), fullness in my entiire thorax and throat, consequent lightheadedness, sometimes blurred (once grey) vision and a near-fainting. This condition is triggered by either one basketball game one on one or three on three, or more intense jogging for about a mile (3 laps around a soccer field), or swimming about 10 laps in a 25m-long pool, or moderate weight-lifting for 15 minutes. It is always triggered by more "strenuous" exertion, the latter being nothing, zero effort compared to the three-times-a-day practice during my basketball career. And the awful feeling lasts until I sit, calm down, lay down horizontally, and decrease a bit my heart rate which nonetheless remains at a higher-than-normal level hours after the practice. As for the "activation" part regarding the pattern, as if there is a "red line" and when I cross it the pattern starts making me feel I am done for this life. Weirdly, the red line is sometimes higher, sometimes lower., very much depending on my mood and previous rest. Sometimes I get these consecutive symptoms after only a 200m run or just 4 laps in the pool, yet sometimes I have to "overexert" myself with one-mile jogging or 10 laps in the pool before the symptoms start menacing my positive spirit. The major problem now is that after all these complementary diagnoses and continuing problems affecting the quality of my life and sports activities, my Canadian/Manitoban doctors have found nothing wrong with my heart. They say that cannot see any MVP, nor even mild, that I have no structural issues with my heart. They not only deny the original Macedonian diagnosis but also cleared me, verbally suggesting that, so far as they are concerned, I can get involved in professional sports:). In 2013 I have made all the normal, non-invasive tests known to mankind, namely ECG, stress test, 24h holter monitor, and echo cardio (which should logically be a more sophisticated instrument than the one that originally discovered MVP in 2001). they only found sinus tachycardia (my family MD in Manitoba initially suspected atrial fibrillation) and "anxiety disorder" and POTS (postural orthostatic tachycardia syndrome). Please advise. Despite the fact that these problems have began occurring at rest and continue to prevent me from weight-lifting and playing the game of basketball which I love, my MD is currently unwilling to continue with any tests suggesting that I take some pills to calm down.
Posted Tue, 25 Feb 2014 in Hypertension and Heart Disease
Answered by Dr. Shanthi.E 16 hours later
Brief Answer: get 3D TEE done Detailed Answer: Hello, Thank you for the elaborate description. I understand your concerns and worries. You are a young 34yrs old, physically active chap with no major health issues. You must be glad about this. I am sorry but I do not see there is any XXXXXXX MVP in you. Reviewing your history again and again, and also considering the fact that all the non-invasive tests in 2013 came negative for MVP, you must RELAX now. Even if at all, a trivial or mild MVP does exists in you, that the investigations could not detect, let it be alone. Mild MVP do not cause any harm to normal routine life. It is not mandatory to detect and treat all cases of MVP. Hence, I request you to please relax on this front. You have been lucky so far that every time you face such issue, you were able to get back to life quickly. And, I am sure you would remain in good health for long years. Conventional 2D Echo is no more the investigation of choice for MVP, a better version is 3D Transesophageal echocardiography (TEE) that could better study the mitral valve. You may want to get this done. I must tell you this; most patients of MVP will have autonomic dysfunction. This can manifest as Anxiety, Panic attacks, Arrhythmias, Exercise intolerance, Palpitations, Atypical chest pain, Fatigue, Orthostasis, Syncope or presyncope, Neuropsychiatric symptoms. Therefore, it is obvious that you are experiencing this too, and it is expected. Coming to your major problem - Your Canadian/Manitoban doctors have found nothing wrong with your heart. A doctor cannot make a diagnosis if there is no sufficient clinical or radiological data supporting the same. It would be medically unethical to diagnose without strong evidence of the same. If you still want to disprove the doctor, request for 3D TEE as suggested. You can get involved in professional sports, even in my view. I would suggest you to avoid weight lifting - prevention is better than cure. I understand that you love playing basketball. You can do so at your comfort. When you can, you must play. When you are in discomfort, do not play. After all, it is YOU who knows your body better than anyone else. So, you can set your body clock accordingly. You have come this long; I do not think any major, serious or XXXXXXX heart condition including MVP can do any harm to your life. You must let go of this, and enjoy your life and also the basketball. Life is short; do not waste it by thinking on unnecessary and unwanted things. In my view, you also do not require to take pills to calm down. You are fine, in perfect health. Embrace your good health and move on. This is my broad overview of what is happening to you. Please feel free to write back. I would be more than glad to discuss further with you. P.S.: I would like to see how you look, if there are any physical signs of MVP. If possible, please upload a complete picture of yours. Thank you!
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