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Worried about abdominal aortic aneurysm due to stomach pulse with palpitations, lower back pain and high BP

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Practicing since : 2001
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Hi there -

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 suspect left ventricular hyperthrophy, as it happens to athletes. 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 inclined 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, 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 interval or resistence 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. Apical impulse has been suggested as an explanation. I did lose a bunch of weight, so perhaps the location of the apical impulse has changed and the diastolic BP is letting me feel it. 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 Sat, 28 Apr 2012 in Hypertension and Heart Disease
Answered by Dr. Shiva Kumar R 54 minutes later

Thanks for the query.

From the description given to me it looks like you are only suffering from phobia and anxiety neurosis. I personally feel you do not have AAA (Abdominal Aortic Aneurysm). I do have explanation for the symptoms you are experiencing.

Regarding the stomach pulse, I feel probably weight loss in you has made the stomach pulsations more prominent in you. The mere presence of stomach pulsation does not indicate AAA.

Regarding the feeling of the vigorous heart beat on stomach, I feel nothing to do with the vagus nerve theory or the change of the position of the apical impulse. I feel it is probably related to the medication (Metoprolol) which decreases the heart rate and increases the force of contraction of the heart. Hence you feel it as a palpitation without any increase in the rate of the heart beat.

So I personally feel Ultrasound is not required as there is nothing to suggest AAA. Physiological parameters like HR (Heart Rate) and BP (Blood Pressure) can be changed voluntarily by altering the balance between the sympathetic and parasympathetic responses. You need to fix up an appointment with you psychiatrist for the treatment of anxiety neurosis and with clinical psychologist for relaxation exercises.

I hope this information has been both informative and helpful for you. In case of any doubt, I will be available for follow ups.

Wish you good health.


Dr Shiva Kumar R
Consultant Neurologist & Epileptologist
Above answer was peer-reviewed by
Follow-up: Worried about abdominal aortic aneurysm due to stomach pulse with palpitations, lower back pain and high BP 3 hours later
Hi there -

Thank you for your thoughtful reply. It is reassuring to know that you don't think it's AAA. I think I will get an ultrasound anyway b/c seeing is believing, and it's the most effective way to put down this health anxiety. However, due to doctors' schedules, it's going to be 2 weeks before I have the results. That is a long time to live with this kind of anxiety. So I'm looking to see if I can have some further reassurance and understanding based on science.

The beta blocker may be doing exactly what you said, or at least exaggerating it, because your heart cannot go through its normal stress response and beat faster, so it feels "harder". But these symptoms preceded taking the beta blocker by 2-3 weeks, so that theory cannot be entirely correct. It may be worse now due to the beta blocker, or more noticeable, but it started before I ever took the drug.

I know and agree that I need to deal w/ anxiety. I am 100% confident that I will succeed in that w/o benzos or SSRIs, just through a combination of CBT therapy, pranayama breathing and vipassana meditation (which I had practiced for years but have lapsed in recent years), and some practical major life changes to reduce chronic stress. I just need to have a "medical clearance" first.

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 we 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, blood clot, 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, 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?

Clarification: my heart _does_ beat faster when it palpitates. It's just not racing as I had previously thought. 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 again, b/c of how "hard" it seems to beat, almost as against some obstruction, and again, this precedes the beta blocker by few weeks. 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 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 when I have a certain thought or find myself in a certain situation, and pair the physical symptoms w/ it. I suppose it's possible that I have subconscious fears 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. Any ideas?

Also, should I suspect left ventricular hyperthrophy?

If you were in my position and wanted to do some investigative tests just to put the health anxiety to bed, as unlikely as the causes may be, which ones would you do? What's been done so far is lots of blood and urine, chest x-rays, ECG, and manual and stethoscope exams. Results all clean so far. No pheochromocytoma, no anemia, total cholesterol under 200, ECG looks good, no thyroid issues, chest x-rays all clean, liver, kidneys, electrolytes ok. Just some vitamin D and magnesium deficiency. I don't want to chase a phantom forever or develop hypochondria. I just want to look into possible organic causes for these particular physical symptoms that I experience, and if we can rule those out, then I know 100% it's all anxiety and its somatization, and then I can deal w/ the anxiety much more effectively.

Pls let me know your perspective and recommendations. Thanks again.
Answered by Dr. Shiva Kumar R 14 hours later
Hello and thanks for the query.

Regarding the orthostatic vitals it is to look for orthostatic fall of BP (Blood Pressure) and increase in the HR (Heart Rate) to look for the possibility of "Postural orthostatic tachycardia syndrome" and autonomic disturbances.

Regarding the Left ventricular hypertrophy (LVH), ECG (Electrocardiogram) and echo are sensitive enough to pick LVH. Normal ECG, rules out the possibility in you.

As most of the required tests are done and normal in you, I personally prefer not to investigate further except for USG (Ultrasound) of the abdomen which you can do to rule out the possibility of AAA (Abdominal Aortic Aneurysm). If palpitations persist, Holter monitoring and Tilt table test would be an option to look for cause of palpitations.

I hope this information has been both informative and helpful for you. In case of any doubt, I will be available for follow ups.

Wish you good health.


Dr Shiva Kumar R
Consultant Neurologist & Epileptologist
Above answer was peer-reviewed by
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