Hello Dr. Gopi-

I am a 40 y/o Caucasian male. 6'-4" and 200 lbs with a BMI of 24.5. Resting HR of about 62 bpm, BP of 118/72. Never smoke/drink/do drugs. I have been a swimmer, scuba diver, and volleyball player for years. My mother is 60 and hypertensive; my father is 58 and had a triple angioplasty at 47. Both of my parents live very stressful, sedentary lifestyles, are overweight, and have a history of poor health choices (poor diets, exercise, smoking, etc). None of my grandparents had a history of heart problems (living into their mid-80's or later...I'm suggesting environment not genetics).

Over the past 10 years I have had an extremely high level of anxiety (spouse blindness, lawsuits, self-employment, foreclosure, bankruptcy, etc). About 4 years ago I began having panic attacks off and on for a span of several months. For the past 2 years I have had palpitations in my chest that I am consciously aware of (to me, they seemed to occur around 5 times a day). They seem worse when I feel any anxiety-especially when I consciously think about the palpitations...it is as if they scare me into having more of them. When I was routinely exercising on the ellipticals at the YMCA, as recently as a year ago, it seemed that I had a lower number of these palpitations that I was consciously aware of. Two FP (family practice) doctors dismissed them as a benign, transient irregular heartbeat, presumed congenital or caffeine induced. A third doctor sent had me wear a 24-hour Holter monitor.

The Holter monitor showed a 5-beat V-Tach (5 beats at a .10 sec interval). The timing seemed to correspond with the time I awoke to a brand-new alarm clock that my wife had purchased. The new alarm literally woke me with a jump. (I can't guarantee that the times were identical, but they were notably close). The Holter monitor also showed a number of transient PVC's. I should note that for the time I wore the monitor, I basically sat around the house or slept, as I didn't want to cause any problems with the test (and felt reasonably limited wearing the monitor and leads). I didn't feel any real undue anxiety, but was consciously aware of 4 PVC's during the test. (I am waiting for the report to show how many I actually had).

The doctor called me on a Sunday morning with the news of the V-Tach and told me to get to the ER at the U/T Medical Center asap as this was potentially life threatening. (I had worn the Holter from 3 pm Friday to noon or so on Saturday).

At the ER, they took a blood sample (Troponin 0.00%), 2 chest xrays (negative), normal potassium, normal magnesium, normal T3 & T4...basically ruled out metabolic causes, infection, or other disease state. I was on a 12-lead EKG for about 7 1/2 hours. Although I felt somewhere around 300 (or more) PVC's, the EKG did not register a V-Tach event. 4 doctors told me I would probably need an ICD and that the V-Tachs could kill me. The cardiologist finally came in and told me that he thought this was probably benign and wanted to run more tests as an outpatient, and promptly discharged me from the hospital.

2 days later, I took an echo and a treadmill stress test. During the echo, the technician saw what she believed to be a very slight mitral valve prolapse (MVP)...the test also showed some regurgitation. She thought both were so minor that she wasn't sure if the cardiologist would even call it MVP w/regurg. There was no sign of myopathy-all measurements looked to be in range. I also took the stress test. It took 9 1/2 minutes of exercise (increasing incline and pace at 3 minute intervals) to get my BP and HR where they wanted them to be. I stayed on the machine until 10.25 minutes had passed and the tech was satisfied. (I felt entirely capable of going another 10 minutes, but I had already reached their target rates and I was starting to sweat a bit and breathe heavier...not Heavy, just heavier than normal breathing). The test registered 4 couplets and a 3 beat V-Tach near the end of the test. I should note here that my anxiety was also high during the test, as I knew fully why I was being tested and felt grave concern when I was the youngest person in the waiting room by probably 20-25 years.

I was placed on 25 mg of Metoprolol XR and 81 mg of children's aspirin per day. (I should note that my cholesterol 2 1/2 yrs ago was 157, LDL was 56 and HDL was 39. I have also used one 14-day course of OTC Prevacid for Reflux in each of the past 2 years, and drink less than 4 cups of coffee/Pepsi per week...typically I drink skim milk or water...I've had no caffeinated drinks in a week now).

The 1st day in the ER, I felt in excess of 300 PVC's. The EKG alarm kept going off for the PVCs, and every time it went off, my anxiety shot up and I would have several more (I'm having a few now as I write about this!)...they were worst when I first received the phone call telling me to go right to the ER, and again when I was first told that I would probably need an ICD...The next 2 days the number of PVCs was under 100, and then for 3 days it was below 50. Today (day 6), I would put that number at closer to 20. I don't know if the medication is doing anything, since I am still well above the number I normally am aware of in a day, but my anxiety about this situation is pretty high.

The cardiologist called and wants to do an angiogram and place stents immediately if he finds any blockages. He also wants to take all of those results and send them on to an electrophysiologist to see if I am a candidate for an ICD, RF ablation, or medicinal therapy.

A friend, who is an FP, thought it would be best to raise my dose of Metoprolol a bit (to 50 mg), add a low dose of Prozac to keep my anxiety down, and keep me on the aspirin as well. He also thinks they should do a "calcium scoring" test and an HsCRP (High sensitivity CRP), along with a Lipomed to evaluate the liklihood of my having a blockage without doing an angiogram at this point. His point was that he thought it better that if the other tests were negative, they should treat me with the meds for a good 4-6 months and then re-test/re-evaluate at that time before running off and doing an angiogram now. He does think that this entire situation is probably much ado about nothing, and could potentially self-resolve with proper medicinal treatment and good diet and exercise habits.

The FP I am currently seeing (I just relocated to another state, 650 miles from home), as well as the cardiologist, both want me to get the angiogram and stenting as necessary.

I am very conflicted and frankly, scared. I certainly want to do what is best. There are possible complications with an angiogram. The 10-year mortality for patients receiving a stent seems to run about 33%....a very big number in my opinion.

So I want to know:

1) Do the V-Tachs I've described seem terrible? (One of my professors is an FP and he cited a study done in Philadelphia where they strapped Holter monitors on med students for 48 hrs and found that over 80% of them had a minimum of a 4 beat V-tach in that time frame. Another FP professor suggested that if you put Holter monitors on our entire class of med students before an exam, that at least 1/3 would register V-Tachs.

2) Can anxiety induce PVC's and V-Tachs?

3) Does a medicinal approach with follow up testing seem prudent at this point?

4) Is an angiogram necessary or wise at this point?...

5) If they do an angiogram, can I/should I insist that they do not place any stents?

6) Can you comment on life expectency for stent recipients?

7) Do the calcium scoring and HsCRP tests have diagnostic merit over an angiogram given my other history, signs, and symptoms?

8) If those alternate tests look good, is it fair to skip the angiogram and move on to an electrophysiologist for EP testing and possible RF ablation?

9) Can you comment on the efficacy of RF ablation relative to V-Tachs and PVCs?

10) Can you comment on life expectancy if an ICD is necessary?

11) If an ICD isn't necessary at this time, are there diagnostic criteria I need to be aware of and watching to know when I am at a level of substantially elevated risk?

12) Is there any reasonable chance that the combination of medicinal treatment and (possibly) RF ablation may either eliminate the V-Tachs and PVCs or at least be a successful means of postponing an ICD for another 5-10 years?

13) I saw a presentation by a researcher from UW-Madison that indicated they were having some success regrowing cardiac tissue in MI patients from stem cells that were being taken from the patient themselves. Is this a potential future cure for V-Tachs (say, within the next 10-20 years)?

14) Is there a chance that years of anxiety has allowed for some level of heart remodeling that makes me more suscptible to an epinephrine surge, and if so is there any chance to undo that change?

15) I am on state-sponsored health care insurance. Do you have any idea what "level" or type of ICD they would allow? I understande there are a number of different types. To that end, is there a brand/model you would recommend and why?

16) If I were your patient, how would you advise me to proceed?



Thank-you in advance for your time and consideration. I greatly appreciate your insight as an objective expert.