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Fast heart rate, chest discomfort. Had some episode of arrhythmia. Is it anxiety attack?

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Practicing since : 1966
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Dr. Ramakrishnan:

Its me again.. XXXXXXX from Toronto. Since closing the discusion with you a few days back...I have had a couple of episodes of some type of arryhthmia lasting approximately 15-20 minutes each time. The heart rate felt fast and irregular..tightening/sharp chest discomfort. The first one happened as i was about to do to sleep around 11:30pm last Thursday....the second one happed yesterday around 1:30am. Previously I had gone to the cardilologists office to pick up an event monitor on Friday around 2pm. He had advised me previously.... to do so if anything new happens. The second event is recorded and I hope to see the results sometime soon after the device is taken back on Monday. Again the usual staff happens (SpO2 numbers drop down below 90%) when I use the SpO2 alarm to wake me up if numbers go below 90%. I am using at 3 pillows to sleep upright because its easier to breath. Even when awake...its difficult lying in supine/left side/right side positions...upright makes breathing better. Based on this information....can this still be something other than Congestive Heart Failure? The ambulance paramedics saw the SpO2 numbers drop down during the ride to the hospital in their monitor an commented something like..."there is something physiological going on here...its not a case of simple anxiety panic"..By the time I was checked in the emergency all had was normal I was sent home. I did not go the hospital after the second event..becuase I felt that i would waste my time once more...the paramedics came again...they looked at the dropping SpO2 numbers when lying flat...and they said that is was good that finally something was recorded.....any advice would be greatly appreciated and your opionion(s) highly regarded. If it is CHF..can these arrhythamias be fatal? with CHF....can fluid build around/side of waste when lyinng in supine postion...say for 30-60 minutes...and drain back to normal slowly as one resumes walking/standing? Or the fluid build in CHF cases remains steady in various locations of the body, accumulating over time?

Looking forward to your response.
Posted Thu, 8 Nov 2012 in Hypertension and Heart Disease
Answered by Dr. Anantharamakrishnan 4 hours later

Good evening

I am writing the following mostly in the form of answers to your queries. I have added additional information at places.

The venous return increases when we lie down. When upright, it has to climb against gravity. The right heart pumps it to the lungs and on to the left. If the left heart has problem pumping out, it stays back in the lungs – pulmonary oedema. It causes breathlessness – orthopnoea. Once upright, the return is reduced; the backlog is cleared; breathlessness disappears. "The fluid is shifted out of lungs – not out of the body". That is how diuretics (like furosemide) help. Turning to sides obviously will not help.

Other conditions that cause this are few and uncommon – abdominal distension from any cause, paralysed diaphragm, huge hiatus hernia, bronchial asthma at times, morbid obesity... and they are easy to diagnose.

Chronic Heart Failure (CHF) can cause hypoxia; Hypoxia can cause CHF – it is a vicious cycle.

The seriousness of arrhythmia depends on the nature – a majority of them may not harm. Ventricular fibrillation (VF) is often fatal; Ventricular tachycardia (VT) is the next most XXXXXXX one. If they are documented by Holter, an implantable defibrillator (with or without pace maker) affords relief.

Atrial arrhythmias do not generally cause heart failure. Ventricular arrhythmias like VT need immediate attention. Prolonged arrhythmias can lead to failure and failure can lead to arrhythmia – both can be the result of a common cause

24 to 48 hours ambulatory monitoring (Holter) should have documented the arrhythmia.
Approved sleep laboratory can document ECG, EEG, saturation and so on

At last your low SpO2 has been documented – long known to the patient, but not believed by the physician! The dictum in Medicine is this - Absence of proof is no proof of absence.
Patient knows himself - not his physician; not always...

I am afraid it is rather long!

I shall sum up thus -
1. We need a diagnostic plan - admission to a multi-specialty tertiary care hospital and investigation will clear the issue. Heart and lung specialists can join hands for proper assessment with a view for future assistance. Emergency departments cannot provide a comprehensive answer. They are trained to only to deal with emergency.

2. We need a treatment plan – why suffer because diagnosis is delayed?
*Non-invasive breathing assistance from BiPAP machine at home may give dramatic relief.
* A trial of failure treatment – like diuretics like furosemide and Angiotension Converting Enzyme (ACE) inhibitor or Angiotension Receptor blockers (ARB) is an option...

I hope I have been of some use! Do write back for further assistance.

God bless you and Good luck...
Above answer was peer-reviewed by
Follow-up: Fast heart rate, chest discomfort. Had some episode of arrhythmia. Is it anxiety attack? 18 hours later
Dr. Ramakrishnan:

Just got back from cardiologist. Upon viewing the recording from the event monitor...he said that the sinus rhythm was normal although the heart rate was fast.
He does not think its a heart issue....I mentioned the dropping SpO2 numbers in the supine position....he asked me to assume the supine position on a table....i ramained in this position and the SpO2 dropped as low as 92% within ten minutes....he said this was mysteriously unusual and could not provide an explanation. He refered me to another doctor who specailizes in sleep studies specifically related to anxiety disorders. So in about a month I intend to go through this study. He also mentioned about the possibility of a hole in the heart...and perhaps tp test for this later on.

Have you ever heard of any cases in your professional practice or otherewise where anxiety/panic disorder cause SpO2 values to drop all the way down to 90% when someone is lying down on their bed awake?... let alone when they fall asleep. Do you know any sleep experts that may be able to shed some light regarding this issue?(I dont mind paying a fee to get an opinion)

I will definately look into the other possibilities that you mentioned. The strange thing is that it feels my heart rate slows down as I fall asleep and it almost feels like it stops once I am sleeping? The only thing I can do for now is set the SpO2 alarm to wake me up as soon as it reaches 90%...

I wish I could follow your logical appraoch to getting tested. That be admitted in hospital on order to be seen by various specialties. Unfotunately here in Toronto, Canada....unless someone is close to death....admission is not that easy....although i think in my makes perfect sense.

I hope I will get to the bottom of this health issue very soon.

Thank you, XXXXXXX
Answered by Dr. Anantharamakrishnan 1 hour later

Fluctuations in heart rate are common and often are normal. They are of concern, at certain levels...

I have not seen anxiety alone causing such a fall in SpO2. Hyperventilation causing CO2 wash out leading to alkalosis and tetany is the common presentation.
[If you won’t mistake, shall I say (off the mark) humorous view? to lighten the situation – Such uncommon situations stimulate the treating doctor to work out hard on the problem and that is how a new entity is often found; they name it after the patient or his doctor!]

That the monitor documented a normal sinus rhythm is good news and reassuring. No cause for concern.

Glad to hear that sleep studies are planned. The doctor has seen the problem – seeing is believing.
Things are moving in the right direction; soon your problems will find a solution.

Hope this is reassuring.
If you have no further follow up, please close this discussion.

If you wish to contact me again for future concerns, I will be available on WWW.WWWW.WW You can leave your queries there....

God bless you...

Good luck
Above answer was peer-reviewed by
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