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Feeling skipped heartbeats. ECG and blood test done. Took phosphate and ativan. What's going on?

Answered by
Dr. Anantharamakrishnan


Practicing since :1966

Answered : 4506 Questions

Posted on Thu, 14 Feb 2013 in Heart Rate and Rhythm Disorders
Question: Hi, my name is XXXXXXX 38years and i would like some information on skipped heartbeats. On Dec 25 I had a couple of drinks and The next day I started feeling the skipped beats. 3or4 at a time, about 100that day. The week went on and they started fading away just as a old came on. The past 3 weeks have been without a lot of sleep and have been working out alot(hockey and phsical exercise. I felt these skipped beats while playing hockey which got me pretty nervous. Last saturday I started feeling the beats that we're out of control. Skipped beat followed by 2-3fast beats for about an hour. Went to the hospital and they did an ECG which was not normal and they did some blood work, which came back okay except i was low on 200 of phosphate(apparently 800 is normal). I was in the hospital for another 6 hours on a bed waiting four results and another ECG. While there, my heart rate went haywire in terms of abnormal rhythm. When they did the second ecg theybcaught the irregular beat 1skip,4beats in a row and then 1 skip,2beats. This went on for 6 hours. The doctor made it seem like my body was in shock(I think she mentioned low enzymes), possibly after over exerting myself with the exercise. I do not smoke or drink coffee and have cut down on alcohol since this thing started. Imam taking 2 phosphate pills and an Ativan pill that she suggested I take for a while. The erratic beats have come and gone in the past 3 days. I am supposed to have aholter monitor put on shortly and then go for another blood test and echocardiogram. I am still not sure what is going on. Any help would be appreciated. Thanks
Answered by Dr. Anantharamakrishnan 8 hours later
Hi friend,
Welcome to Health Care Magic

Irregular heart beats need to be DOCUMENTED by ElectroCardioGram (ECG / EKG).
YOU ARE IN GOOD HANDS and getting proper scientific approach.

Feeling of ‘dropping / skipping / missed’ beat points ECTOPIC beats.
A beat comes earlier than normal – this itself is not usually felt. The next beat is a bit delayed - longer time to recover form early extra beat – so heart fills more and the beat appears forcible – thud / lubb - - dubb - - lubb - - dubb - lubb - - - DUBB

Ectopic beats can arise from ventricle (lower chamber of the heart - Ventricular Ectopic; VPC) or Atrium (upper chamber - Atrial Ectopic; APC).
APCs are generally harmless. Even VPCs are often harmless – ‘benign’.
If they are frequent - more than 5 per hour, 2 or more beats coming consecutively – they should be investigated further.

     Anxiety / Alcohol / Tobacco (smoking, chewing) / Caffeine (too much coffee, cola) are common causes.
     Medicines may be responsible – like Phenylephrine, Pseudo-ephedrine used for ‘cold’ / Salbutamol, Salmeterol used for asthma and so on.
Illicit ‘drugs’ like Amphetamine are notorious to cause abnormal beats
     At times, abnormal nerve paths in the heart (bypass tracts) are responsible!
These beats are common and often may be normal.
Yet it is advisable to have it investigated.

A thorough history and physical examination is the first step -
ECG (Electrocardiogram / EKG) – Routine 12-lead – is part of clinical examination.
     HOLTER is done to analyse and plan for further management, if a routine ECG does not show, 24 to 48 hour ambulatory monitoring
     ECHOcardiogram is necessary to see the heart valves (Mitral Valve Prolapse) / heart muscle (Cardiomyopathy) and heart function (Ejection fraction, wall motion abnormality).
      TMT (Treadmill exercise ECG) is done to exclude Ischemia (reduced blood flow).
     LABORATORY work-up is routine - like blood counts, sugar, urea, electrolytes (potassium in particular), thyroid (over-active) and so on. Your Internist shall suggest based on the situation.
     If there are no clues and if the problem is still bothering to the extent of interfering with life style, there are more tests. These are advanced techniques of investigations of increasing complexity – Electro Physiological Studies (EPS) > it resembles angio – a catheter is put inside the heart / electrical activity recorded / stimulation and suppression tests are carried out / suitable medicine tested and so on. Though the test is the gold standard, it is INVASIVE and has a risk (though minimal) and is not generally done unless there are compelling indications. This super-speciality expert is called ELECTRO-PHYSIOLOGIST. The treating doctor may suggest them depending on need, based on his assessment of the situation.
     These ectopic beats are not always symptomatic.
The feeling depends on individual sensitivity – some do not feel them at all / some may feel every beat.
     Specific treatment may not always be necessary.
     The first line medicine is generally beta blockers, like Metoprolol – slow release and small dose. It will benefit both anxiety and missed beats. Your doctor will give proper prescription and follow up
     If they are not effective and if the problem is severe, several other classes of drugs are available – acting by different mechanisms - the specialist will decide tailored to your needs / they may have side effects and need follow up.
There are other advanced treatment modalities - like RF ablation, which could be done during EPS.

Rather a long treatise?

Relax. You are young; you sound intelligent – you stand an excellent chance of returning to normalcy.
Be positive – why fear the heart beats faster? The problem is only if it could not beat!
You are tolerating the rate well - means that you may not have any basic disease of the valve, muscle and so on.
Be in touch with your doctor - it is a question of time and you will be well.
Medicine is well advanced nowadays – management is possible for almost all situations...
Take care
Wishing speedy recovery
God bless
Good luck

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Anantharamakrishnan 9 hours later
Hey Dr,

Thanks for the reply.

Do these ectopic beats remain ectopic beats, or is this an arrythmia? I have taken it easy tha past couple of days and the Ativan seems to have helped me calm down and finally get some sleep. I have noticed less ectopic beats since Saturday. I have always lived with skipped heartbeats (occassional ones) in the past. After a night of drinking, the following day they are present ,especially at night. I know that I have to cutout the alcohol. The one thing that scares me is what I went through on Saturday, this was not just a skipped beat or 2. It was skipped beat followed by a pause and then 3-4 fastbeats. This repeated itself for about a 1/2 hour at my place and then i finally went to the hospital. The same thing happened at the doctor's office for the 6hours. They were able to see this on the electrocardiogram. The doctor was saying that my heart has veered off course slightly, sort of like taking a detour around a straight line. Skipped beats is one thing, but this thing is a bit more worrisome as I do not know how to stop it. Can this be stress or panic attacks, Christmas brings out a lot of things on different people. Can these phosphate pills regulate my heart rate? And is their any danger of exercising with this? Thanks Dr
Answered by Dr. Anantharamakrishnan 10 hours later

Arrhythmia means abnormal rhythm – ectopic beat is a form of arrhythmia

Anxiety is one of the causes and ativan helps.

Yes, you have to cut the alcohol.

When two beats come consecutively, it is called a couplet or bigeminy / three - trigeminy / more is tachycardia...

Phosphates pills are less likely to cause or regulate it.

Panic can be responsible.

Exercise has different effects in different people – in some, it can cause / in others, it can reduce the abnormal beats. TMT (Tread Mill Exercise ECG Test) will be necessary to know the change in a particular person.

     The gold standard for diagnosis is to undergo EPS (Electro Physiological Studies). It also can help to plan the treatment – decide the drug / treat by radio-frequency ablation, if an abnormal/bypass tract is mapped out.

All the best
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Anantharamakrishnan 1 hour later
Because I have already had 2 treadmill stress tests done in 2000 and 2007(both tests came out okay) the doctor only recommended the holter monitor for 24 hours and the echocardiogram. Not sure what she was thinking when she recommended the phosphate pills. I am normally a healthy person, but with christmas and the lack of sleep and the cold that I had for a week, I am sure this had something to do with it. I thought i was being smart by working out intensely every day up until this event happened to try and get rid of the cold, instead it put more pressure on my body. Weird though, when I was working out while a had this cold, I would almost not get any skipped beats. For the past couple of days i have taken a nice walk for an hour with my son to get some fresh air a bit. This seemed to have helped. I wanted to say thanks for your help on this. It is just tough to go through this with a 16 month and another one on the way in 8 months. Thanks doc
Answered by Dr. Anantharamakrishnan 17 minutes later

Treadmill is done to detect ischemiachest pain.
Holter is done for arrhythmia – missed beats.
ECHO is for valves, wall motion and pump function
Each investigation has different indications.

Stress complements, but we can not be complacent!
The general tendency is to associate the present event to the past – post hoc ergo propter hoc (after this therefore because of this). It is often true, but one should keep an open eye and not overlook the alternatives!

You are young.
You have a positive outlook.
You WILL be alright.
It is a question of time.

All the best
God bless you

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Anantharamakrishnan 4 days later
Hey Doc,

I just wanted to let you know that I have the test for the Holter in about 10 days and 3 days later I go for more bloodwork in the morning and later on that same afternoon, I go for the Echocardiogram, and then immediately after I see the Doctor. It seems since I last spoke to you that these Ectopic beats have subsided somewhat. I have another cold and have been taking Tylenol Daily Cold and Nyquil at Night in hoping that this will give me a good's night sleep. Instead of the Nyquil helping me sleep, it is having an adverse effect on me, as if it is keeping me agitated, like I have to move around in bed every 30 seconds. Maybe this thing is all in my head right now. I am having trouble getting a good night's sleep right now and am hoping that my 1/2 pill of Ativan will help. My body feels kind of numb after all this lack of sleep. I know that I am really anxious to get the Holter and Echocardiogran out of the way. I think once the Dr Verbally Says that everything is alright, my bady will get back to Normal. The only time the Ectopic beats seem to come back are when i do not get a good night's sleep, not sure if this makes sense or not. I just have to try and believe that if there was something seriously wrong, then I would be back in the hospital. I am trying to keep active, I played Hockey last week( no Ectopic beats), however I was thinking about them the whole day though. In your professional opinion, what pecentage of this is more Mental than Physical?

Thanks Doc
Answered by Dr. Anantharamakrishnan 1 hour later

Some ‘cold’ medicines contain decongestants like phenylephrine or pseudo-ephedrine – which could cause skipped beats.
Most of them also have anti-histamines, which could cause drowsiness.
Ativan is anxiolytic and helps, but may lead to habituation. Take care.
An abnormal nerve (Bypass tract) in the heart causing this is the least common of the causes. Anxiety is the most common cause and comprises more than half the outpatient visits.
Anxiety causes arrhythmia – arrhythmia causes anxiety and a vicious cycle sets in, perpetuating the symptoms...
If you could play a strenuous game like hockey, your heart, for sure, is good.
The symptoms do not sound serious, but looks like more of an inconvenience.
The Investigations are done more to rule out / they will clarify and re-assure.
Until then just ignore it / concentrate on work / have diversions /


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Anantharamakrishnan 2 days later
I think that after the holster and echocardiogram, it will come down to getting some sleep, cutting out the alcohol, and stop stressing. It is unreal how much power the mind has over the body. I have taken your advice and tried to stay busy for the pas while and it seems to have worked. After the holter and echonitnwill be time for some lifestyle changes. I have had these skipped beats on and off for the past 12 years, but never anything like when I had that attack for 6 hours a couple of Saturday's ago. I think my alcohol abuse in the past 4 years has caught up with me and this is a wake up call too cut the stuff out. Thanks for your help doc, I will try to keep you posted.
Answered by Dr. Anantharamakrishnan 1 hour later

Glad to hear the good news.
As you said rightly, the mind is the master.

It is a great decision to stop alcohol.
Motivation is the first step and you are on it.

Psychiatric consultation will help – it does not mean you have a ‘mental’ problem. They are the specialists – trained – in this field of Medicine.
Counselling, at times medicines, will go a long way.

Avoid friends and functions that involve drinking.
Seek the support of spouse. Mother, if there.
Community could also help – there are Alcoholics Anonymous (AA) – search for them (net) in your area and get into contact.

You are young and intelligent. You have a great future.

God bless you

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

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