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Dr. Andrew Rynne

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Exp 50 years

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Suggest treatment for shortness of breath, tachycardia, bilateral arm pain and chest discomfort

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Dr. Ilir Sharka

Cardiologist

Practicing since :2001

Answered : 2381 Questions

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Posted on Tue, 4 Apr 2017 in Hypertension and Heart Disease
Question: I have been dealing with shortness of breath and tachycardia for over 2 years. I have had a million dollar workup and everything has come back relatively normal. About 2 weeks ago I developed intermittent bilateral arm pain, worse in the right arm and chest discomfort. I was placed in the hospital for 2 nights for observation. My EKGs were normal and my troponin was negative. They said that there was a fluctuation of my blood pressure and heart rate. My BP would range from 80s to 130 systolic. My heart rate would increase dramatically upon standing. I have been telling my doctors all along that my symptoms only occur when I am upright. I immediately feel better when lying down. They discharged me saying I had atypical chest pain and they started me on diltiazem 30mg twice daily for what they said might be coronary spasms that caused the chest pain. and orthostatic hypotension. However, they never even checked my BP lying, sitting and standing. I assume that they saw I had low BP when lying and a high HR when standing and just gave me that diagnosis. I have done orthostatic BP at home and my BP increases with standing as does my heart rate. Whenever I go to the doctor and they take my vitals when I get there, they check my pulse when I walk back to the room and it is high, so they wait a few minutes after me sitting and check it again and it is normal. Then they chart the lower number. I am wondering if this fits with a "POTS" diagnosis. I never had a tilt table test, but I am not sure if I need to pay for one more test. I have been telling doctors over the past year that everything is better when I lay down. I see my cardiologist at the end of the week, but my concern is, will this diltiazem slow down my heart rate to the point that they won't be able to see how fast it goes up when standing?
doctor
Answered by Dr. Ilir Sharka 1 hour later
Brief Answer:
I would recommend as follows:

Detailed Answer:
Hello!

Welcome and thank you for asking on HCM!

I passed carefully through your question and would explain that your symptoms are suggestive of POTS (except for the chest pain, which is not typical of this disorder).

You should know that POTS is characterized by a raise in the heart rate more than 30bpm when standing up compared to sitting or lying position.

Nevertheless a Head Up Tilt test is necessary to rule in/out the diagnosis of POTS.

I would also recommend performing some blood lab tests (complete blood count for anemia, thyroid hormone levels for thyroid dysfunction, blood electrolytes for possible imbalance and PCR, ESR for inflammation).

Regarding Diltiazem, although it is in a low dose, it can mask your symptoms. That is why I would recommend stopping it 48 hours before physical check up or Head Up Tilt test.

Considering your chest and arm pain, I would also recommend performing a cervical spine X Ray study to exclude possible chronic degeneration of the intervertebral disks, which may lead to irradiating radicular pain in this region.

What about pulmonary function tests? A lung disorder could also cause similar symptoms. I would recommend performing also these tests if all the above tests result normal.

I know that it is difficult and expensive for you, but sometimes medical disorders are really complicated and many tests are needed to find the possible underlying causes.

Hope you will find this answer helpful!

Feel free to ask me again whenever you need!

Kind regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Ilir Sharka 16 minutes later
Can POTS cause shortness of breath? A weird thing I have noticed is when I am upright or doing certain activities I take these deep breaths. I don't hyperventilate I just take deep breaths. It is not something I am conscious of, it just happens. My question is, does this help with venous return? I know that with POTS a lot of it has to do with the blood flow and I know deep breaths help with that. So I wondered if that was a compensatory mechanism. I had pulmonary function tests and they were normal. Also My symptoms get worse when I do activities with my arms, like lifting or carrying things, and I have a lot of difficulty doing activities with my arms above my head. For instance I was trying to paint my bathroom, and my symptoms were so intense I had to go lay down. It also happens if I am bending over to get something from a shelf or picking stuff up. Would this be related to POTS?
doctor
Answered by Dr. Ilir Sharka 2 hours later
Brief Answer:
I would explain as follows:

Detailed Answer:
Hello again!

Thank you for the additional information!

In fact these symptoms are not typical of POTS: it does not cause shortness of breath, but palpitations.

Besides the fact that your symptoms are worse when you work with your arms, could be related to a cervical spine disorder (like a bulging disc compressing the root of the nerves) or thoracic outlet syndrome.

Coming to this point, I would recommend performing a cervical spine X ray study. to exclude this possibility .

Anyway, a Head Up Tilt testis also necessary to exclude POTS, because this diagnosis is not based just on the clinical symptoms. This test is needed to definitely rule in/out this disorder.

Hope you will find this answer helpful!

Wishing all the best,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 2 hours later
With POTS does someones heart rate drop quickly when lying down? Because when I am lying my heart rate is 60-70s and then when I stand it will go up 100+. However, when I lay back down it quickly goes down again. This happens all the time. The one doctor said it was odd how quickly my heart rate goes up and how quickly it recovers when I lay down.

Wouldn't calcium channel blockers be bad for someone with POTS? I didn't feel good when I first took them, but when I took salt tablets and increased fluid with them I felt a lot better. However I have only been taking them for 5 days
doctor
Answered by Dr. Ilir Sharka 14 hours later
Brief Answer:
I would explain as follows:

Detailed Answer:
Hello again!

I agree with your doctor on the fact that your symptoms are not very typical of postural tachycardia.

But the fact that your heart rate raises more than 30bpm in standing up position compared to lying position, raises high suspicions on this disorder.

A Head Up Tilt test is needed in this case to rule in/out this disorder.

Regarding calcium channnel blockers in many cases they have been known to exacerbate the situation, but in some cases they have also helped to reduce the tachycardia related to the change in position.

For this reason, I would recommend stopping Diltiazem 48 hours before the Head Up Tilt test to avoid possible interference with the test results.

Hope to have been helpful!

Wishing all the best,

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