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Worried about abdominal aortic aneurysm. Have stomach pulse with palpitations, back pain and high BP

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General & Family Physician
Practicing since : 2009
Answered : 674 Questions
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 it has changed and the diastolic bloor pressure it 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 Thu, 26 Apr 2012 in Hypertension and Heart Disease
Answered by Dr. Yogesh D 8 hours later

Thank you for posting your query.

I understand your concern and greatly appreciate your rather elaborate description of your symptoms.

I would like to answer your primary concern at the beginning itself so that you do not get confused by the following explanations.


Now, I would like to point out a few things you yourself have described in such detail so that you understand yourself better.

1. You are a healthy adult male who has been doing a regular exercise routine.
2. You currently can withstand a rigorous physical activity without any features of breathlessness or signs of heart related symptoms.
3. You have recently been diagnosed to have anxiety.
4. You do not have any risk factors to develop a cardiac disease excepting may be alcohol consumption in moderate amounts once in a while(Assuming).
5. You have never had similar complaints in the past.
6. You have undergone a battery of tests during your last visit to the ER and were told by your doctors that all your reports were fine.
7. You are worried about the hard beating of your heart when you change position, like laying on your abdomen, sitting up, rolling over to the sides and so on.

After carefully going through your description, I am convinced that the reason for your recent experiences is a very benign and simple one.



Explanations for the above statement.

1. Laying on the stomach or on sides :- Laying on stomach and on sides does cause your heart to beat harder, and is a normal phenomenon.

When you change your position from laying facing upwards to laying on abdomen, the blood in the dependent parts of the lungs(the part of the lung that was towards the ground) goes up, and the blood present in these parts starts pouring into the heart more rapidly, causing a sudden increase in the force of contraction leading to very well appreciable heart beat.

This happens with all of us, but we generally do not notice this because this has been happening in us since we were born.

But once we start noticing it due to any reason (In your case, the anxiety-which resulted in you visiting the ER and starting to worry about your heart, make you extra aware of the normal happenings) it becomes very easy to notice them again and again.

2. Any sort of physical activity that increases the venous return to the heart or increases the resistance to the pumping action of the heart (In your case tightening the belt, causes a temporary increase in the resistance to the flow of blood from the left ventricle of the heart into the aorta) will cause the heart to pump harder.

More the resistance, more will be the work done, hence better the appreciation. And once you are sensitized to notice such changes(that happened due to your visit to ER) you will tend to notice it often. If you were not to be sensitized this way, you hardly would have noticed this.

3. Eating on empty stomach or eating fast is also known to cause an increase in the cardiac output. The probable reason for this is, an increased abdominal pressure leading to both an increase in the venous return as well as some amount of obstruction.

4. Forcing XXXXXXX breaths around 4 per minute will also cause a very significant increase in the venous return to the heart. The negative intra-thoracic pressure created while doing this kind of breathing definitely cause more blood to be sucked into the thoracic cavity and subsequently into the heart, there by increasing the cardiac output. This increased cardiac output is achieved by a forceful contraction of the heart. And this forceful contraction is what is felt as a palpitation and this also causes an increase in the heart rate.

5. When you are pressing below the solar plexus, you are directly pressing on the abdominal aorta, so there is an increased resistance leading to forceful contractions.

Even though you feel you are producing these at your will, in fact this is a reflex mechanism which happens due to certain postural and physical changes. And this is very much normal.

If you still want to confirm that you do not have an abdominal aortic aneurysm, you can go ahead with an ultrasound examination/Doppler/2D Echo of the abdominal aorta.

I suggest you talk to your psychiatrist or your psychologist to help you deal with the situation. I am saying this because I can see how worried you are because of the issue.

Hope I have addressed all your concerns. Please revert back if you have additional queries or doubts, I would be glad to help you further.

Please do accept this answer if you have no additional concerns at this time.

Wishing you a happy and worry free life.

Above answer was peer-reviewed by
Follow-up: Worried about abdominal aortic aneurysm. Have stomach pulse with palpitations, back pain and high BP 33 minutes later
Hi there -

Thank you very much for the detailed reply.

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 are conditioned to act as if it is, or expect it to be. So the fact that no one can tell me for sure (so far) 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 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, pranayama 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?

Thanks for starting out w/ the AAA, b/c that's the big nightmare scenario. I will get an ultrasound, b/c seeing is believing and the overall/generalized anxiety focused in on this health anxiety recently and I need to relieve it. I'm not going to get hypochondria -- just want to rule out ominous causes for the actual physical symptoms I'm experiencing that are not known to be part of a panic attack. I'm not worried about panic attacks - I know they're medically harmless. I'm only worried about the symptoms that I described that are not consistent w/ a panic attack and mechanically reproducable. Once that's cleared, hopefully, I will move on and deal w/ the anxiety. CBT therapy, meditation, etc. I'm 100% confident it will work.

But due to doctors' schedules, it will be 2 weeks before I know the results of an ultrasound. 2 weeks is a long time to be in this state of extreme anxiety, so any further reassurance you may be able to offer would be greatly appreciated. Is AAA rare in general? How many people who are only 40 and otherwise healthy get it? My only risk factor appears to be high BP, which probably was the case for the last few years. And I used to be a weight lifter many years ago. V. heavy isometric weights, but haven't done so in many years. Again, turned vegan and lost a whole bunch of weight, but there's some distended abdomen so that's the last to go. I was thinking that there may be abdominal sensitivity and/or some kind of vagus nerve phenomenon simply due to the weight loss as well.

You did provide specific explanations re: all the "mechanical" ways in which I can produce the symptoms. To be sure, this is not like "phantom pain", i.e. a strictly "emotional interpreter" phenomenon. The heart rate does go up -- though only from a resting low 60s to 70s, XXXXXXX low 80s, so it's not real tachy but it does beat _harder_ as if against some resistance or blockage, and the tremor is visible on the thorax, abdomen and sometimes the brachial. The BP goes up, especially diastolic, by about 10-12 points. So there's something quantitative here, though not a huge XXXXXXX between resting state and what I experience as v. uncomfortable palpitations. But I'm not imagining this. The GP wants to do an orthostatic vitals exam. Not sure what he's looking for. Any ideas?

Where it gets confusing is, how much of this is just exaggerated due to all the adrenaline and cortisol and floating anxiety, and more importantly, how much of the actual _sensation_ can I trust that feels so abnormal, b/c, as you point out, once your higher cortex tunes into something, that sensation gets magnified (literally taking up more space in the cortex visible in an fMRI) and noticed 10-fold by your conscious mind. And again, chronic amygdala activation creates changes in somatosensory cortex, meaning the representation of our body in our "mind" becomes inaccurate after getting soaked in fear long enough. That bit is a physical nervous system phenomenon -- not "worry". I wrote 2 theses in behavioral neuroscience, so knowing this stuff doesn't help. In this case, it works against me.

I just want to know the odds. Every explanation you provided to explain the various times the symptoms happen (from belt tightening to eating) is reasonable. Unfortunately, AAA seems to be the other, much more ominous, though unlikelier explanation. If it's not AAA, why is it not going away despite normalized BP 24x7?

And if there's not a serious organic underlying cause (tumor or other growth compressing organs, circulation problem, major left ventricular hyperthrophy, etc.), then what's my remedy? How do I sleep at night again? B/c this keeps waking me up and I don't want to take benzos b/c they are addictive. And during the day also - it comes w/o fair warning. How do I de-sensitize my brain/nervous system again if that's in fact all it is (which would be a huge relief). Many thanks!
Answered by Dr. Yogesh D 18 hours later
Hi again,

Thank you for writing back.

I am starting to appreciate your reasoning and the cause for your worry.

But let me again reassure you, you do not have an abdominal aortic aneurysm.

When I can fit all your symptoms into one particular category, I would rather limit my imagination from going wild in search of an elusive and impractical explanation for your symptoms.

I agree with you, medicine is not a deterministic science in its absolute sense, which is why medicine is still being practiced by human beings we call doctors and not computers.

When we a doctor makes a decision regarding a disease condition or when he discounts the condition to be a disease condition, he/she considers more than a million pieces of facts(According one study). This unique ability of human analytical mind is why we makes the decisions we make.

Whenever we say this could be one particular thing, it does not mean we have not considered other possibilities.

Since even a general practitioner has more medical knowledge than any other professional, more often than not they are correct or they make better judgment calls than a layman.

The gist of the above narrative is that, the choice of believing or not believing what a doctor says is up to you.

From my experience I can say this for sure, you are extremely anxious about your condition and are not easily driven to believe everything a doctor says.

We see individuals with such traits once in awhile, most patients/individuals we deal with daily are more than willing to believe the explanation we offer them because the way they look at doctors is like an authority in that particular field.

But when a person possess enough knowledge to question back the doctor, it becomes quite a messy situation. The doctor believes that he knows what he is talking about and the other party believes that the doctor can not answer all his questions satisfactorily. This is not a very uncommon scenario.

We do know that these situations can arise. And increasingly the doctors are realizing the importance of dealing with this new phenomenon which has arisen due to the easy accessibility of everyone to medical literature on the internet.

This excessive information available on the internet leads to the confusion in the reader and he starts to believe less and less in the credibility of the doctors.

Just the raw data does not help you make decisions, a clinical approach and proper training is required to understand the data in the right perspective and to interpret it the correct way.

Now coming back to your problem at hand.
1.     How rare is the AAA? – AAA incidence in the US varies from 0.5-3.2% based on the autopsy studies. The likelihood of development of AAA after the age of 50 years 3-117 per 100,000 person years.
2.     How many people get it that are otherwise healthy and aged 40 years get it? – The problem of AAA begins at the age of around 50 years, and reaches the maximum incidence by around 80 years. And it is seen mostly in smokers. The incidence of AAA begins to increase sharply after 50 years of age and peaks at age 70-79 years.
I am hoping that this site will give you the right information regarding Abdominal Aortic Aneurysm, Please follow this link, WWW.WWWW.WW , Please let me know if you are unable to view the content.

I would like to make an observation here; you have mentioned that you do not believe these symptoms could be a part of panic attack. But I would like to inform you that indeed these symptoms of yours can be caused by a panic attack or anxiety. This is some food for thought considering your belief that you have a problem regardless of the countless reassurances by the doctors.

Phantom pain has a different explanation, the pain sensation is sent to the brain by abnormal ways, so it interprets them as pain signals originating from a nonexistent part of the body. But In your case the palpitations and the abdominal pulsation you feel are genuine; there is no doubt about that. But your worry regarding the cause for such pulsations is not a necessary one.

Another important point I would like to make, which I forgot to mention in my earlier response is that. The impulse from the beating heart is felt in many different areas, to name a few locations where is can be felt extremely well are;
1.     The apex of the heart (Just medial to the left nipple in males).
2.     Just on the outer border of the sternum on the left side of the chest.
3.     Just below the xiphisternum (The lower most end of the sternum).
4.     On the lateral aspect of the left side of the chest when you roll on to your left side.

Since I have not examined you physically, I can not be 100% sure which is the impulse that is troubling you so much, but my best guess is the impulse that can be felt just below the end of the sternum. This is the one that has got you so worked up If I’m not wrong.

Now regarding your blood pressure readings and a marginal increase in the heart rate, as I have mentioned and explained in my previous reply, an increase in the venous return will automatically increases the heart rate, force of contraction of the heart as well as the blood pressure transiently and not to a very high level. To put it in your mathematical terms, you can google XXXXXXX Starling’s law.

Orthostatic vital exam simply means, your GP will be measuring your pulse rate, blood pressure in different positions, i.e. in sitting, standing and laying down positions. He will be looking for a recordable and out of range values in any of these, but he does not expect to find any neither am I.
None of your symptoms are exaggerated according to me. They are perfectly within normal limits but your interpretation of the same has gone way too high and haywire if I could use that word.

Yes, as you have mentioned, knowing these medical things does make it worse. You have said about the somato-sensory interpretations and heightened acuity to certain physical stimuli by our brain do get worse when you have some amount of knowledge regarding the same.
I would like to give a very good example to make things clear to you.
This has happened to me, and is true. During my graduate schooling, I had developed what is called fasciculations (muscle twitches) all over the body, and got worried as they got worse by the day and consulted my neurology professor, who after actually examining and seeing these fasciculations happening on my body ordered a battery of tests to rule out conditions like Amyotrophic Lateral Sclerosis, MS Spinal degeneration syndromes. But each and every test came back negative.
To this day she tells me, I taught her a very important lesson. She had gone crazy looking at my physical manifestation of what was in mind. The actual reason for me developing those symptoms was nothing but my knowledge about the condition.

I had read enough neurology to understand the diseases and their manifestations and my mind tricked me into believing that I did have a problem.

This happens with most doctors, they at some point of time will think they have some or the other problem but at the end everything turns out to be nothing at all.

Now coming to the part how you can deal with the issue.
1.     Once you get your ultrasound scan of the abdomen done, I feel you will realize how un warranted your worry was.
2.     Till then, talk to a counselor or a psychiatrist to help you deal with the anxiety as you do not have any organic cause for your symptoms and all your symptoms are just physiological.
3.     You can sleep in any other position; you can even sleep prone if you believe that you do not have a problem.
4.     You can de-sensitize your brain by consciously making an effort to believe that the symptoms you are having are just physiological.
5.     Once you get the required investigations done, you will believe that you do not have any problem, because it gives you objective evidence.
6.     The more you dig into the dirt, dirtier you will get, so quit worrying, AAA does not happen in your age. And it is extremely rare in nonsmokers. It is a degenerative disease of the aorta which starts after 50 years of age and it takes approximately 20 to 30 years before it can be ditected.
Hope You will find this information helpful.

At the end I would like to to add just this, If you had an abdominal aortic aneurysm that is causing such severely noticeable symptoms in you, the doctors during your physical examination itself would have picked it up. Another thought you should consider, because not every doctor is stupid or careless, and I believe you must have been examined by many doctors by now.

I hope I have addressed every concern of yours. And any more information regarding your condition is beyond the scope of this portal/medium, I sincerely hope you will get better and will accept this answer.

I have put in a lot of effort to help you out considering the level of anxiety you are in. Please write back if you have any more queries. (I hope you will not have any, with the information given here :-)).

Wishing you a great life ahead and here is to your health.

Above answer was peer-reviewed by
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