20795335 tn?1509515226

My chest always feel funny

It all started around a year and a half ago. When I get kind of tired, my heart beats really hard once or twice and then my HR takes off like a rocket. I've been to two different ERs and had EKG and chest XRay that all came out clean. Normally they hook me into a monitor and it slowly starts to come back down. I get super freaked out by it and my first thought is like I'm having a heart attack or a clot is moving through my heart. A little Background on me. 26/m I smoked for a while but went to vaping a few years ago. About 4 or 5 months ago. I cut soda completely out with the exception of a sprite every now and again. Sometimes I feel like I have some control over it like if I put my mind to it I can trigger an event. But other times they come from nowhere. I feel scared cause I'm a truck driver and I don't want to die out on the road. The last time I was in the ER the doc said that it could be stress related but when it happens sometimes I'm not even stressed about anything, I feel fine up until the hard heart beat. Any ideas? Thanks and God Bless.
5 Responses
20748650 tn?1521032211
Probably pvc's, try asking for a referral for a holter.
1423357 tn?1511085442
How often does this occur? Daily, weekly, etc.
Do these events exhibit the same symptoms?
How does a typical event end?
Have you ever tried to palpate your pulse say in your neck or wrist and count the beats?
Tom. Usually they occur every other day give or take a day(usually at night before I go to bed cause I'm tired). Yes the symptoms are always the same. It usually ends with me falling asleep cause I'm so mentally worn out from the days I have (constantly paying attention to everything around me while moving an 80k lb vehicle down the road). Yes I've checked my pulse on my neck when it happens, everything seems to feel normal. My heartrate is usually elevated cause I'm worried about whats going on.
20748650 tn?1521032211
Got some more time to explain my logic here.. If we break down the history i think this is a simple one... At least compared to 7 ablations guy, or the dude with a typically compelling sick sinus argument in his 20's.. Theres some real interesting ones that pop up here... Fortunately for op i dont think this is one of such cases.

"When I get kind of tired, my heart beats really hard once or twice and then my HR takes off like a rocket."

With regards to this bit of the history. This fits the ectopic description like a glove, its basically textbook. You get tired, heart rate slows down, 'un-suppresses' the ectopy... You get a pvc.. Compensatory pause ensues.. Combination of normal tachycardic response and anxiety sustains atrial tachycardia.. Visit the ED, rate tapers down.

"Normally they hook me into a monitor and it slowly starts to come back down."

This is a key point, reentry terminates abruptly. Atrial tachycardia will terminate more gradually.

In any case the answer ultimately comes from an ambulatory monitor of some sort, such as a holter. Only way to definitively answer these types of questions is to witness the episode evolve.
2210485 Thank you for your comments. I have scheduled an appointment with a doctor in my hometown and will explain to him everything that is going on. See if he can get me set up with one of those monitors (I googled what a holter was). I'm hoping that whatever I have going on is just something that is stress related and not an actual physical issue.
1423357 tn?1511085442
"Normally they hook me into a monitor and it slowly starts to come back down."

I noticed,this was mentioned in the comment above.  While supraventricular tachycardias "take off" suddenly, they subside just as quickly.  When you drop out of svt, heartrates can elevated a bit above normal for a few minutes and gradually return to normal resting rate.  You didnt mention how fast, and that is an extremely important item to note.  If you're experiencing near daily symptoms, a Holter monitor might be an aid in diagnosing what you're feeling.  But I've seen plenty of people on the forum who are prescribed a 24hr. monitor, have no recorded events that day, and who then have their possible legitimate cardiac issue passed off as anxiety, only because the physician saw nothing on the monitor except a normal heart rhythm and waveform.  So just be cautious, and just dont accept a diagnosis of anxiety.  Drugs to treat anxiety come with their own nasty problems.  Once you start them, halting treatment is typically a long, difficult, process.
20748650 tn?1521032211
"So just be cautious, and just dont accept a diagnosis of anxiety.  Drugs to treat anxiety come with their own nasty problems."

This my friends is good advice.. Some anxiety drugs, benzodiazepines in particular carry a risk of status epilepticus and death if stopped too quickly after long term use.

As for the limitations of a 24 hour monitor it is unfortunate.. They do offer alternatives though.

My favorite are the 2 week holters, cardiokey being the brand name,that sticks out to me, but im sure every company has its own variant of it.

My least favorite are 30 dsy event monitors because they require the patient to actually push a button when they have symptoms... If you fail to push the button within 10 seconds of feeling crappy you risk not capturing the arrhythmia.
My 30 day monitor absolutely, positively autorecorded events and came with a manual button as well.  This was 7 years ago.

My monitor had rate set points which would trigger an auto record.  As a double E, I was interested in the stuff, so I coaxed the cardiology tech to let me watch him set up the recorder before giving it to me to wear.  The recording, either auto or manual would jump back 30 seconds in time so to capture the event initiation.  It would then record for 3 minutes before placing the recording in one of 3 memory slots.  During an SVT event, the recorder auto-started, and I let it (and my SVT) run the 3 minutes, and heard the double beep to signify it had finished.  Then I halted the SVT event by using the standard Valsalva maneuver, then pressed the manual button which jumped back 30 seconds, and captured me dropping out of SVT and back to NSR.  The recorder given to me to wear was a simple, 2 lead device.  My cardiologist  had previoisly pleaded with me to drive to the hospital when an SVT event occurred and the ER would immediately hook me up to a EKG.  But I was either at work, or otherwise away from home most of the time.  The few times I was at home, I either complete forgot that I was supposed to let it run and dash to the hospital, or it was just too darn uncomfortable to let it run on.  I had a rate on the higher end of the range, and despite 50 years of having it, it was really unnerving to me, so I would try to immediately halt an episode when it started up.  Ironically, as I aged the events became more common when I was at rest then when I was under heavy respiration as when I was younger.
I hasten to add that the term "30 day monitor" referred to the length of time the monitor was given to the user to wear.  The device itself was nothing more than a loop recorder with 3 memory slots.  Once filled, it was up to the user to transmit to recording to the lab.  This was before the devices were equipped with cellular technology.
See everything you say makes sense, from a design perspective.

Im sure ours also have rate triggers or something equivilent, but in terms of how effective they are at detecting snd recording rhythms automatically i dont know..

What i do know is the patient initiated strips our only 20 seconds long, and the lowdown i got was 10 seconds in either direction.

I would love to verify these things and see how effective they are.. But of course.. I cant!

Why not? Well dear watson, let me tell you! These monitors these days are all outsourced and analyzed by outside providers.

With a holter (24/48) at least i receive a whole strip to interpret as i see fit... All analysis is done in house.

14 day holters are also handled outside but at least the ***tech*** has a whole.. But at least you can request a whole strip.. That said theres not much data that were missing out on at 14 days that we would see at 30.

Which reminds me! The second bone i got to pick with these monitors!

The technicians that analyze these things are certified cardiac rhythm analysts or certified cardiographic techs...

What does this mean? Squat! Im all game with the notion that everyone in healthcare has a role to play.. Unfortunately these credentials can easily be earned by someone whos dismally qualified for the task,at hand.

Ive worked with them... Ive taken their preperatory exams.. I would trust them to sit on a telemetry unit and watch for vt/vf... Id trust them to ID potentially life threatening problems, even to help facilitate stress testing under the physician of a CARDIAC nurse, or physician.. Of course i trust them to hook up leads and acquire ecgs.. These are the types of roles they're designed to fill.

But no, i do not think its apprppriate to have these guys going through potentially complex long term monitoring results coming from cardiology.

Imo even if it substantially raises the cost of these units (right now theyre paying someone 30k annually, they need to be paying someone 100-150k).. They should have rces, ceps or even ccds technologists checking them.

Tech*** has a whole strip... AND <--- corrrection
Of course mind you the above rant is very personal in nature and im sure there are a few great rhythm analysts in the world.. But unfortunately first impressions matter..

That image of a rhythm,analyst throwing away any segment with artifact without even trying to spot an underlying..

Or the expression on their face when pointing out the rate dependent delta waves they missed (the 'wtf is a delta wave' look)..

Lets not forget the pansystolic excitation that cant be a true pvc because the rhythm is regular.

Dear god its all there.. Burned in the subconscious and unfortunately it would take a pretty sharp cookie to pry them out.

Try holter first lol.
My recordings, were read by an independent lab and if necessary were forwarded to my cardiologist for further analysis.  I had 3 SVT events recorded during the 30 day wear time.  When I transmitted the SVT recordings to the lab, the technician, ordered me to take a new recording and send it to her to verify I was in NSR. I told her that I was, and balked at making another recordibg.  She said it was either that or cops and rescue squad at my door.  I made the recording....
I have to disagree with you regarding the use of a 24 hr. Holter. For me, they raised more questions and provided no answers.  I would go to a cardiologist and explain my history with SVT which I got anywhere from 1 to 5 times a month.  They would go and prescribe a 24 hr. Holter after being told that odds were theres was a pretty good chance nothing would happen.  And for the 6 to 8 times I wore a Holter, nothing did happen.  Just a clean waveform.  This woild raise additional questions: was I anxious, did I feel panicky, even, was I a drug user?  Yes, I had one cardiologist ask me if I used cocaine.  He couldnt wrap his supposedly brilliant mind around the nature of many SVT's, going as far as saying I could level with him because all indications pointed to drug use.  At the time, I was a nationally ranked speed skater and a member of the US world team.  So yeah, there were no drugs.  "How could someone with a superbly conditioned heart be sitting in my office complaining of an arrhythmia?"  I knew what I had.
I lived with it for 50 years.  But the only other physician to see it was my long deceased pediatric physician. I had to convince someone of what I had been dealing with almost all of my life. It took a move to another region and a new cardiologist to finally find someone who listened to me, who gave me an office EKG, then spent an agonizing amount of time looking at my waveform.  He swore there was a slight, almost unseen slur in the wave.  He finally proclaimed Wolff-Parkinson-White.  Knowing the spacing of events, he prescribed a 30 day monitoring period and a loop recorder which at this point had replaced the old cassette recorder which had to carried on a shoulder strap.  With the digital recorder, I could do practically anything except shower with it.  And as expected, about 2 weeks into the monitor period,  I got a good recording I described above.  Seeing that proof, I was hooked up with three electrophysiologists. I spoke with them and selected one.  My cardiologist was almost right.  It was left sided AVRT, but not WPW.  It was something called Circus Movement Tachycardia with orthodromic conduction.  It was ablated and that was it.  But if it hadn't been for the long term monitor, I probably would have done nothing, because nobody could catch it in a 24 hr. monitoring span.
Im not disagreeing.. it certainly has a high enough diagnostic yield and has been successful in enough cases such as yours to be a valid option.

I prefer a device that gives me everything.. im uncomfortable with the notion of having 'blind spots' or being dependent on a computerized algorithmn or a patient triggered event recording to make a diagnosis. Of course you do have exceptions such as yourself where the in house holters just dont catch the rhythms..

In cases such as the one you were forced to endure, unfortunately a provider is forced into choosing another device.. and having some sort of monitoring from a tech or a computer is preferable to repeatedly placing holters that arent sufficient to capture the abnormalitt. I wont deny that at all.

If we can do 2 week holters in house that would be ideal.. because then i have a 14 day continuous strip.. and i can look at it myself as opposed to having to rely on someone ive never met face to face or even spoken to email me or upload a "summary" of the findings.

So yeah.. basically im not disagreeing with the view that 30 day events are useful.. theyre just not my personal preference for capturing an arrhythmia.. id rather do what they did for you and place a bunch of holters first.. outsource as a last resort. I think they made the best decision in that regard.

Wpw cases are actually a prime example.. the staff in these outsourced labs dont go through the type of training needed to be able to consistently identify delta waves, concealed lqt, brugada syndrome or something like say.. an unstable bundle branch type of situation thats rate dependent.

Machine algorithms dont always pick this up either because theyre not tachycardia or bradycardia events.. theres the potential for it to highlight these abnormalities but its no substitute for a live person that knows what to look for. I have a few ecgs actually in my possession right now that are blatant examples of an ecg machine failing to correctly identify an abnormality or coming back sinus despite something very concerning going on.

when looking at a holter im literally scrolling through the strip looking for any sort of change in morphology or axis.. im gonna take my time and really put a fine tooth comb through every inch of available data. Im scrolling through the strip and pausing at key places that may be an area of interest that can aid in providing a detailed interpretation and discussion with the electrophysiologist.

Im gonna look at some of the lower rates at night.. and put them next to some of the higher rates during the day or with exertion... and im not only looking for what rhythm the patient is in but im also looking at all those fine nuances.. im attempting to get a picture of how those electrical forces are behaving under different conditions, such as change in autonomic tones or at different intervals.

Each ectopic gets an approximation in terms of its location and a close look as to the circumstances surrounding the ectopy.. is there entrance or exit block.. can i identify any rettograde conduction and at what interval does it occur? Do retrograde intervals vary at different coupling intervals.. additionally i wanna look for paterns that may indicate situations that aggrevate or alleviate ectopy.. are they coming out with a reduction in overdrive supression like an escape beat, is an entrance block rate dependent, autonomic contributions to the abberrancy, things that might indicate underlying structural pathology and soforth.. even the artifacted areas are gonna get looked at the see if theres any usable data that can point to an underlying rhythm.. the list could go on for days.

That said,

Your specific case is actually pretty interesting in alot of ways. Firstly theres how long you lived with that arrhythmia.. which is pretty remarkable in its own right.. and for it to have gone undetected that long..

Before i get into that though..

Do you remember if the delta waves he saw wound up being legitimate? Did the pathway allow for any retrograde conduction? Or was it strictly orthodromic?

If the waves were real.. i just dont see how it was missed that many times or how a holter or your prior ecgs werent sufficient.. someone should have spotted that sooner.
I literally had an event while reading these comments. This time however, I put all of my energy into keeping calm and not panicking. I feel like I am noticing a pattern with the events. They only seem to happen when I am reading about heart issues, or thinking "man, I haven't had an event in a while" I don't know if any of it is relevant or not but I thought I'd share it with you.
The delta wave was very slight.  My cardiologist chuckled and said that he talk himself into seeing it.  The electrophysiologist also said while it was very slight,  he could identify it in every QRS complex.  I can't answer the question regarding the conduction direction.

I'll tell you why I let it go for 54 years.  My first episode was when I was 6 years old.  I was running a high fever and was sick at the time.  By the next full day of rhis illness, my mother (who dispised modern medical science) noticed my lips and nail beds were bluish in color.  She referred to it as "cyanotic".  Not sure if thats a real word or not.  She finally called our physician who made a house call (this was 1957) he put his stethoscope to my chest and within minutes I was being raced to St. Christopher's Children's Hospital in Philadelphia.  I was immediately admitted with a heart rate of 312bpm; 5 beats per second.  My heart was beating so fast, that my ventricles couldn't fill fast enough before it was pumped away.  They estimated I had been at that rate for over 24 hours.  I eas chemically converted with I believe digitalis and or digoxin.  I was monitored for 2 days before going home trained with the ability to perform Valsalva in the event it would happen again.  I took digitalis and digoxin for many years. Until it was recommended thatnI cease taking it.  From then on, I was unmedicated.  I would get a dozen or so events every  year.  SVT became an accepted part of my life.  I accepted it and dealt with it when it occurred.  I began to challange it by doing high respiratory sports like track spring cycling and speed skating.  These sports would occasionally trigger an event.  But Valsalva kept them under control, and out of the ER.  I remember going to one cardiologist in the mid 1980's (my mid 30's) who told me of a new procedure that could fix it, but reqiired open heart surgery.  Now with children and a blossoming career, I decided to just deal with it as I always did.  Fast forward 25 years later in 2010 when the electrophysiologist peered into my heavy eyes as I was coming out of anesthesia, and said to me, "Shoulda seen me sooner!  That won't be giving you any more problems."  I guess better late than never.  He told me I was his dream patient. Just touching the catheter to a spot in the left atria cause me to jump to lightspeed.  As a bonus, the transseptal puncture was avoided by finding an area in the septal wall that overlapped but did not seal completely.  He always checks his patients, and there it was.  So that's why it took so long to get it fixed.  A good portion of my life with it, technology did not exist to repair it.  Now repaiired and living life to its fullest, I hang around to offer suggestions and hope to others who show up here with the same problems.  Before the advent of the internet,  I had never met another person with SVT.  I thought it was this rare condition that no one else had.  Boy, was Ibwrong about that!
This has been an interesting exchange, and I appreciate our conversation.
FBomb, I have no way of making an accurate diagnosis nor am I qualified to do so.  But you could  possibly rule one condition out.  SVT starts ona dime.  You'll jump from  resting rhythm of say 68 bpm to 240bpm in literally one beat.  This is thw Hallmark of SVT.  It terminates in the same manner, but sometimes people are so amped up from the event, that they could have a somewhat elevated rate of say 100bpm or so before gradually returning to a normal resting pulse rate.  If your "episodes" don't include this behavior, you can pretty sure rule out SVT.
It's very important that you "listen" to your body and take note of the symptoms.  Accurately describing theae symptoms will give your physician a better starting point.  When you speak to you physician, avoid using vague terms like "palpitations".  I hate that word.  It can mean anything.  Describe how it started and how it ended.  Don't tell your physician your heart was beating fast.  To some, 140bpm is fast.  To a person with SVT, thats a walk in the park rate.  Try another 100 beats per minute.  Thats SVT territory.  Finally, dont lead your physician.  Give him the facts and let him make the call.  Avoid terms that would indicate anxiety.  I had SVT for iver 50 years.  I was nervous and anxious during every single one of them.  What you dont want is to be treates for anxiety when none exists.  Drugs to treat anxiety are a bi*ch to stop once they become intertwined in your brain.  Benzos, SSRI's, and SNRI's are all tough to stop once you begin them, yet physicians seem all too willing to prescribe them like they're a box of Mike and Ikes.  So be very careful, and I hope you get answers.
I apologize for the typos.  Ive been typing on my smart phone keyboard for hours now.
I apologize for the typos.  Ive been typing on this tiny smart phone keyboard for hours now.
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