Questions about arrhythmia in younger age (AIVR, NSVT, etc)

[pharmerguy]

So I am a 28 y/o male in pharmacy school, with a 6+ year history of palps. At first, the palps presented lock step with my generalized anxiety (really a health anxiety) but as time goes on the palps seem to have become their own entity, at times unrelated to my anxiety. I had a run of PSVT caught at the ER when I was 22 and it was fully resolved with IV fluids and Ativan. I've relocated a few times and persisted with cardiologists in my new cities, in the past 2 years I have had blood work, echo, MRI, and holters. Holter last year only caught symptomatic PAC's, but I insisted that the PAC's detected weren't the palps that I was concerned about and that I needed a longer monitor period. This May they finally caught a run of NSVT/AIVR - it was a wide complex run with <10 beats, a capture beat, and then another <10 beats, with a rate of 110 bpm during the episode. Since this run was detected my anxiety has, admittedly, ramped up significantly above baseline, and I have had 4 more of these 'episodes'. This is a large increase in frequency, and only adds to my health anxiety.

I have taken my tracings and the holter report to the EP my cardio referred as well as a second EP for a second opinion. Both EPs are of the opinion that the detected 'episode' was an AIVR due to the "warm up and cool down" observed as well as the relatively slower rate of 110 bpm. I was prescribed atenolol and took my first dose yesterday evening - made me feel a little weird but my heart rate and blood pressure were rock solid all night and remain good into today. Having just got married back in Feb, this arrhythmia scares the crap out of me and I am looking to MedHelp for others' experiences or perhaps some context.

All AIVR/NSVT episodes seem to come while I am at rest or only lightly active, in fact the last 4 runs I had while sitting on the couch and playing video games. As soon as the fluttering sensation is over (usually in less than 10 seconds, often 5 seconds or less) my heart starts to race and I either have a panic attack or I just deal with my heart racing until it calms down (5-10 minutes). EP 1 wants an implantable loop recorder to catch more of these episodes, EP 2 wants a stress test to provoke PVC's or another episode to see exactly where they are coming from. I don't know what diagnostic value that the loop recorder has aside from confirming what my cardiologist already knows - that I am having random episodes of symptomatic palps.

Workup so far:
Numerous ECG's
Holter (May) - captured AIVR/NSVT
Echo (March) - normal, but notes indicated LV hypokinesis which no cardio seemed concerned about(?)
Holter (Oct '17) - symptomatic PAC's and/or SVE's
MRI (Jan '16)

My questions:
1. The EP who went over my holter with me does not think that the AIVR is originating from the RVOT based on how it presents, but it is my understanding that the only way to surely know the arrhythmia's origin is to catch it on a 12 lead. Is this correct?

2. My biggest concern is something like ARVD. Given that my MRI in 2016 was normal, will another MRI be useful? Is it possible for ARVD to come on/progress that rapidly?

3. These palps feel scary, but each cardiologist or EP I've seen says that these look fairly benign. What is keeping these from turning into something more concerning/malignant?

4. Given that these palps are occurring in what the docs are saying (so far) is a "structurally normal" heart, how are channelopathies being excluded? They all say that since my ECG is normal that they don't think channelopathies are a concern, but aren't they classically transient and hard to diagnose?

Thank you for reading through this, I know I have a lot of specific questions, I have made sure to pick my cardio's brains but it is also helpful hearing from other people who are going through the same thing.

[lmgggg5]

For many years now I have had PVC's/PAC's and short runs of Atrial Tachycardia, although I'm older then you I know how you are feeling. In February I was diagnosed with NSVT. I knew what I was feeling wasn't normal. I had extreme stress, panic and anxiety with it and that only made the situation worse. My EP/Cardio that I have seen for many years put me on an Event Monitor and that captured it. My report stated: Monomorphic unifocal wide complex beats, probably ventricular runs of 4-9 beats long, the longer ones being irregular, couplets and triplets and a 5 beat run of Atrial Tachycardia at 150bpm. I was able to get the print out and the longer NSVT runs were at 110, 120 and 130 bpm.  Needless to say my whole life changed when I found out. I also had a stress/echo that came out normal. I have been on Toprol XL 25mg for many years. My EP believes the extreme stress and anxiety and adrenaline triggered an irritable spot in the ventricle that caused it. He says I'm at NO increased risk for a sustained V-Tach (hard to believe) and I have no restrictions. I continue on the beta blocker and was encouraged to take Ativan or Xanax when needed. When I feel any palpitation I try my best not panic, sometimes that is very hard. It has been on my mind daily since it happened which was for couple weeks basically on a daily basis. I pray it never comes back or never gets worse. I hope this helps!

[anxiousalways93]

What did your runs of NSVT feel like?

[lmgggg5]

Like PVC's in a row

[anxiousalways93]

Is there any way you could describe runs of atrial tach opposed to NSVT?

[anxiousalways93]

Does nsvt kinda feel like the post pvc thumps just in a row?

[lmgggg5]

Both can feel the same. They both start and stop suddenly. The only way to know for sure is to have it documented by monitor or EKG. For me personally, the Atrial Tach is lighter quick beats and the NSVT was stronger harder beats.

[anxiousalways93]

Not sure if I'm any help but from what I've read NSVT is considered benign in hearts free of disease and without symptoms. I'm not sure I can answer all of your questions though.

I do have a question for you though. When you have the NSVT what does it feel like? And where do you feel it? I believe I have more PACs than PVCs, but I am so terrified of getting a run of PVCs.

[pharmerguy]

I was telling my cardiologist/EP that I could write a playbook on how my palps present and fee. It's a really strange fluttering sensation in the left lower center of my chest. Imagine almost like you quickly tap three fingers on the table. Following this fluttering is usually a really hard thud, and then another flutter or then I just return to normal sinus rhythm. Feels really weird.

[anxiousalways93]

I've had a couple flutters here and there but what from I've read I guess PACs present themselves more as a flutter. What do I know though haha. Last Friday I was laying in bed on my right side and got some spasms in my stomach towards my left side and convinced myself I had a run and somehow felt them in my stomach? Lol. These things terrify me.

I think if you do enough digging on here you may find the answers to your questions. I'm not sure a lot of people visit this site anymore. Which is a bummer.

[pharmerguy]

I've learned to live with my PACs, they used to really worry me, but I've had them for so long that I don't let them get too crazy. I can feel when one's about to come on, it's like my chest has a 'buzzing' feeling and then I feel a little blip in my chest. Sometimes I'll have several, sometimes it's isolated. Anxiety always makes them worse though. But they can definitely be brought on when you lie down in certain positions, that much I know, it happens to me occasionally where I sit down or lie down in a certain position and I'll get hit with a few PACs, it's super weird.

[anxiousalways93]

Yeah I think I just had gas because my stomach was super rumbly that day, and the night before I had a couple twitches in the same area while I was laying on my stomach.

Do you PACs feel like a double beat then a quick pause? And oh yeah when my anxiety is bad you can bet I will get a ton of them.

These never bothered me until earlier this year when I started reading more about PVCs (bad idea!). Now I'm terrified of Vtach and ICDs and all of that.

[pharmerguy]

Good question, my PACs either feel like a little "blip" like I mentioned above, or a fluttering sensation in my chest, or when they happen as I'm working out they feel more like that double beat. That quick pause you're mentioning is actually a really neat function of the heart, it's called a compensatory pause, I even saw one on my holter after one of my PACs.

Not gonna lie, it's all a little terrifying for me as well, but fortunately if you're only dealing with PVC's you really only have to be concerned if they occur way too often (literally thousands per day) or if they are short coupled. Have you gotten a holter to find out about your PVCs?

[anxiousalways93]

I have ones where I feel a complete skipped beat, I'm pretty sure those are PVCs. Then I have the double beat and a quick pause, sometimes no pause, and I think those are PACs. Just going off of what I've read on here, it seems to line up with the way I feel mine.

What do you mean by short coupled? Like in a run? I think I've only had a couplets 1 or 2 times. I don't think I've ever had a run. But the thought of it happening scares me to death! I have not had a holter but I'm seeing my PCP on Thursday and I'm going to ask for one there.

I've been pregnant more or less for the past couple years (2 pregnancies 1 year apart) so I've been seeing my OBGYN and occasionally a high risk doctor (for blood pressure issues). I was having PACs or PVCs while hooked up to some heart monitor when I was getting my epidural last year and they didn't say anything about them. I know I was getting them because I was super nervous about them shoving a huge needle into my spine! Lol.

[anxiousalways93]

Nevermind..just googled it.. probably shouldn't have lol.

[pharmerguy]

It's so easy for someone to say "don't worry about it" lol but essentially the coupling is how soon after the first beat/PVC that your PVC presents its self. There is a "vulnerable period" within the T wave where the ventricles are repolarizing, and this coupling is only uncovered with an ekg reading.

Get a holter, wear it for as long as you can and get some reassurance about what your palps are or how they come on. PACs and PVCs, or palpitations in general, are highly variable between people so without an ekg reading its tough to determine what those weird flutters are that you are feeling. Be your own advocate and ask for that holter though! Peace of mind can certainly help with how often you experience or perceive these palps .

Congrats on your two kids, I understand that a big piece of stress could be wanting to be around for them. Your PCP visit should be helpful with that.

[anxiousalways93]

Ohh ok. Well I guess some reassurance for me is that I've had these things for 4 years now, and nothing bad has happened, even without treatment. Never passed out, never feel short of breath, dizzy, etc. Just horrible anxiety! Yeah I am definitely going to push for the holter. I would feel good with a 24 hour one. I just want to know that I'm okay. Deep down I know I am, that's why I don't go running to the ER every day lol. But sometimes the fear is so debilitating I don't know I get through it.

Thank you! I actually have 3 kids :) My 5 year old is starting Kindergarten this fall so I'm trying to make the best of the summer. These things have taken over my life, I'm missing out on so much with my kids. It's even hard for me to go outside. I'm constantly worrying.