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Heart & Cardiology/PFO, palpitations, shortness of breath, chest discomfort

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Hi Dr Mustafa:

I am a 39 years old woman, 1.60 m, 55 kg, mother of 2. I currently do not exercise but walk and climb stairs a few days a week when I have to take my girls from school, I have normal colesterol but slightly high glicose under normal limits. My mom is diabetics, has high BP and had a myocardial infarction and 4 stents placed when she was 60 (but she had a more unhealthier life style than mine). My dad also had cardiac issues, stents placed and high BP (also in older age), in the end his circulatory problems caused his kidneys to stop working and he needed dialyses for the last 4 months of his life. My usual bp is low: 110-70, I often feel dizzy and tired, especially when changing positions. I have vitamin D deficiency but take pills to compensate (started around 4 y ago).  I've always had palpitations during stressful situations and some difficulty when exercising. Thought it was normal. That didn't stop me from running 4 km once a week and going to the gym or walking the other days when I was 30. By that time, I noticed my heart rate would quickly go to 180 bpm while exercising or climbed stairs. Again I thought it was normal, until 2 friends told me it was too high. When I was pregnant of my second daughter, the palpitations got worse, I had some high bp episodes and some shortness of breath. I decided to check my heart. All blood tests for deficiency in electrolytes/iron, etc were good. I had a 24 h holter monitor test which only detected episodes of sinus tachycardia (including the 180 bpm while climbing stairs), but all regular rythms. The echo revealed a small PFO. I was told that both the tachicardya and the PFO were benign and that I should not worry about them. The cardiologyst told me that my body reacts exaggeratedly to both physical and mental stress and prescribed some beta-blocker that I never had the courage to take (he said it was benign after all, so I didn't want medicines for something that would not kill me). That was almost 6 years ago. The palpitations have become more frequent and lasting longer (can take several minutes to go away). I have them also while lying to sleep and when waking up. I also suffer from depression and I am on welbutrin XR 300 mg for about 6 months (after having taking Cipralex for about 6 months).I also drink coca tea and green tea and occasionally up to 2 cups of coffee a day (lately 1 a day).


2 months ago, after several nights of few sleep (4-5 h a day), I accidentally took 2 pills (600 mg). My heart pounded the whole day, my bp got high 140/90 (usually is 110/70), I had some chest pain and shortness of breath. Went to emergency. Initial Ekg showed 99 bpm with poor R progression but regular sinus rhythm. Later I was on the monitor for several minutes with bpm between 99-110 bpm. Blood tests came normal, x-ray came normal. I was discharged with diagnose of anxiety and prescribed Lorivan on demand. But the hospital doc recommended another 24 h holter monitor testing. For that whole week I had persistent symptoms of tachycardia, high bpm, chest discomfort. I rested a few days at home, reduced Welbutrin to half and things got better. I did the holter test a month ago, but not in the time window close to my period. I did not get any abnormal rythm, only 184 episodes of tachycardia and my average bpm was 90. Here are the results of my holter:
Total beats: 126615
Average HR: 90 bpm
HR from 73-165 (I went to the gym to test the heart rate in this condition)
184 episodes of tachycardia (> 110) (several of them when waking up and early hours, some during sleep and of course when exercising)
Min RR (ms): 296
Max RR (ms): 2296

Heart rate Variability:

SDNN (ms): 126.29
SDANN (ms): 51.99
RMSSD: 62.93
HRV triang. Index: 30.89

ULF: 91.57
VLF: 275.8
LF: 247.80
HF: 110.83

Other symptoms I have are:. Ocasional difficulty catching my breath (need to yawn sometimes, especially before sleeping), occasional pressure in my chest. Feel tired after eating.

I do not like the average 90 bpm. Feels like I am almost tachycardic for the whole day.The holter I did 6 years ago, when pregnant of 4 months, had average of 86 bpm and min of 61 bpm. The current results seem worse and I am not even pregnant. My psychiater also thinks 90 bpm is high. We believe welbutrin is contributing to this. He gave me the option of taking a beta-blocker, but I really don’t want to start taking too much medicines if I can survive without it. I really want to continue wellbutrin as it is helping me beat depression like nothing else ever did. I've always felt tired and now I have energy (I wonder if my fatigue has something to do with the PFO). But I am afraid I am damaging my heart. I am afraid my conditions might not be benign anymore and I am afraid of the long term effects (read something bad about anphetamines long term effects on the heart). I have not only one question, but a few: 1) Should I be worried about my holter results? 2) Can a small “insignificant” PFO be the cause of palpitations, dizziness, shortness of breath, fatigue, exercise intolerance and chest discomfort (everything else seems normal with my heart, I had these things even before welbutrin, just got a bit worse)?  3). Does the PFO grows/becomes more open with age (I prefer not to have any procedure to close it)? 4) I am still looking for a cardiologist to check my tests. What do you recommend me to tell him/ask him?
Thanks a lot for your help and sorry for the long text.
Gi

Answer
Hi, http://myheart.net/articles/ http://myheart.net/articles/inappropriate-sinus-tachycardia/

I read the description in full, here are my thoughts within the limitations of the fact that this is based only on what i have read from your history,


1) Should I be worried about my holter results? These holter results are not particularly concerning. One thing i always look for in holter results is the symptoms diary, its important to see if the symptoms themselves are correlated to the holter findings.

2) Can a small “insignificant” PFO be the cause of palpitations, dizziness, shortness of breath, fatigue, exercise intolerance and chest discomfort (everything else seems normal with my heart, I had these things even before welbutrin, just got a bit worse)? I doubt the PFO is related to these at all. The PFO is likely of no significance whatsoever.

3). Does the PFO grows/becomes more open with age (I prefer not to have any procedure to close it)? Not necessarily no, and you certainly have no indication to close the PFO. If someone recommends it is closed i would get a second opinion and ask to know why.

4) I am still looking for a cardiologist to check my tests. What do you recommend me to tell him/ask him? I would ask them whether longer term monitoring would be useful and to review your imaging studies such as the echocardiogram.

Since it has been suggested, i think its reasonable to try a trial of beta blocker, if it helps with your symptoms then great, and if not you can always stop it.

Hope that was helpful,

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Mustafa Ahmed MD

Expertise

Cardiology, Interventional Cardiology, Cardiac Surgery, Hypertension, Pulmonary Embolism, Structural and Valve Disease

Experience

Board Certification Internal Medicine and Cardiology Interventional and Structural Cardiology

Organizations
http://blog.myheart.net

Publications
Multiple Publications In High Quality Peer Reviewed Journals. Internationally Recognized.

Education/Credentials
MD from The Royal Victoria University of Manchester, England Medicine, Cardiology, Interventional Cardiology, Research Training - University of Alabama

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