Heart Palpitations: When to Worry and Medication Guidance

Consultation for occasional skipped heartbeats and arrhythmia?

Hello, Director.
Sometimes when I lie on my side in the morning or at night, I can feel my pulse in my ear.
If I count carefully, I notice that it beats several dozen times and then pauses for a moment.
However, sometimes it doesn't happen at all.
I have undergone an electrocardiogram (not a 24-hour one), exercise echocardiography, X-rays, and thyroid tests, all of which showed no issues.
Previously, during a health check, I was diagnosed with autonomic nervous system dysfunction, and I sometimes feel sudden anxiety, especially in crowded or noisy environments, or when I am sleep-deprived and overly fatigued.
At times, I experience palpitations and an increased heart rate, which has reached up to 140 beats per minute for an hour.
Both my cardiologist and psychiatrist have prescribed me Xanax (Alprazolam) and Inderal (Propranolol).
I would like to ask you a few questions:
1.
It seems that arrhythmias can also be benign, and medication is only needed when symptoms occur.
For someone like me, should I only take medication if my heart rate exceeds 120 beats per minute and lasts too long? If I occasionally feel a missed beat, can I ignore it?
2.
When I need to take medication, what is the usual dosage? (A rough estimate for a 41-year-old male weighing 70 kg would be appreciated.) Initially, my cardiologist prescribed 10 mg twice daily.
However, I felt short of breath during gentle exercise and became easily fatigued.
I later reduced the dose to 5 mg, which felt better.
3.
My psychiatrist also prescribed me Lexapro (Escitalopram), an SSRI for autonomic nervous system dysfunction, which I take at 5 mg before bed.
However, I often wake up feeling particularly dizzy and lethargic, and I notice my heart beating a few times and then pausing in the morning.
Should I take Inderal (Propranolol) before bed to help normalize my heart rate in the morning, or can I ignore the occasional missed beat?
4.
Sometimes I also experience dizziness or palpitations.
I read online that this can be related to arrhythmias and autonomic nervous system dysfunction.
How can I usually determine whether the issue is with my heart itself or if it is truly caused by autonomic nervous system dysfunction or anxiety?
I appreciate your assistance in clarifying these concerns.
Thank you.

Bi Xiansheng, 40~49 year old female. Ask Date: 2016/05/27

Dr. He Dongjin reply Cardiology

Hello, sometimes you may feel a missed heartbeat, but it is usually nothing to worry about.
The typical dosage is around 5 mg, which is generally sufficient.
Conditions like autonomic nervous system imbalance or anxiety can lead to arrhythmias, but they are mostly benign and not life-threatening.
If you feel a missed heartbeat, it is usually okay to disregard it.
Changhua Hospital cares about your well-being.

Reply Date: 2016/05/27

More Info

Dear Patient,
Thank you for your detailed inquiry regarding your experiences with heart palpitations, anxiety, and the medications you are currently taking. It’s understandable to feel concerned about these symptoms, especially when they can be quite distressing. Let’s address your questions one by one while also providing some context about heart palpitations and their management.

1. Understanding Heart Palpitations: It’s important to note that heart palpitations can be benign, especially if they occur infrequently and are not associated with other concerning symptoms like chest pain, shortness of breath, or fainting. In your case, since you have undergone thorough cardiac evaluations (ECG, echocardiogram, X-rays, and thyroid tests) that have returned normal results, it is reasonable to consider your palpitations as likely benign. If you experience a heart rate exceeding 120 beats per minute for an extended period, it is advisable to take your prescribed medication, such as Propranolol, as directed by your physician. However, if you notice occasional skipped beats or palpitations that are brief and do not escalate, it may not be necessary to react immediately.

2. Medication Dosage: Regarding the dosage of Propranolol, it is crucial to follow your physician's guidance. The initial dose of 10 mg twice daily is a common starting point, but if you experienced side effects such as breathlessness or fatigue during exercise, reducing the dose to 5 mg is a reasonable adjustment. The goal is to find a balance where the medication alleviates your symptoms without causing undue side effects. Always consult your healthcare provider before making any changes to your medication regimen.

3. Managing Morning Symptoms: The morning symptoms you describe, such as dizziness and feeling your heart skip beats, can be influenced by several factors, including the effects of Escitalopram, your sleep quality, and anxiety levels. If you find that taking Propranolol at night helps stabilize your heart rate in the morning, it may be worth discussing this with your doctor. However, it’s also essential to recognize that occasional skipped beats can be normal and may not require treatment unless they are frequent or symptomatic.

4. Differentiating Causes of Symptoms: Distinguishing between cardiac issues and symptoms stemming from anxiety or autonomic dysfunction can be challenging. A good approach is to keep a symptom diary, noting when your palpitations occur, their duration, and any associated activities or stressors. If your palpitations are consistently linked to anxiety-inducing situations or physical stress, they may be more related to your anxiety or autonomic nervous system rather than a primary heart condition. However, if you experience new or worsening symptoms, it is always best to consult your healthcare provider for further evaluation.

In summary, it is essential to maintain open communication with both your cardiologist and psychiatrist. They can work together to ensure that your treatment plan addresses both your cardiac health and mental well-being. Additionally, lifestyle modifications such as regular exercise, stress management techniques (like mindfulness or yoga), and adequate sleep can significantly improve your overall health and help manage anxiety symptoms.

If your symptoms persist or worsen, do not hesitate to seek further medical advice. Your health and peace of mind are paramount.

Wishing you good health and peace of mind.

Best regards.

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