How to Manage Palpitations: Insights from Cardiovascular Specialists

How to improve palpitations?

Thank you very much, Doctor, for taking the time to assist with my concerns.
I have been experiencing palpitations, anxiety, and discomfort in my neck, throat, and chest for over three months.
In the past month, I underwent an echocardiogram, an exercise stress test, and a 24-hour Holter monitor.
The results are as follows:
Echocardiography Report:
- Clinical Diagnosis:
- RVD (mm): (07-23)
- AO root (mm): 34 (20-39)
- IVS (mm): 10 (06-11)
- LA (mm): 33 (19-40)
- LVEDD (mm): 47 (36-52)
- EF (%): 67
- LVPW (mm): 10 (06-11)
- EF by Simpson’s (%):
- LVESD (mm): 29 (20-36)
- Rhythm: Normal sinus rhythm
1.
Cardiac chamber and Aorta:
- NORMAL CHAMBER SIZE
- NORMAL WALL THICKNESS
2.
Mitral flow:
- E/A: 38.9 / 63.5 cm/sec
- MS: None; MR: None
3.
Wall motion: NORMAL
4.
Aortic:
- AS: None; AR: None
5.
Aortic valve: NORMAL
6.
Tricuspid flow:
- TR: Mild TR - PG: 1.26 mmHg
7.
Mitral valve: NORMAL
8.
Pericardial effusion: NONE
9.
Others:
- Mitral flow E/A reversed
- Thrombus: NONE
Comment:
1.
Normal chamber size
2.
Normal wall thickness
3.
No regional wall motion abnormality with preserved LV systolic function
4.
Mild TR
5.
Mitral E/A reversed
6.
IVC diameter: 1.26 cm
24-hour Holter Monitor Report:
1.
Sinus rhythm with rate 51-121/min and mean 78/min.

2.
Two APCs.

3.
Rare VPCs (total 10) with multiform.

4.
No pauses longer than 2.0 seconds.

5.
No ST segment deviation more than 2mm.

6.
Total 10 events: 7 events were normal sinus rhythm, 2 events were sinus tachycardia, and 1 event was sinus rhythm with VPC.

Note: Three Channels (Lead aVF, III, I)
Exercise Stress Test Report:
- Negative for ischemia.
Two and a half years ago, I underwent a cardiac catheterization, revealing approximately 50% blockage.
Currently, I am taking medications including clopidogrel, atorvastatin, and half a dose of bisoprolol.
In the past two weeks, I also consulted an endocrinologist regarding thyroid function and adrenal hormones, and all blood tests returned normal.
My low-density lipoprotein cholesterol has consistently remained below 60, and my high-density lipoprotein cholesterol, uric acid, and hemoglobin A1c levels are also normal.
A month ago, I purchased an Apple Watch and have been measuring my ECG multiple times daily without detecting atrial fibrillation.
However, from November 21 to 26, I activated the atrial fibrillation monitor, which indicated a probability of less than 2%.
According to the manual, the Apple Watch will never show atrial fibrillation data as 0%, but rather as 2% or below.
I am currently concerned that the worsening coronary artery blockage may be causing my palpitations or atrial fibrillation.
However, my cardiologist is hesitant to perform another catheterization due to the risk of vascular damage.
I still experience palpitations and have been taking lorazepam, which has provided some improvement but has not completely resolved the issue.

Could you please provide your recommendations, Doctor? Thank you very much.

Yi Xiang, 50~59 year old female. Ask Date: 2023/12/02

Dr. He Dongjin reply Cardiology

Hello, all tests are normal.
There is no need for cardiac catheterization.
You can manage autonomic dysregulation with medication.
Changhua Hospital cares about you.

Reply Date: 2023/12/02

More Info

Managing palpitations can be a complex process, especially when they are accompanied by discomfort in the neck, throat, and chest, as you have described. Given your detailed medical history and the results of your recent cardiac evaluations, it is essential to approach this issue systematically.

Understanding Your Symptoms
Palpitations can arise from various causes, including anxiety, stress, hormonal changes, or underlying cardiac conditions. In your case, the presence of palpitations for over three months, along with the discomfort you experience, warrants a thorough evaluation. Your echocardiogram results indicate normal chamber sizes and wall thickness, which is reassuring. The mild tricuspid regurgitation noted is typically not a cause for concern unless accompanied by other significant symptoms.

Cardiac Evaluation
Your 24-hour Holter monitor report shows a normal sinus rhythm with occasional atrial premature contractions (APCs) and rare ventricular premature contractions (VPCs). The absence of significant pauses or ST segment deviations is also a positive sign. The exercise stress test being negative for ischemia further supports that there may not be an immediate cardiac cause for your symptoms.

However, your history of coronary artery disease (with a previous 50% blockage) raises some concerns. While your current medications (antiplatelet and statin therapy) are appropriate for managing your cardiovascular risk, the potential for worsening coronary artery disease should not be overlooked, especially if your symptoms persist.

Potential Causes of Palpitations
1. Anxiety and Stress: Given the duration of your symptoms, psychological factors could be contributing significantly. Stress and anxiety can lead to increased heart rate and palpitations. Cognitive behavioral therapy or relaxation techniques might be beneficial.

2. Electrolyte Imbalances: Although your recent blood tests have returned normal, it may be worthwhile to periodically check your electrolyte levels, especially if you experience changes in diet or hydration.

3. Thyroid Function: Thyroid disorders can lead to palpitations. Even though your thyroid tests were normal, it might be worth re-evaluating if symptoms persist.

4. Medication Side Effects: Review your current medications with your physician. Some medications can cause palpitations as a side effect.

5. Coronary Artery Disease: While your stress tests have been negative, the history of coronary artery disease means that any new or worsening symptoms should be taken seriously. If your palpitations are accompanied by chest pain, shortness of breath, or other concerning symptoms, further evaluation, such as a coronary angiogram, may be warranted despite the risks.

Recommendations
1. Lifestyle Modifications: Ensure you are maintaining a heart-healthy lifestyle. This includes regular exercise, a balanced diet low in saturated fats and sugars, and avoiding stimulants such as caffeine and nicotine.

2. Follow-Up with a Cardiologist: Given your ongoing symptoms, a follow-up appointment with your cardiologist is essential. Discuss the possibility of further testing, such as a coronary angiogram, if your symptoms do not improve or worsen.

3. Monitor Symptoms: Keep a diary of your palpitations, noting when they occur, their duration, and any associated symptoms. This information can be invaluable for your healthcare provider.

4. Consider Psychological Support: If anxiety is suspected, consider speaking with a mental health professional. Techniques such as mindfulness, cognitive behavioral therapy, or even medication may help manage anxiety-related symptoms.

5. Medication Review: Discuss with your physician the effectiveness of your current medications and whether adjustments are needed.

In conclusion, while your cardiac evaluations have not indicated any immediate life-threatening issues, the persistence of your symptoms necessitates a comprehensive approach that includes both physical and psychological assessments. Regular follow-up and open communication with your healthcare provider will be key in managing your palpitations effectively.

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