Atrial Premature Contractions: Causes and Management Strategies

Hello doctor, how can I determine whether my atrial premature contractions are due to abnormal electrical discharges from a specific area in the atrium or caused by autonomic nervous system dysregulation leading to erratic signals, especially after a long period of time?

Cardiology → Diagnosed with mitral valve prolapse → Autonomic nervous system dysfunction → Psychiatric consultation → PANIC → After stabilizing the autonomic nervous system and tapering off propranolol, I frequently experience premature ventricular contractions (PVCs) that trigger palpitations.
During a cardiology examination, a resting electrocardiogram (ECG) captured an episode, and the doctor mentioned that this type of arrhythmia is common with mitral valve prolapse.
The report indicated APCs (atrial premature contractions).
I only inquired about the possibility of using propranolol for control, as the doctor was fully booked and referred me to another physician in the same department.
During the second consultation, the attending physician stated that even normal individuals can experience this.
After reviewing the 24-hour ECG that he arranged, he noted that the frequency seemed to be within normal limits.
Subsequently, I continued to see a psychiatrist and take medications (Mirtazapine + Duloxetine + Propranolol).
However, I didn’t think to ask during the resting ECG when the issue was detected whether my condition was due to abnormal electrical discharges in the left and right atria or if it was triggered by the autonomic nervous system causing the heart to beat continuously.
The autonomic dysfunction may lead to abnormal signal transmission, resulting in atrial premature beats.
Moreover, the ECG reports I received only contained text without waveforms, making it difficult for the doctor to assess.
I wonder if the cause of the APCs is due to abnormal electrical discharges in the atria or if it is related to autonomic dysfunction sending erratic signals to the heart.

Years later, the frequency of episodes is irregular.
Once, I couldn’t control it, experiencing continuous premature contractions and palpitations, with my heart rate reaching 170 bpm.
I recall thinking this warranted a visit to the emergency room.
However, when I sought help from someone I knew, a cardiologist, they dismissed my concerns, measuring my heart rate with a blood pressure monitor and not considering it exceeded normal limits, only suggesting I go to the ER.
After undergoing various tests, I still couldn’t find a cause, and it took about an hour for my heart rate to return to normal.
Now, how can I clearly inquire about the cause of these abnormal heartbeats? (Online sources state that premature contractions are caused by abnormal electrical discharges in the heart and can occur in normal individuals.) There have been instances when I experienced episodes on my way home from exercising, triggered by anxiety over safety concerns.
After exercising, my heart rate hadn’t decreased, leading to more premature contractions, making it difficult to calm down.
During these episodes, I sometimes feel a strong heartbeat, and performing self-relaxation techniques helps me feel more comfortable.
Other potential triggers include cold weather, muscle tension, and encountering anxiety-inducing stimuli.
Given that normal values and occurrences in healthy individuals are still likely not due to abnormal electrical discharges in the heart, the episodes cause panic and anxiety, with the frequency of panic attacks being unpredictable.
Resting ECGs or 24-hour ECGs may not always capture these events.
Is there a way to investigate this further? For now, I can only focus on stabilizing my autonomic nervous system with psychiatric medication to manage daily life.

Another issue I have is that when I doze off at night without fully waking up, I experience myoclonic jerks in my eyes.
The attending physician mentioned this is related to my autonomic nervous system and psychogenic issues, but I worry that this sensation might extend to my heart, fearing it could be atrial fibrillation.
I’m also unclear if these myoclonic jerks can occur in the myocardium.

ZZZ, 30~39 year old female. Ask Date: 2024/03/05

Dr. Wu Xueming reply Cardiology

Atrial premature contractions are not the same as atrial fibrillation; they can occur in normal individuals.
Myoclonic jerks can also manifest in the myocardium.
Many factors in daily life can contribute to this condition, such as emotions, stress, irregular sleep patterns, or excessive caffeine intake.
It is advisable to adjust your lifestyle and engage in regular exercise.
If symptoms persist, it is recommended to seek assistance from a psychiatrist or a psychosomatic medicine specialist.

Reply Date: 2024/03/05

More Info

Atrial Premature Contractions (APCs) are a common type of arrhythmia characterized by early heartbeats originating from the atria. They can occur in healthy individuals and are often benign, but they can also be associated with underlying heart conditions or autonomic nervous system imbalances. Understanding the causes and management strategies for APCs is crucial for patients experiencing symptoms such as palpitations or anxiety related to their heart rhythm.

Causes of Atrial Premature Contractions
1. Structural Heart Changes: Conditions like mitral valve prolapse (MVP), which you mentioned, can predispose individuals to APCs. MVP can lead to changes in the heart's structure and function, potentially causing ectopic foci in the atria that trigger early contractions.

2. Autonomic Nervous System Imbalance: The autonomic nervous system regulates heart rate and rhythm. Stress, anxiety, and panic attacks can lead to increased sympathetic activity or decreased parasympathetic tone, resulting in APCs. Your experience with panic and anxiety suggests that these factors may be contributing to your symptoms.

3. Electrolyte Imbalances: Abnormal levels of potassium, magnesium, or calcium can affect cardiac excitability and lead to premature contractions.

4. Stimulants: Caffeine, nicotine, and certain medications can provoke APCs. If you consume these substances, it may be worth evaluating their impact on your heart rhythm.

5. Other Factors: Conditions such as hyperthyroidism, sleep apnea, and excessive alcohol intake can also lead to APCs.

Management Strategies
1. Lifestyle Modifications: Reducing caffeine and alcohol intake, managing stress through relaxation techniques, and ensuring adequate hydration can help minimize the frequency of APCs.

2. Medications: Beta-blockers like propranolol can be effective in controlling symptoms associated with APCs, especially if they are linked to anxiety or autonomic dysregulation. It seems you have been prescribed propranolol, which can help reduce the frequency of these contractions and alleviate palpitations.

3. Monitoring: Continuous monitoring through Holter monitors or event recorders can help capture APCs during episodes of symptoms. This can provide valuable information to your healthcare provider regarding the frequency and context of your APCs.

4. Psychological Support: Since you have experienced panic attacks and anxiety, working with a mental health professional can be beneficial. Cognitive-behavioral therapy (CBT) and other therapeutic approaches can help manage anxiety symptoms, which may, in turn, reduce the frequency of APCs.

5. Further Evaluation: If APCs are frequent or symptomatic, further evaluation may be warranted. This could include echocardiography to assess for structural heart disease or electrophysiological studies to evaluate the electrical activity of the heart.

Addressing Your Concerns
Regarding your specific questions about the nature of your APCs, it is essential to understand that while APCs can be caused by ectopic foci in the atria, they can also be triggered by autonomic nervous system imbalances. The fact that you experience these contractions during stressful situations suggests a potential link to your autonomic regulation.

As for your concern about the muscle twitching you experience at night, this is likely related to your autonomic nervous system and may not directly involve the heart muscle itself. However, if you have concerns about atrial fibrillation or other serious arrhythmias, it is crucial to discuss these with your healthcare provider. They may recommend further testing or monitoring to ensure that your heart rhythm is stable.

In summary, APCs are often benign but can be influenced by various factors, including structural heart conditions and autonomic dysregulation. Management typically involves lifestyle changes, medication, and psychological support. If symptoms persist or worsen, further evaluation may be necessary to rule out any underlying conditions. Always consult with your healthcare provider for personalized advice and treatment options.

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