Oct 3, 2013

Tachycardia, Arrhythmia

Last updated: May 16, 2014

This post summarizes my experiences with episodes of tachycardia and accompanying arrhythmia. My earlier posts, which partly were journals of events as they happened, were:
(1) March 30, 2011: http://www.anti-itisdiet.blogspot.com/2011/03/metoprolol.html
(2) January 25, 2011: http://www.anti-itisdiet.blogspot.com/2011/01/my-atrial-fibrillationflutter-adventure.html

EPISODES. Through the last twenty years, I have had five episodes of tachycardia (rapid heart rate). 

EPISODE 1. The first episode, in Portland, Oregon occurred around twenty years ago, after Christmas day, about thirty minutes after an extraordinarily large evening meal. I was out walking and bent over to retie my shoe laces. Emergency medical people said my rate was about 175 beats per minute (bpm). In an emergency room of a hospital, a doctor injected a substance (unknown to me now) that stopped the racing and restored my normal rate of about 65 bpm.

EPISODE 2. The second episode occurred about five years ago, in Auburn, Washington, shortly before Christmas day, about thirty minutes after a very large evening meal, while I was cleaning my kitchen. An emergency room doctor tried but failed to stop the racing heart by injecting a substance through a tube. Doctors there persuaded me to stay in the hospital to test the functions of my kidneys, liver, thyroid, and pancreas. All were operating normally. The doctors also checked my lungs for an embolism and found none. Likewise, a CAT scan revealed no brain tumors or other problems. Finally after three days of testing, the doctors said "cause unknown" for the racing heart and slight arrhythmia (either atrial fibrillation or flutter, but the diagnosis was not clear). About three months later, I underwent electrical cardioversion, a shock to the heart, and it succeeded in returning my rate to normal and without arrhythmia.

EPISODE 3. A year after the e-cardioversion success my heart rate again went into tachycardia. This was my third episode; it occurred in Shelton, Washington. This episode happened in early March while I was sleeping—after a very large evening meal. The emergency room doctor was unable to stop it. They released me (at 2 am) to return home. My rate was about 135 bpm. This episode ended after about six months of medication (described below) designed to lower the heart rate.

EPISODE 4. A fourth episode occurred, also in Shelton, about a year later, again in March (2013) and again in the evening after a large meal eaten hurriedly and without adequate chewing. This episode ended after about nine months of medication—and three months of taking Vitamin D3 (1000 IU three times weekly).

EPISODE 5. My fifth episode began on April 29, 2014, after about four months of no tachycardia or irregularity (December 2013 to April 2014). The event started in the evening. The immediate trigger was eating a meal too quickly. I bloated. Then after dinner I bent over to untie my shoe laces. My heart began racing. I could not stop it with deep breathing and back bends. Compression of the heart seems to have been the cause. I began taking 50 mg Metoprolol and 0.25 mg Digoxin. In the following two weeks I went through the familiar stages: (1) At first the medications seem to have little effect; (2) after a few days the heart rate dropped into the 80s; (3) on May 11 (much sooner than in earlier episodes), my heart rate dropped into the 40s-50s. I needed to cut back my walking and walk more slowly too. I reduced my digoxin to 0.125 mg, and then after a few days, deleted it as my heart rate continued to be in the 40s. This episode has shown faster recovery than ever before.

SUMMARY. There is a general pattern: onset in the dark months of December through April; often in the evening after hastily eating a large meal; often following compression by bending over, though twice the racing heart rate began in my sleep.

MEDICATIONS. In the first episode, the ER physician released me from the ER without prescribing any medications. In the second episode, while I was in the hospital for the long series of tests, the physician prescribed 100 mg of Metoprolol, taken daily, which is the standard dosage. (The range of dosage is now about 25 to 400 mg/day.) I said I preferred to start at the bottom of the range and work up if that amount was insufficient. (The purpose of Metoprolol is mainly to reduce the heart rate, although it also lowers blood pressure.) The doctor insisted on 100 mg that first day. That night, the hospital monitors sent an alarm to the head nurse because my heart rate down into the low thirties. The nurse said I might be a hyperresponder.) The doctor adjusted the dosage to 50 mg. That brought my heart rate down to the mid forties in the following night, but no lower. (Normally, without medication, the heart rate is lowest in the deepest part of sleep, typically about four or five in the morning.)

After leaving the hospital in the second episode, I began working with a non-interventionist cardiologist, Dr. VK. After long discussion, he recommended that I try the first step in the staircase of treatments available: electrical cardioversion. Preparation for that treatment was long: about 10 weeks of treatment with a variety of drugs designed to shape my heart's action. Dr. VK said my arrhythmia was difficult to diagnose. He was not sure whether it was atrial flutter or atrial fibrillation. After a treadmill and other tests, he decided on atrial fibrillation.

During this period of preparing for e-conversion, I took Pradaxa (an expensive, strong anti-coagulant), which I used reluctantly, Multaq (apparently designed to "shape" the rhythm of the heart beat), and Metoprolol (50 mg, time release). I took the Metoprolol at breakfast and the other pills at lunch and dinner. 

The time release version of Metoprolol, which is more expensive, is supposed to have a steady effect of lowering the heart rate throughout the day but loses its strength somewhat very late at night when the heart rate is normally lower already. Even the low dosage of 50 mg made me very sleepy after breakfast for about two hours. (Fortunately I am retired and do not need to drive, which would have been dangerous.) Another result for about one month was intestinal upset (gas, loose stools), but this diminished with time. I suspect that the Multaq (prescribed for only a month or so as preparation for e-conversion) and the Pradaxa also contributed to the upset.

After the successful e-conversion, ending my second episode of tachycardia, I took 50 mg of Metoprolol and an 81 mg aspirin daily. (The aspirin, like the Pradaxa, is designed to reduce the chance of a blood clot forming in the heart, when the heart is not operating properly; the clot can be expelled from the heart and into an artery, thus blocking the artery and causing a stroke.)

After the onset of my third episode, I again took 50 mg of Metoprolol. I had much less intestinal upset, and even that diminished within two weeks or so. The gut does seem to become accustomed to the Metoprolol.After my fourth episode has ended, I continued to take 50 mg of Metoprolol. I also continued to take Digoxin. One of my physicians recommended it as a way of addressing the slight atrial flutter that accompanied the fourth episode of tachycardia. 

The prescription for Digoxin for my fourth episode was for 0.25 mg. I started by taking it at dinner. (I always take these heart tablets in the middle of meals unless the doctor says otherwise.) It seemed to make me jumpy. Going to sleep in the evening was difficult, which was unusual for me. I switched to taking the Digoxin at lunch, and that ended the jumpiness and sleeplessness.

After about two months of taking 0.25 mg of Digoxin (an extract from Foxglove, the drug that painter Vincent Van Gogh was taking when he cut his ear off with a razor), I began having vision problems: bright lights seemed to flicker. I also felt a little disoriented and I was not able to walk straight. I cut the Digoxin tablets in half, and the problems went away. (Any pill that has a "score" down the middle can be cut in half.)

My cardiologist for my second episode, Dr. VK, convinced me that even if the tachycardia disappeared, I should continue taking the Metoprolol for the remainder of my life, as a way of reducing the chance of the problem returning. That is why now, after my fourth episode has ended (lasting six months), I continue to take it. For the moment, I will also continue the 0.125 mg of Digoxin. I may wean away from it in a month or so and judge the effect.

JOURNAL OF READINGS. I measure and record my heart rate and blood pressure at least once daily, usually about 30 minutes after breakfast. Meals make the rate go up. The lead up to a bowel movement makes the heart rate go up. Of course any other physical or emotional event (such as reading the news) can elevate the heart rate and blood pressure. 

USUAL CAUSES. According to what I have read and have been told by physicians, the usual trigger for tachycardia is one or more of these: surgery (and the anesthesia); overweight; severe long-term stress; liver problems; kidney problems; brain tumors; embolisms in the lung; alcohol; stimulants (such as strong coffee); thyroid problems. Most victims of tachycardia are old, overweight, and damaged through an unhealthy lifestyle. However, some victims of tachycardia are young athletes—such as basketball players and runners—who subject their heart to long-term physical stress.

I am old (70), but my first episode occurred 18 years ago. I have been lean or very lean (now Body Mass Index of 18) for most of my adult life. I have frequently pushed myself physically (running up the steepest hills for the challenge of it, for example), and pushing myself to work very long hours without adequate relaxation. I still do not know the long-term cause of my tachycardia episodes, but I suspect that the physical pressure of eating too much volume was probably the direct trigger in each case.

BEHAVIORAL CHANGES. Why did my fourth episode of tachycardia stop by itself? Why was my fifth episode so short and stopped by itself? Possible causes are:

(1) Curative effect of taking Vitamin D3 for several months. I was taking a standard, low dose of 1000 IU three times weekly. This seems to me, a layman, to be the most likely cure. Inadequate Vitamin D intake was the most likely cause of the tachcardia: All four onsets began in the December to March period of the years, the time when my Vitamin D level would be lowest. On my diet, I take in no Vitamin D from food (no fish, for example) and I live in rain-forest country, where, even walking outside two hours daily, I receive little sunshine from September to May.

(2) A cumulating effect of the medications. Does the Metoprolol "train" the nerve to fire at a slower rate? I do not know.

(3) Stopping  "pushing" myself when I walk; I now still walk up steep hills, but I do so slowly, without accelerating my heart rate much. I continue to walk two hours daily, but I cover less distance.

(4) Avoiding stressful situations such as reading the news. I can do nothing about the events featured in the news. They make me angry or sad, but I have no way to correct them. Now, when eating, I read a novel instead of reading the news stream of mostly terrible events.

(5) Monitoring myself: Am I physically and mentally relaxed? Am I focused on one task? Being relaxed does not mean being unproductive or working less.

(6) Stretching more, especially before sleeping.

(7) Resting more. A short nap can reduce my heart rate by 20 bpm.

(8) Avoiding all stimulants, but still drinking sufficient liquid. I avoid coffee, black tea, green tea, and even herbal teas that might stimulate the heart rate. The only teas I drink at the moment are Lemon Balm and Mint and occasionally "Nighty Night," a mixture designed to encourage relaxation and sleep. By drinking one cup of herbal tea or water (with or without a squeeze of lemon) after each meal, I consume plenty of liquid. Plus, most of my meals are either potato stew or steamed rice (which absorbs a lot of water in cooking).

(8) Being objective, by which I mean focusing on objects directly in front of and not worrying about real or imaginary events occurring outside of my life. This focusing includes engaging in one task at a time and not multitasking. Often slower is faster.

(9) Chewing my food thoroughly and eating slowly, without stress.

Burgess Laughlin
Author of The Power and the Glory: The Key Ideas and Crusading Lives of Eight Debaters of Reason vs. Faith, described here

P.S. If you have successfully stopped your own tachycardia episodes, please comment below.

1 comment:

Paul said...

I do hope it goes away for you, looks like you got most bases covered.