Tachycardia only at night with high TSH afterward

[dizzytizzy]

Does anyone have tachycardia episodes only at night? I've been diagnosed with the general and vague term autonomic dysfunction.  Before diagnosis and starting midodrine, increasing fluids/salt, and wearing compression socks, my BP and HR would increase quite a bit upon standing, though HR increase never exactly fit the requirements for POTS I don't think. EP has said he thinks I have low blood volume and peripheral pooling, though no tests to actually confirm that.

My tachycardia episodes - with HR ranging from 150s to 160s - always occur at night and wake me up.  They either occur during the hours of 4-6am or within one hour of me falling asleep. I usually wake flushed/warm and with a noticeable pounding in my chest/throat. HR is faster than usual for sleeping but not necessarily to the 150+ range yet. By the time I get up to get an ice pack or prepare to possible do a vagal maneuver, the HR is up to 150+. I had always been able to stop these fast rates by bearing down and placing an ice pack on my face with deep breathing - usually works quickly and breaks the cycle and then HR gradually slows back down.

Three nights ago, none of these techniques worked. Took a 30mg diltiazem as EP told me this would work if other techniques didn't though I question the effectiveness of this because it didn't ward off a prior episode a few months ago. The EP had me trialing diltiazem at that time and taking it every 8 hours. I took it at 10pm one night (as usual) and woke a little after 11pm with tachycardia of 150+. Bearing down worked that time and that was also when he switched me to midodrine.

Anyway, the other night I landed in the ER because of the intensity of the episode, lightheadedness, etc. They gave me a bolus of IV fluids and then another bag at a slower rate, which worked to bring HR rate below 100. EKG in ER showed sinus tachy. Only other oddity was lipase was slightly elevated (had eaten a late dinner) and TSH was triple what it had been just 10 days prior when PCP ran my thyroid panel (I have Hashimoto's). Interestingly, TSH has been high each time (though free T3 and T4 are normal) I've landed in the ER with these nighttime issues, which makes me wonder if this is playing a role or is an after effect of whatever is causing the tachycardia. 

As an aside, I had also eaten homemade guacamole that night. Within 20 minutes of eating it, my throat got very itchy and nose congested. I actually was a bit worried I was having some type of allergic reaction although I've eaten guacamole plenty of times. It made me wonder about histamine release/mast cells causing the tachycardia, particularly because I have rather high systemic inflammation based on labs.

I frequently have lightheadedness, palps, and presyncope during the day, but no actual tachycardia when upright. I head to Cleveland in November for a second opinion with Dr. Mayuga at the autonomic clinic. Can't come soon enough!

TL;DR - 

1. Anyone have tachycardia episodes only at night?

2. Anyone have high TSH, but otherwise normal thyroid tests following these episodes?

Edited July 5, 2018 by dizzytizzy
added more symptoms

[StayAtHomeMom]

The only question I have is when is the last dose you take of your midodrine? You don't mention what your blood pressure is during these episodes. Do you have an idea of that too? And you have HyperPOTS, right?

[dizzytizzy]

Last midodrine dose is always taken at least 4 hours before laying down. I also sleep on a reclining sofa, so I don't lay flat either just in case to avoid supine hypertension.  I take my nighttime BP when I lay down and it's always on the lower side around 90/60, sometimes a few points lower. 

These episodes happened well before I started taking midodrine too - they were the original symptom that launched the search into dysautonomia. And nighttime has been the only time I have actual tachycardia (aside from the obvious like exercise). When I've had to call the ambulance, BP has been 120s/60s and 130s/60s. This is after 20-30 minutes of the high heart rates and trying not to freak out further, so I don't feel like those numbers are excessive. 

Wondering if it's more of a drop in BP or blood sugar than actual POTS???

EP just says I have dysautonomia. He won't actually call it POTS, but my suspicion has been that hyperPOTS is the most likely cause if it is truly POTS. Hopefully, my visit to Cleveland in November will net me a more detailed diagnosis. 

[StayAtHomeMom]

I know sometimes HR increases trying to compensate for low blood pressure. But your blood pressure doesn't seem really low. Except maybe the bottom number. My doc told me five hours for the midodrine but either way that doesn't make work because you said it was from before.

Do you have delayed gastric emptying? My sister in law has gasteriparesis and her blood sugar is backwards. Low during the day and high at night. Maybe if your stomach is backwards your body is freaking out trying to digest food? What do you usually eat for dinner those nights? Things heavy or bready? 

[Pistol]

9 hours ago, dizzytizzy said:

Last midodrine dose is always taken at least 4 hours before laying down. I also sleep on a reclining sofa, so I don't lay flat either just in case to avoid supine hypertension.  I take my nighttime BP when I lay down and it's always on the lower side around 90/60, sometimes a few points lower. 

These episodes happened well before I started taking midodrine too - they were the original symptom that launched the search into dysautonomia. And nighttime has been the only time I have actual tachycardia (aside from the obvious like exercise). When I've had to call the ambulance, BP has been 120s/60s and 130s/60s. This is after 20-30 minutes of the high heart rates and trying not to freak out further, so I don't feel like those numbers are excessive. 

Wondering if it's more of a drop in BP or blood sugar than actual POTS???

EP just says I have dysautonomia. He won't actually call it POTS, but my suspicion has been that hyperPOTS is the most likely cause if it is truly POTS. Hopefully, my visit to Cleveland in November will net me a more detailed diagnosis. 

I know from my specialist that they now shy away from classifying POTS or even calling it POTS anymore. It was too confusing, at first everything was POTS and then they found so many sub-types that it was difficult to name them. So now they are trying to call it dysautonomia instead. When he saw my sister he told her that she has what I have ( hyperadrenergic POTS )but in her medical record he called it " a type of dysautonomia with orthostatic intolerance " .

[dizzytizzy]

On 7/5/2018 at 10:54 PM, StayAtHomeMom said:

I know sometimes HR increases trying to compensate for low blood pressure. But your blood pressure doesn't seem really low. Except maybe the bottom number. My doc told me five hours for the midodrine but either way that doesn't make work because you said it was from before.

Do you have delayed gastric emptying? My sister in law has gasteriparesis and her blood sugar is backwards. Low during the day and high at night. Maybe if your stomach is backwards your body is freaking out trying to digest food? What do you usually eat for dinner those nights? Things heavy or bready? 

@StayAtHomeMom I can't recall what I've eaten the other times that this has happened, but the most recent time I had a BLT sandwich for dinner. I had some of that guacamole too, until I realized I may have been having some time of allergic reaction to it and stopped eating it. It wasn't necessarily a heavy meal, but was definitely eaten later at night than usual. 

[dizzytizzy]

@Pistol - Yeah, I can see that my EP is probably trying to do the same thing with the lingo. I think more people became aware of POTS and that led to fewer people realizing it's actually a continuum. At the recent ER visit, I told the nurse that I had autonomic dysfunction and she was immediately like, "Oh, POTS?" So there you go. She seemed rather confused when I was trying to explain there are more types than just the "traditional" POTS. 

[StayAtHomeMom]

9 hours ago, dizzytizzy said:

@StayAtHomeMom I can't recall what I've eaten the other times that this has happened, but the most recent time I had a BLT sandwich for dinner. I had some of that guacamole too, until I realized I may have been having some time of allergic reaction to it and stopped eating it. It wasn't necessarily a heavy meal, but was definitely eaten later at night than usual. 

Try to keep track of what you eat and when. Maybe it is just the reaction to eating too close to bed. I know if I eat a heavy meal or too much food I get exhausted. Like my heart rate is too high.