HELP interpreting autonomic testing results

[TorturedSoul]

I'm very confused. I went to Brigham because I have been struggling so much with autonomic symptoms. Lightheadedness and shortness of breath are my most severe symptoms. I literally have crashes where I feel so weak and often have episodes of "hyperventilation". I was so hopeful to go see Dr. Novak. I waited a year. Then after the testing I get a call saying results are "essentially normal" and no follow up needed. I look at the results in my portal and it says: during tilt CBFv declined by 17.5% and it was due to hypocapnic induced cerebral vasoconstriction. Blood pressure and heart rate responses were normal. CO2 normal during supine position but hypocapnic hyperventilation upon standing. So this is exactly what he has researched and discovered and yet he said no follow up needed. Does this make sense? What can I do to treat this? 

[bumpkin]

That's a long time to have waited for testing, just for them to tell you it's essentially normal, when the report mentions hypocapnia and cerebral vasoconstriction right on there.. I'm sorry you're dealing with that, doesn't get more frustrating than waiting forever and having the experts seemingly blow you off like it's supposed to be fine. 

I don't know how to interpret it, but is there an option in the portal to send the doctor a message? Maybe just to play dumb and say "Am I understanding my results correctly?" Or if you can call and see if a nurse would relay whatever questions you have.. Maybe they'll elaborate more instead of leaving you hanging.. ya didn't wait a year to see them to be left with more questions!

Sometimes the doctors idea of normal seems to just mean that they accept we are suffering but since we're still stable it's normal by their standards. Kinda like all the pointless ER visits some of us have gone through, since we weren't dying.. apparently everything was normal. I'd imagine even an autonomic specialist has a line drawn where they won't dig too much deeper if the blood pressure and heart rate aren't bad enough. 

Right there with ya though.. The CO2 reading on my home air quality monitor when I'm in a room alone will routinely reach 1200+ppm, some nights 1500ppm. 5 months ago (and for the year I'd owned it before the POTS symptoms struck), it was always right around 600-700ppm.. but we can be hyperventilating and not even know it til the lightheadedness and shortness of breath knock us off our feet. 

As far as how to treat, it depends on the root cause. Between the organic acids testing that my doctor had me do, and my history of gut issues and mold exposure etc, my hypocapnia seems to be tied into the relative hypoglycemia and low norepinephrine. All I'm currently doing about mine is trying to treat the gut for clostridia and mold, and trying to supplement to help get my very high dopamine levels back down to normal, so that the norepinephrine is balanced out. My own blood pressure and heart rate issues are not nearly as bad as many people on here.. my bp is just low enough to make me miserable, and the cerebral hypoperfusion and adrenaline surges are just enough to scare the h*** outta me.

Hang in there!

[TorturedSoul]

@bumpkin thank you for responding so quickly. When I have my "crashes" and feel so weak the adrenaline surges and hyperventilation episodes are absolutely frightening.  I'm assuming the most severe episodes are the result of a larger decline in cerebral blood flow than usual. I don't know. This is a scary place to be. I feel like I'm dying sometimes and when I go to the ER when the hyperventilation episodes are escalating they just say it must be anxiety. It is so frustrating and honestly my daughter has similar symptoms and it just breaks my heart that I may have passed on this monster. What doctor do you see? 

[bumpkin]

Np, I happened upon the thread and knew the feeling, plus your user name is all too relatable 🥲

Apologies in advance for this lengthy reply, I try to put stuff into context as best I can. 

When I went to the ER the other night the doctor there actually knew what dysautonomia was and she was even curious to know whether I was a hypermobility case (I'm not), she said she felt bad that they can't run more than just the basic tests. That's ok, it was 3am and I just needed to make sure it wasn't a heart attack, or plummeting electrolyte levels again.. It's hard to stay on top of nutrition when you're living in a fog, and honestly electrolytes are tedious, since I can't tolerate the packets or sports drinks anymore it's been this whole mess of my cognitively impaired self trying to make sure I get plenty of nutrients from food and without losing track and overdoing it.

I am really trying to get ahead of the symptoms to avoid future ER visits, because I know they're gonna start thinkin I'm silly.. Thankfully they don't usually accuse me of anxiety, whenever it does come up I just tell them that I don't deny my body is in an anxious state, but it getting that way had nothing to do with my mental state, it's allllll nervous system.

Apparently now there are direct lab sites we can order our own discount tests from.. it's still another expense, BUT if we know what to look for (thanks to swapping stories on forums like this one), then having the labs done on our own can help get us answers quicker.. because the ER isn't going to look, my regular traditional healthcare providers aren't going to look, and they seem to pace our care like we're all the same body being fed into the system.. it's CBC panel, Metabolic panel, seeya in a few months to follow up, repeat. 

The dread and dying feeling is seriously awful, and I don't know how I'm finally beginning to get comfortable with it but that almost scares me worse since we're supposed to listen to that instinct.. I guess I've learned for right now I'm safe and it should pass... Like tonight's been up and down, I spent too much time on my feet this afternoon and my brain has been paying for it all evening, so I tell myself it'll be ok "just need to lay in bed and take in more salt and water, put the phone down (all that blue light is h*** on our brain), breathe.."  It's all brown paper lunch bags and cans of carbonated water over here (I reach for the paper bags a few times a week, the carbonated waters are usually one or two in a day... With the exception of salt, my body has trained me very well to respect the need for moderation and balance). So yeah, that's how I've been managing. 

As for doctors, I go to a functional neurologist chiropractor in PA, when I first looked into the functional neurology stuff I noticed more of them seem to be popping up around.. I like how they take a very practical approach. I've always been a little leery of the types of clinics that target certain chronically ill patient subsets (like the ones for CFS, or for Long Covid/Post Covid, or even some of the Dysautonomia clinics reviews I've seen are concerning), my partner has had ME/CFS for several years and from all the research we've done trying to find more support to add to his treatment team, it seems like there are very few good ones out there compared to how the number of clinics is growing.. then when you look at what most of them are charging patients compared to what the patients are reporting they get out of it, the moneygrab becomes clear.. seems like a lot of them don't even stick around too long they get into the business and make a killin and then get out. 

So I was extremely fortunate that my functional primary referred me to the functional neuro, that they turned out to be solid human beings, and they have seen me through this entire mess.. I'd say it's definitely worth finding a reputable one nearby to be able to count on seeing in person, or even calling ones far away just to ask if they know of ones more local to you (the good ones will network), some of them will offer virtual consults that could still help you steer treatment. 

I'm sorry it's affecting your daughter as well, I will say at least you really care enough about the situation to feel bad about the possibility of it being genetic, because some parents out there will just laugh these things off like the kid is stuck with it too "oh well that's life" and it's so lousy when they do because it can leave a person feeling really lost. But you'll get to the bottom of what's going on with yourself and then you'll be able to help her through it, it's just a matter of figuring out what's triggered it and how to calm things down and bring things back to homeostasis again. 

I sincerely hate to ever suggest mold as a cause because I know firsthand what a total nightmare it is, but on the chance that it isn't actually anything genetic but possibly environmental that's affecting both you and your daughter, you could try something like Immunolytics or MicroBalance online to order some agar mold test plates to test your home and help rule it out. Mold exposure is known to cause dysautonomia.. for years I wondered why I never had POTS from it like most people complain of, just had the temperature dysregulation and occasional MCAS symptoms from it.. but then I finally quit the 4-5 energy drinks I was pounding every day (ironically never had palpitations 'til I quit 'em), and there the POTS was.. all that caffeine and the B vitamins, l-carnitine and taurine in those had propped up my system for years, it's remarkable but now I can't even really tolerate caffeine anymore, so there's no going back lol, most days I wish I could (I was still barely getting through the days back then anyway though) but now that I've got decent doctors on my side I feel like I'm on the path to actually healing (and without all that excess sugar causing more inflammation). 

[TorturedSoul]

@bumpkin hmm interesting about the mold, but my daughter has had symptoms since birth. We moved a couple of times too. Honestly, it would be one thing for me to be suffering, but knowing I may have passed on this "monster" breaks my heart. That's why I made an appt with Dr. Novak. Hope and answers for my family. For him to say it was "essentially normal" and to follow up with my neurologist confuses me since the report says my results are abnormal. Well the autonomic and tilt table was normal. It was the cerebral blood flow during tilt that was abnormal with almost 20% decline in blood flow upon tilt. When I had my "crash" I kept telling the doctors it's not a panic attack in the sense that it's psychological,  something is happening physically that is making my body panic. I kept telling them I feel like something is wrong with the blood flow to my head. No one took me seriously. When I read Dr. Novak's research I was excited in a way bc it sounded like my struggles. During my crash I would hyperventilate even walking or after eating. The blood flow everywhere felt so off. Even weird feelings in my abdomen. Honestly it felt like I was bleeding out and I felt incredibly weak like my muscles were jello. I suffered for a year. The extreme lightheadedness got better after a round of Cipro for a UTi which is so weird. The suffocation feeling at rest only got better when I drank 2 bottles of salt water a day. It's the only thing that gave me relief.  I would love to see a functional neurologist. I live in NJ. I'll have to do some research. The report says hypocapnic hyperventilation upon tilt. I'm trying to research, but I don't see any treatments for this. Do you have a similar diagnosis? We share a lot of symptoms. 

[Amyschi]

Bumpkin, Could you explain further what your feeling of "dread and like you are dying" feels like?(although that is an excellent description).    I have had dysautonomia for many yaars, but have just started getting this feeling regularly for the past few months   It is the scariest thing I have ever experienced.  It is difficult to describe.  I started out waking up with this sensation along with internal shaking and sometimes tachycardia, but now I can feel it at any time of day - it come over me  like a wave and definitely feels like something physcial that overtakes you.  .  Is this what you experience?.   I have read too that you should not ignore this symptom and seek immediate help, as it can be the body's way of warning you that something major is happening.  I'm sure you are younger than I, but at my age of 65 now, it is more concerning.  But Thank you.the fact I have gotten it so often is a little reassuring.   My norepinephrine levels have been high in the past, so assuming it is part of adrenaline surge, but just don't know. 

[TorturedSoul]

@Amyschi I know your question wasn't directed at me, but I have felt the dread, doom, and death feeling on multiple occasions followed by "hyperventilation" symptoms that have sent me to the ER. What the doctors never seemed to understand was that there was something physical happening not psychological. Coincidentally, during my most severe crashes my d-dimer is always elevated so when I go to the ER they always do a CT scan to check for a clot. It almost feels like that could be the cause because it could be a sudden feeling of doom and weakness and difficulty breathing. It always comes out clean. Now I have some information with the testing in Brigham. It's the cerebral blood loss that is most likely triggering these symptoms , but I still don't know why. Why when I stand up am i hyperventilating in the first place? When I lay down I'm not. It's all so overwhelming. Yes I do get worried because I feel the doom and "dying" feeling a lot and I have to stop myself from going to ER. I often wonder if it is something like a clot or a heart attack I would never know the difference. Scary place to be.  

[bumpkin]

On 3/7/2024 at 4:23 PM, TorturedSoul said:

@bumpkin hmm interesting about the mold, but my daughter has had symptoms since birth. We moved a couple of times too. Honestly, it would be one thing for me to be suffering, but knowing I may have passed on this "monster" breaks my heart. That's why I made an appt with Dr. Novak. Hope and answers for my family. For him to say it was "essentially normal" and to follow up with my neurologist confuses me since the report says my results are abnormal. Well the autonomic and tilt table was normal. It was the cerebral blood flow during tilt that was abnormal with almost 20% decline in blood flow upon tilt. When I had my "crash" I kept telling the doctors it's not a panic attack in the sense that it's psychological,  something is happening physically that is making my body panic. I kept telling them I feel like something is wrong with the blood flow to my head. No one took me seriously. When I read Dr. Novak's research I was excited in a way bc it sounded like my struggles. During my crash I would hyperventilate even walking or after eating. The blood flow everywhere felt so off. Even weird feelings in my abdomen. Honestly it felt like I was bleeding out and I felt incredibly weak like my muscles were jello. I suffered for a year. The extreme lightheadedness got better after a round of Cipro for a UTi which is so weird. The suffocation feeling at rest only got better when I drank 2 bottles of salt water a day. It's the only thing that gave me relief.  I would love to see a functional neurologist. I live in NJ. I'll have to do some research. The report says hypocapnic hyperventilation upon tilt. I'm trying to research, but I don't see any treatments for this. Do you have a similar diagnosis? We share a lot of symptoms. 

I was thinking the same, I only ever had poor man's tilt tests done at my drs but yeah every time I complain to my docs about my various symptoms flaring up, they reassure me it's from the hyperventilation, hypocapnia, and hypoglycemia reaction.. It took me awhile to fully wrap my head around it all because I didn't realize all the missteps I was still making by trying to eat and do the things I used to, and do them the way I used to do them.. I've had to slow myself down a lot, no more hopping out of bed or up from my seat etc. And thanks to the organic acids test (expensive as it was), I know where about my catecholamine levels are and how that all tracks with my symptoms, because the low norepinephrine can definitely cause all the crap I've been feeling. I'm trying to get another one done soon since it's been about 6 months and I really wanna see where things are at now. 

Lately I'm minding my carbs and being mindful to drink plenty of salt water, eat lighter meals, and snack a little more often. Last month I had a half dozen adrenaline surges and a really horrible degree of cognitive impairment, but so far for March, I only got the racing heart when I waited too long to go pee the other night.. Something with the bladder signal and the nervous system it'll bug right out if I hold it. Still feel like death at least once a day, but I just tell myself to relax, drink some more salt water, reduce external stimuli and keep resting in bed until it eventually passes, and it always does. 

 

It's definitely worth looking around for a good functional that you like, I know some will do trial consultations to make sure everybody's on the same page since it's not everyone's cup of tea. I hadn't started making any progress on my chronic fatigue at all til I stumbled upon a good functional medicine primary and started getting some real answers (my traditional drs back then just kept telling me it's just anemia, allergies, depression, anxiety etc, when I was never depressed..and the anxiety only stemmed from my bosses being highly annoyed with the chronic illness I was struggling to get treated and burning thru all my sick days).

It does suck when the functional ones don't take insurance (usually they can at least do a superbill if your insurance covers out-of-network), but it seems like everything hinging on the insurance has only ever held me back anyway, and I'd rather pay someone directly whose own business hinges on them working to successfully help their patients, vs paying copay after copay going towards being patronized and told I'm just depressed etc (I was actually healthier back then, had never met any depression cases who got up and showered every day, groomed, went to work, ate three square meals and snacks, enjoyed their hobbies, looked forward to making plans and socialized as often as their schedule allowed, and more or less slept all through the night.. but nope, it must have all been in my sad head 😂)

I get a weird feeling in my abdomen sometimes too, I know what you mean about the blood flow, I'll catch myself tensing my stomach muscles without realizing it trying to make the feeling pass. 

 

The fact that you felt better on Cipro, I would think suggests that the antibiotic had started killing something else off that was causing trouble, but the work it was doing would've been cut short when the UTI course ended, and you know what they say about always finishing the full course when treating for certain infections.. could be there's another underlying chronic infection it was helping with, but just wasn't a long enough course to fully address it. 

If you're curious about microbe and gut stuff and how it impacts different conditions you could check out Microbiome Prescription, it's a pretty wild site but they have a big database of all the ways they've found the gut microbiome can be manipulated, and they compare their own test results to healthy peoples to try to remove and add things into their diet in order to bring their counts into balance to put their conditions into remission, it's all based on research studies and case studies, etc. If I recall correctly, the guy who runs it is a statistician with CFS, so the site itself is really way over my head but some of his blog articles help break it down a little better, it's interesting stuff. 

When you consider the gut brain axis and how our gut health and our hormones and catecholamines play into everything, it makes a lot of sense that there's probably some gut imbalance at the center of different dysautonomia conditions, it just takes some doing to get to the bottom of it and a team of drs willing to find the root cause. 

For me the idea of having to live around these symptoms another year scares the h*** out of me, let alone to go decades like some people have had to.. there has to be a way back that doesn't involve begging traditional doctors to run the right tests and make the right inferences from them.. I really don't want to settle for going back on pharmaceuticals, I'm not comfortable going that route after mainstream medicine let me down so much in the past..

Suffice to say I'm real big on second, third, fourth opinions these days lol.. I can't believe how much time and health I lost until I found some drs who really think outside of the box. 

Here's hoping you can get some guidance soon on what the next step should be, nobody should be told their hypocapnic hyperventilation is normal, it's an awful symptom that needs looking into further.. You know something's causing it to happen, and hopefully nailing down the cause will mean treating it and moving on from the horrible symptoms. 

[bumpkin]

On 3/7/2024 at 6:39 PM, Amyschi said:

Bumpkin, Could you explain further what your feeling of "dread and like you are dying" feels like?(although that is an excellent description).    I have had dysautonomia for many yaars, but have just started getting this feeling regularly for the past few months   It is the scariest thing I have ever experienced.  It is difficult to describe.  I started out waking up with this sensation along with internal shaking and sometimes tachycardia, but now I can feel it at any time of day - it come over me  like a wave and definitely feels like something physcial that overtakes you.  .  Is this what you experience?.   I have read too that you should not ignore this symptom and seek immediate help, as it can be the body's way of warning you that something major is happening.  I'm sure you are younger than I, but at my age of 65 now, it is more concerning.  But Thank you.the fact I have gotten it so often is a little reassuring.   My norepinephrine levels have been high in the past, so assuming it is part of adrenaline surge, but just don't know. 

It's like a wave of impending doom that washes over, like your body is signaling something horrible is about to happen to you, but then it eventually passes and you're fine (well y'know, "dysautonomia fine"). But sorry to hear you're dealing with it too, and yeah since they tend to lump risk factors by age I can imagine it's even more troubling, you don't want to run to the ER on a false alarm when you know your body is prone to throwing weird symptoms, and at the same time you're also aware you're not gettin any younger. Don't let it throw you for a loop like that though, as others have said on here in the past: If they get chest pain and heart attack symptoms then they're going to the ER and they're not apologizing for it because they're not taking chances. Really if we could get better healthcare we wouldn't be in this situation to begin with to be worrying and wondering.  

I would think it's got something to do with the adrenaline too, because the feeling is very similar to the awful sense that accompanies panic attacks. 

And right I read that too, and like TorturedSoul said it's scary because how the heck would we know the difference of whether it's a false alarm or a stroke or heart attack? Dysautonomia and strokes and heart attacks aren't mutually exclusive.. so sometimes when it's really bad we drag ourselves to the ER, only for them to hand us a clean or unconcerning EKG, look at us like we're silly and hurry us out. 

Do you get enough time during the day to unwind and rest (like really, really rest)? I know my system gets really buggy and very very panicky feeling if I'm overstimulated from getting hit with too many stressors and spending too much time looking stuff up on my phone (blue light really is bad for us) my body will be completely amped up, my pupils will get weird and everything, I'll hit my limit for interacting and won't be able to handle texting people back for a couple hours.. My last drs followup they could tell right off the bat that I had been through too much the few weeks between appointments. Usually when I get that bad the only thing that brings me back down is vagus nerve stimulation where it literally dials in the anxious feeling and grounds me. I've heard of people doing this at home with an external unit, but I don't know if that's contraindicated by age or medical conditions etc. But trying to stay on top of managing my symptoms and limiting screen time and other stimuli has been helping limit those episodes, where it's not all day for weeks but a couple times a day for shorter periods of time. Still not fun when it happens, but with enough rest and salt water and stabilizing my blood sugar, it passes a little quicker. 

[bumpkin]

@TorturedSoul 

Took me a minute to realize I'd heard of Dr. Novak somewhere before, it was this HealthRising article I read awhile ago, though you've probably seen it already. The blog author Cort is good at summarizing this stuff:

https://www.healthrising.org/blog/2022/03/10/hypocapnia-chronic-fatigue-syndrome-pots/

[Amyschi]

On 3/8/2024 at 10:58 AM, TorturedSoul said:

@Amyschi I know your question wasn't directed at me, but I have felt the dread, doom, and death feeling on multiple occasions followed by "hyperventilation" symptoms that have sent me to the ER. What the doctors never seemed to understand was that there was something physical happening not psychological. Coincidentally, during my most severe crashes my d-dimer is always elevated so when I go to the ER they always do a CT scan to check for a clot. It almost feels like that could be the cause because it could be a sudden feeling of doom and weakness and difficulty breathing. It always comes out clean. Now I have some information with the testing in Brigham. It's the cerebral blood loss that is most likely triggering these symptoms , but I still don't know why. Why when I stand up am i hyperventilating in the first place? When I lay down I'm not. It's all so overwhelming. Yes I do get worried because I feel the doom and "dying" feeling a lot and I have to stop myself from going to ER. I often wonder if it is something like a clot or a heart attack I would never know the difference. Scary place to be.  

Thank you so much - I appreciate you responding!   Interesting about your d-dimer results; shows something is happening   I believe you are right about the cerebral hypoperfusion as a possible cause - maybe the body is sending out a "panic signal?."  What is confusing to me is that I wake up with this feeling around the same time - makes me think it is an adrenaline release.  Good luck to you.

[Amyschi]

On 3/9/2024 at 12:01 AM, bumpkin said:

It's like a wave of impending doom that washes over, like your body is signaling something horrible is about to happen to you, but then it eventually passes and you're fine (well y'know, "dysautonomia fine"). But sorry to hear you're dealing with it too, and yeah since they tend to lump risk factors by age I can imagine it's even more troubling, you don't want to run to the ER on a false alarm when you know your body is prone to throwing weird symptoms, and at the same time you're also aware you're not gettin any younger. Don't let it throw you for a loop like that though, as others have said on here in the past: If they get chest pain and heart attack symptoms then they're going to the ER and they're not apologizing for it because they're not taking chances. Really if we could get better healthcare we wouldn't be in this situation to begin with to be worrying and wondering.  

I would think it's got something to do with the adrenaline too, because the feeling is very similar to the awful sense that accompanies panic attacks. 

And right I read that too, and like TorturedSoul said it's scary because how the heck would we know the difference of whether it's a false alarm or a stroke or heart attack? Dysautonomia and strokes and heart attacks aren't mutually exclusive.. so sometimes when it's really bad we drag ourselves to the ER, only for them to hand us a clean or unconcerning EKG, look at us like we're silly and hurry us out. 

Do you get enough time during the day to unwind and rest (like really, really rest)? I know my system gets really buggy and very very panicky feeling if I'm overstimulated from getting hit with too many stressors and spending too much time looking stuff up on my phone (blue light really is bad for us) my body will be completely amped up, my pupils will get weird and everything, I'll hit my limit for interacting and won't be able to handle texting people back for a couple hours.. My last drs followup they could tell right off the bat that I had been through too much the few weeks between appointments. Usually when I get that bad the only thing that brings me back down is vagus nerve stimulation where it literally dials in the anxious feeling and grounds me. I've heard of people doing this at home with an external unit, but I don't know if that's contraindicated by age or medical conditions etc. But trying to stay on top of managing my symptoms and limiting screen time and other stimuli has been helping limit those episodes, where it's not all day for weeks but a couple times a day for shorter periods of time. Still not fun when it happens, but with enough rest and salt water and stabilizing my blood sugar, it passes a little quicker. 

Thanks so much, Bumpkin.  You understand it completely, and your description is right on.   So right about not knowing when and if to seek out help.  Wouldn't it be nice if someday they invent a machine you could just hook up to, like a BP monitor or EKG, to let you know whether something is going on that is serious and requires immediate help?   You give some very good tips on what has helped you - thanks!   Also interesting that VNS has helped.  I have read a lot about the vagus nerve as it relates to neck issues, which is a definite issue in my case and I believe contributing.    Good luck in your continued journey.  

 

 

[bumpkin]

2 hours ago, Amyschi said:

Thanks so much, Bumpkin.  You understand it completely, and your description is right on.   So right about not knowing when and if to seek out help.  Wouldn't it be nice if someday they invent a machine you could just hook up to, like a BP monitor or EKG, to let you know whether something is going on that is serious and requires immediate help?   You give some very good tips on what has helped you - thanks!   Also interesting that VNS has helped.  I have read a lot about the vagus nerve as it relates to neck issues, which is a definite issue in my case and I believe contributing.    Good luck in your continued journey.  

 

 

No problem, I hope it helps, and you as well! 

Also there is actually a mobile EKG device called Kardia, but I believe it's subscription-based and requires some intepreting (likely something one could learn how to do from watching youtube videos on it). Could be worth looking into maybe it would give some peace of mind

[Amyschi]

On 3/11/2024 at 6:44 PM, bumpkin said:

No problem, I hope it helps, and you as well! 

Also there is actually a mobile EKG device called Kardia, but I believe it's subscription-based and requires some intepreting (likely something one could learn how to do from watching youtube videos on it). Could be worth looking into maybe it would give some peace of mind

I actually do have a Kardia, thank you for suggesting that.  You just download the app and put it on your phone, if anyone is interested, and just place your fingers on the device and it takes the EKG; pretty easy, although quite frequently I do have trouble getting the signal,  Only drawback, but in case anyone is reading and has that problem, I finally figured out that if you hold the device right up to your phone's microphone, it is much better.    There is a paid level, where they offer a better 6-lead device and it also is programmed to allow detection of more abnormalities, but the basic will detect normal sinus, tachycardia or bradycardia for free.