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Electophysiologist (sp?)


Hoobaid
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My name is Lori and I am new to this forum.

I had an appointment today with my rheumy that suggested I see an Electophysiologist for my POTS. I had been seeing a Cardio but not much luck with helping me cope with my POTS.

Has anyone heard of zapping your heart (not sure all the correct terminology) to help with the Pulse rate from racing to 160+ every time you stand up? I'm going back to my Cardio and then to see this specialist.

Anything anyone has to say would be appreciated.

Thank you!

Lori (Hoobaid)

PS I had fun reading the funny posts last night! :(

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"Zapping the heart" usually means an ablation.

Ablation is RARELY HELPFUL for POTS due to ANS problems and can often make folks WORSE.

Instead of tachycardia, folks start fainting or faint more often.

This has been discussed numerous times in this illness. Perhaps somebody can find the older links on this subject...I know it's been discussed at this site and others.

I would RUN if somebody wanted to zap me. :(

Also some AGGRESSIVE docs will go in to just 'take a look' and can't seem to be able to STOP themselves from tweaking or "zapping" an area.

Hope you get the answers you need.

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"Zapping the heart" usually means an ablation.

Ablation is RARELY HELPFUL for POTS due to ANS problems and can often make folks WORSE.

Instead of tachycardia, folks start fainting or faint more often.

This has been discussed numerous times in this illness. Perhaps somebody can find the older links on this subject...I know it's been discussed at this site and others.

I would RUN if somebody wanted to zap me. :(

Also some AGGRESSIVE docs will go in to just 'take a look' and can't seem to be able to STOP themselves from tweaking or "zapping" an area.

Hope you get the answers you need.

Thank you for the input! I looked the word "ablation" and it took me to a sight that explained it. Thank you so much!

Lori

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Hi there Lori,

I work in/with electrophysiology. i think you are referring to an ablation. ablation is set aside for people who have one of two types of electrical disturbances within conduction pathways, reentry circuits and triggered automaticity. without getting into the nitty gritty of what these two things actually mean, POTS doesnt fall into either of these two type of electrical disturbances, POTS/autonomic dysfunction is neither a reentry circuit or a type of triggered automaticity.

POTS is what is typically referred to in electrophysiology as a type of ''automatic mechanism''. automatic mechanism's trigger heart rhythm disturbances and so the primary culprit is not the electrical properties in the heart itself. causes for these tachyarrythmia's (automatic mechanisms) are triggered from metabolic disturbances, drug toxicity, our lovely and favored (so being sarcastic) increases in autonomic tone (POTS, vagus nerve problems, pooling problems, excessive catecholamine, beta recetpor issues, etc) along with other things...

........an ablation would not fix the tachycardia in automatic mechanisms because POTS and other things that are classified under "automatic mechanisms" are the primary cause for the tachycardia, not an electrical conduction issue. ablation's only work for actual electrical conduction pathway abnormalities.....people who have ablations that have automatic mechanisms as the cause behind the tachycardia usually end up in worse shape symptomatically than before they had the ablation - because the primary problem hasnt been taken care of. the heart is actually the innocent by-stander here.

i'd make sure with an electrophysiologist that it is 100% POTS and not an actual electrical conduction problem.

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Hi there Lori,

I work in/with electrophysiology. i think you are referring to an ablation. ablation is set aside for people who have one of two types of electrical disturbances within conduction pathways, reentry circuits and triggered automaticity. without getting into the nitty gritty of what these two things actually mean, POTS doesnt fall into either of these two type of electrical disturbances, POTS/autonomic dysfunction is neither a reentry circuit or a type of triggered automaticity.

POTS is what is typically referred to in electrophysiology as a type of ''automatic mechanism''. automatic mechanism's trigger heart rhythm disturbances and so the primary culprit is not the electrical properties in the heart itself. causes for these tachyarrythmia's (automatic mechanisms) are triggered from metabolic disturbances, drug toxicity, our lovely and favored (so being sarcastic) increases in autonomic tone (POTS, vagus nerve problems, pooling problems, excessive catecholamine, beta recetpor issues, etc) along with other things...

........an ablation would not fix the tachycardia in automatic mechanisms because POTS and other things that are classified under "automatic mechanisms" are the primary cause for the tachycardia, not an electrical conduction issue. ablation's only work for actual electrical conduction pathway abnormalities.....people who have ablations that have automatic mechanisms as the cause behind the tachycardia usually end up in worse shape symptomatically than before they had the ablation - because the primary problem hasnt been taken care of. the heart is actually the innocent by-stander here.

i'd make sure with an electrophysiologist that it is 100% POTS and not an actual electrical conduction problem.

Thank you so much for all this great info! It is so great to be able to share with others. Now I can have my ducks in a row.

Lori

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I would also get another opinion also if one suggests doing an ablation. The problems that some have had after having it done, give me the creeps and worries me enough that I hope to never have to have it done.

Cardiactec, what exactly is automaticity when it comes to tachyardia? Can they distinguish these by looking at an ekg? I ask because I wear an event monitor and hit it when I feel the tachy coming on or during an episode. It shows sinus tachy. I can get sinus tachy even while sitting, I don't necessarily have to stand and when it does hit while sitting it goes to the 115-120's and stays for about an hour and slowly goes down.

Just wondering if they can pretty much tell by the ekg's rather than going in and doing ep studies.

Thanks.

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I would also get another opinion also if one suggests doing an ablation. The problems that some have had after having it done, give me the creeps and worries me enough that I hope to never have to have it done.

Cardiactec, what exactly is automaticity when it comes to tachyardia? Can they distinguish these by looking at an ekg? I ask because I wear an event monitor and hit it when I feel the tachy coming on or during an episode. It shows sinus tachy. I can get sinus tachy even while sitting, I don't necessarily have to stand and when it does hit while sitting it goes to the 115-120's and stays for about an hour and slowly goes down.

Just wondering if they can pretty much tell by the ekg's rather than going in and doing ep studies.

Thanks.

Thank you for your reply. My pulse rate jumps to 100-110 during and after I eat.That's about the only other time. My problem is my BP goes down so low that if I had this done where it leave me? Fainting?

Lori :(

hi lori,

welcome around!

i can't really help you with your question as i don't know what "zapping the heart" means. maybe someone else can help you out? just wanted to welcome you!

corina :)

Thank you for the welcome! :)

Lori

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Hi Hoobaid

Just a posting tip, you do not need to do entire quotes on people NOR each time you post....you can basically just address the person you are answering by stating their name.

And if you need to quote, just use the main sentence or two to which you are referring. Usually we can figure it out unless you need to quote something you do not understand or that's convoluted.

Saves us from rereading posts all the time.

Thanks

Sophia

:(

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Hi mom4cem,

"automaticity" refers to the ability of cardiac cells to generate electrical impulses on their own, automatically. cardiac cells are the only cells within the body with this capability. with every cell there is an established electrical charge which propagates throughout the heart to other nearby cells (to cause them to help the muscle of the heart to contract). even though the cardiac cells have this function to work or start electrical impulses on their own, there are things that can alter automaticity....things to either enhance or depress the way the cells fire their electrical stimulus. the sinus node and the av node are richly supplied by nerve fibers of both sympathetic and parasympathetic activation moreso than anywhere else in the heart. if their is an abnormality with the autonomic nervous system (the autonomic nervous system is both composed of sympathetic and parasympathetic nervous system), than it can cause the automaticity of cells to "change" how they generate their electrical impulse to the rest of the heart.

the sinus node (the pacemaker of the heart, where NORMALLY all electrical impulses begin in the heart) is richly supplied by sympathetic and parasympathetic fibers. for example, when their is enhanced sympathetic tone (too much catecholamine's in the blood, beta receptor problems, etc), fight or flight response is the kicks in - when this happens, for example if you get scared, sympathetic nerves are triggered that are sensed within the sinus node (where the fibers hang out) which in turn causes the shape of electrical action within the heart's cells to change, which causes a change in how those cells fire, in this case a faster firing rate - tachycardia)..........sorry if this is very confusing to follow, just trying to answer your question.....

electrophysiologists are generally able to tell if this is the mechanism behind the tachycardia (or inthe case of parasympathetic fiber stimulation, a change in electrical "shape" within cardiac cells which causes the cells to fire very slowly)........

an altered automaticity "automatic" tachycardia can be differentiated from a reentrant or conduction abnormality tachycardia by several mechanisms. the most important being how the tachycardia starts and ends. if it starts and/or ends abruptly usually the tachycardia is most likely due from something other than altered automaticity responses.

some tachycardia's though can mimic sinus tachycardia and usually docs can differentiate sinus tachy from other types of tachy by having patients perform maneuvers that activate sympathetic or parasympathetic nerve fibers (like valsalva maneuvers for example cause a parasympathetic activation which in turn causes the sa or av node to be stimulated and breaks the tachycardia.........how this tachycardia breaks (slowly decreasing in rate or abruptly decreasing in rate) usually helps to determine how and where the tachycardia originated, within sinus node or from another area in the heart and if it's mechanism is driven by enhanced automaticity (something to trigger the cardiac cells ability to increase or decrease in their automatic firing rate).....in the case of POTS, if the tachycardia is initiated by changing position it is most likely due to this enhanced automaticity because standing requires activation of the sympathetic nervous system (in EVERYONE, not just POTS patients)........unfortunately there is too much sympathetic nervous system activation in POTS patients, causing this altered automaticity. in normal people, the heart rate response to standing can be as high as 15-20 points because it triggers the sympathetic fibers in the sinus node to increase it's rate (it's automaticity) to help maintain or increase blood pressure so you dont pass out when you stand up. this mechanism is all messed up in people with autonomic dysfunction.

ekg can give many clues in determining what the arrhythmia is and where in the heart the arrhythmia is occuring. usually for a sinus tachycardia we see a P wave (a hump) before every QRS (the spike) on ekg. if the P wave (the hump) looks like it originated in the sinus node, than we call is sinus tachycardia and docs work from there to determine what the cause of the sinus tachycardia is (usually from metabolic disturbances, fever, anxiety, increase autonomic/automaticity to the SA node, etc)........if the P wave is absent or doesnt necessarily look like it started in the sinus node, than this is when docs will try maneuvers such as valsalva's to see how the tachy stops (suddenly or slowly) or the the shape of the P wave changes on ekg during tilt table testing or valsalvas or carotid massages, etc.

lastly altered automaticity to the cardiac cells in the sinus node can occur while sitting as well as standing...

hope i didnt confuse the heck out of you! it is a very hard concept to grasp. the body is complex, what can i say! ha, i think we all know that anyway, because if it wasnt so complex, we'd all have answers to what is causing autonomic dysfunction!

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Cardiatec

THANKS for explaining this to us

(not that I totally absorbed it all) but I am going to save this.

Thanks again for taking the time to put this out to us.

Sophia

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just adding the comment that i meant to say triggered ACTIVITY, not triggered automaticity when referring to the two things (reentry tachy's and triggered activity, not automaticity) that can be brought in and ablation or study in an EP lab. so triggered ACTIVITY, not triggered automaticity, although somewhat similar, how they both are provoked and end are different (which a doc can easil determine). wha is seen in the tachy that occurs with autonomic dysfunction is neither reentry or triggered activity. it is an "automatic mechanism" tachycardia caused by increased sympathetic tone, which leads to increased automaticity (the firing rate of cardiac cells)......

just clarifying for you all. if it even helps! i feel like such a geek, but i love electrophysiology! woohoo! haha!

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Cardiactec,

Thank you for the great explanation! I've read it over a few times to absorb it. :) I've been always told mine is sinus tachy and my body is appropriately following what my body is innapropriately shooting out, like adrenaline etc. Just hard to believe that your heartrate can go up just sitting and it be sinus tachy. Mine always show a distinct p-wave and my cardio says it is o.k.

Hey, we have to be proactive with our health don't we?

You a very knowledgable and it shows that you know and love your work! Thanks again for the explaination and Hoobaid thanks for you starting the thread ;)

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hey mom4cem,

thanks for your message!

yes, it is strange that you can have tachy just from sitting, doing nothing! it drives me crazy! i get tachy as high as 210 when not on beta blocker.

I, like yourself, have very distinct looking P waves and for awhile they thought it was a type of "ectopic" ATRIAL tachycardia, meaning the tachycardia was originating in the atria, but not necessarily from the sinus node (the sinus node is IN the right atrium).........but, like i said, the docs used many techniques like valsalva, carotid massage, etc to see if the P waves changed at all during these manuevers and what the offset/onset of the tachycardia did, whether slowly slowing or abrupting stopping the tachy.......

me not wanting to believe that i had a chronic condition, that they could just take me in and ablate it is all just denial in not wanting to accept the fact that i must live with a chronic issue like POTS.......ha, i STILL ask my electrophysiologist every time i see him if he is "SURE" this isnt an ectopic tachy that is just being stimulated by sympathetic overdrive and he reassures me every time that it is not, that it is POTS and that there is no ectopic rhythm involved.....i dont want to believe it cuz i know i have to keep putting up with it every day, whereas the patients i see on a daily basis that come in to the EP lab to get their tachy's fixed usually get it fixed and it STAYS fixed. makes me a little jealous...

...then there's the people that come through the E.R. doors that i do ekg's on who have a paroxysmal (sudden onset) ectopic type of tachycardia, the docs give them meds and boom, tachy is gone and taken care of. i did an ekg on this one woman once who was tachy at 170 and the doc gave her some meds to knock the rhythm back to normal sinus rhythm and afterwards the woman looked at me and said "i am so sick and tired of dealing with this". i asked her how long she had been dealing with it and how often she gets the tachy and she repsonded "i have had it over the past 5 years and the tachycardia i get about twice a year".............TWICE A YEAR!!!! oh man, i sympathized with her aloud as much as i could, but in my mind i was yelling at her for complaining about having to "DEAL" with the tachy just TWICE a year! i felt like saying "that is nothing, i deal with tachy that is much higher than yours EVERY DAY". i of course didnt say that, but i cant deny the fact that i tend to get a little frustrated or jealous when a patient comes through the doors that doesnt have POTS or some other form of the automatic mechanism tachy i was telling you about that docs cant just eliminate by ablation or give an injection to stop it for at least another year.........i still try and sympathize with the patient though cuz i understand their frustrations with medical problems.....but man, i'd love to just have to deal with a tachy two days out of the whole year, have docs take care of it with meds ACUTELY everytime, instead of having to deal with POTS that i have to take meds for every day, that isn't just a two day out of the year ordeal, but an EVERY DAY event.

anytime i can try and help explain something to you and the rest of the gang, let me know. i dont know it all of course, but i will share/explain what i know....both from personal experience and from what i have learned through working in the EP/cardiac labs.

have a wonderful day!

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hey maggs,

no prob.

st-t abnormalities are a fairly common finding. let me give you a little info behind what the "st segment" actually is before i just chart off a bunch of causes that can cause st-t abnormalities....not sure how much you know about EKG, so i dont mean to sound rude if i am explaining too simplistically...

the ST and T wave segments on ekg represent the ''repolarization'' phase of the heart........ the ST and T waveforms on ekg represent the repolarization of heart muscle (meaning the relaxation part of heart muscle).....

the depolarization (the contraction) of heart muscle through electrical stimulation is instantaneous, meaning it occurs from cell to cell sequentially. repolarization (the relaxation of heart muscle) occurs in many cardiac cells simultaneously and thus the duration for the heart muscle to relax is much longer than the contraction of heart muscle.

ST-T waveforms on ekg represent/reflect repolarization (the relaxation of heart muscle)...because the relaxation part doesnt occur sequentially from cell to cell like with the contraction of heart muscle, it really gives little directional information and abnormalities that show up on ekg in ST segments and T waves are most often interpreted as being "nonspecific".

your ekg could be showing diffuse st-t abnormalities for a variety of reasons, but typically it may just be "non-specifically" normal for you. :huh:

remember that these waveforms (st-t's) reflect electrically how your heart is repolarizing (relaxing) mechanically, so the things to cause repolarization abnormalities (or how the heart relaxes) include things that suppress the heart muscle or prolong the heart muscle from being able TO relax appropriately. things like tachycardia and even not breathing correctly (taking in fewer breaths or too many breaths than normal, breathing that is irregular) can actually cause st-t wave abnormalities. both deplete the oxygen and blood supply demand to the heart, which interferes with how the heart relaxes (repolarizes). usually with the examples of tachy and how you breathe will only change the st-t wave segments briefly, until the tachy dissipates or in the example of breathing, when you start to breathe normally again.

depending on the depth, shape, whether the T wave is "up" or "down" (positive deflection how it should appear, or downward delfection how it shouldnt appear), whether the t wave is symmetrical or flattened, depending if the st segment is depressed (goes past the normal isolectric baseline), and depending on what leads these abnormalities are occuring all come into play in determining "true" vs. "non-specific/non-life threatening" abnormalities.......

you said you had "diffuse" abnormalities so i take it that these abnormalities were seen within all leads (occuring everywhere) on the ekg.......? we usually say "non-specific" t or st abnormalities when the abnormality occurs in leads which correlate anatomically to each other and when the st-t waves dont reveal a pattern that is a cause for concern (like a pattern that would be cause for concern is deeply inverted t waves or depressed st waveforms like cut below the normal isolectric baseline all showing in the same anatomical region relating to one another, this would signify possible ischemia/lack of blood supply to a coronary artery).........

conduction delays can cause a diffuse skewed st morphology such as a right bundle branch block left bundle branch block, etc.......

hypertrophy (thickening) of the haert muscle (ventricles) can cause diffuse st abnormality.this can be easily diagnosed or eliminated as a possible diagnosis through echocardiography.

electrolyte disturbances are HUGE in playing a role in st abnormality. the heart uses sodium, potassium, magnesium, and calcium mainly for it's conduction properties (contraction and relaxation of cardiac muscle)........deficiencies of sodium dont really cause st abnormality but calcium and potassium can and do.

so ask you can see, the list goes on and on for cause of st-t wave abnormalities on ekg. most abnormalities are very slight (meaning the morphology isnt crazy appearing basically to signify a greater problem) and therefore "non-specific".

...also pericarditis and myocarditis can cause diffuse st abnormalities...

there are many "normal variants" seen on ekg though, most of which are found within the st segment waveforms and these variants usually are not a cause for concern, but always always check with your doc. he/she knows your ekg's/history better than me. but i am more than happy to try and explain ekg/EP stuff to you...............st-t abnormalities are part of that gray line that even a lot of cardio's cant fully explain especially if they do follow up diagnostic testing because of what an ekg may point to as possible pathology that may not even be appreciated on more specific/sensitive tests when further investigated.

for example, my ekg's give all the criteria for a pulmonary diease and/or right ventricular hypertrohpy.....when tested with echo's,TEE'S, and yes even a cardiac cath, they didnt see any sign of right ventricular overload or pulmonary hypertension. the ekg is just the starting point for cardiac diagnostic testing and is very useful in giving the docs a heads up as to what could potentially be going on, but because everyone is different, and not all electrical "shapes" per-say to the cardiac cells are the same, there will always be a "variant" that may or may not throw a doc off.........but usually they work WITH the variant, to disprove or prove a variant as being just what it's described as, a variant, or in fact something to be concerned with..........

hope this helps some! :))

Hi Lori and a big welcome to the forum!

Hi Cardiatec :)

I DO have a question for you.......

What causes 'diffuse ST waves' I sometimes have them on my ECG...

Just curious....

Thanks in advance!

Maggs

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Hi, cardiatec :)

Read most of your posts on here, but everyone I read on this site so far are tachacardic, I'm not I'm bradicardic , when my POBS ( not pots) goes silly my heart beat bottoms out to 40 and below , lowest rate recoded whilst I'm still able to speak and be understood is just 33 BPM. I have a normal heartbeat now of just 50 or if really excited a whopping 65 !!!!!

I used to many , many years ago have a normal heart beat of around 80 standard and 50-60 resting , but that was until my caribbean experience in 2001.

I'm hoping to see an elcto -whats- a- may -call -it soon .

My cardiologist wont fit a pacemaker as he seems to believe that its good to have a low heart rate and keeps quoting 'fit athletes' to me ..........considering I'm a granny of 50+ who's slightly over weight ( about 10 lbs' ) who cannot walk without aids and who's not able to walk more than 5 yards without stopping as she is so tired , goes grey and has blue nails and lips, sweats like a boxer with the chest pain and passes out when the heartbeat goes below about 35 normally, my GP and I both think 'whats he on' ??????

We think its all to do with MONEY here in the UK , nice isn't it that the jolly old NHS would rather I suffer and could possibly die from one of my 'low heart beat ' attacks then give me a cheap pacemaker to improve my standard of life .

Willows.

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wow. i'd get a new doc!!!!!!!!! what is POBS? hmm, a heart rate of 35 i have never seen a cardio turn a shoulder on as being "a good heart rate like an athletes"..............do they tell you where that rate is originating from? ususally a rate of 35 is coming from either the ventricles or the AV node.....the intrinsic sinus rate is typically between 60-100.......AV node 40-60...........and ventricles 0-40.......by the time the sinus node passes the buck to the ventricles, it usually warrants investigation, as you already know from passing out, the body is not being well perfused at 35 beats a minute........and usually indicates some sort of second degree block (not always, but usually).............what do they say about your ekg when it's at 35?

geez....it's a sad sad world if the UK's #1 goal is money based....

i'd say get a different doc to evaluate that 35 heart rate!

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HI all,

Now I am well confused, our daughter has bouts of both tachy and bradycaridia(sp). At one point some months age see went from 40 bpm resting up 170+ still sitting then droped back down to the 40is. This went on for some hours, she looked liked she had been on a rollercoaster the poor thing. A horrid time for her that her pead. just could not explain just said if it happens again get her to the A&E! She has been noted to have a slightly lowish sinus rhythm of 57 bpm and some partial right bundle branch block, but we are still waiting written report on her stress ECG and 24 hour holter moniter. Can one have pots with both bradycardia and tachycardia?

Anna

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hey anna,

i think it is possible to have pots with both brady and tachy, but a brady at 40 is pretty brady...i think there are some people here in the forum that have brady lying down/possibly sitting but not so sure if they are hitting 40....50 or above woud seem more appropriate.

when does she get the brady and tachy? is it positional? is she tachy without position change? i dont know your daughter's medical history, but i do know there is such a syndrome called sick sinus syndrome.........it is usually caused by an intrinsic problem with the sinus node itself. from what i know of it, it usually isnt that common in young people, usually occurs in older people who have a lot of scar tissue formation (from many different causes)........google it for more info, i'm sure there are many resources out there about it...........

from your description of her heart rate going from 40 to 170 with a drop out phenomenon, i'd wonder if there was something aside from POTS happening.........but i'd definitely wait to see what those tests come back showing. has she had a holter or even monitor?

take care. hope you get some answers soon.

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might i add that you CAN have slow rhythm's all occuring from within the sinus node and not necessarily have a block (second degree, third) occuring at the ventricular or AV nodal level........your docs need to be the one's to investigate, to look at your ekg's, and make the determination of what exactly is going on. just dont get scared that i mentioned a possibility of a block occuring cuz because the rate is at 35-40....it all depends on what your ekg is showing for morphology and what your docs are saying about all the diagnostics they run.......

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Thanks for the input cardiactec, our daughters peadiatrician with an 'interest' in cardiolagy has passed her back to her normal Pead. as he said her stress test was ok and her 24 hour holter monitor seems fine except for some flutters!! here and their, that he explained are like poeple get when they have too much coffee or such. Well bit odd too me as our daughter does not drink coffee, tea, coke etc. cos it makes her heart race. The 24 ECG was done on a good day with no real issues that day. I asked him if this could be an ANS thing and he said he did not know maybe I should could ask my sons neuro about it!!! I have requested a written report so I can take it to her GP to see what he thinks.

Our daughter has EDS, so we thought it might be pooling issuses at work but she can get very bradycardic while sitting or lying, Dr.s just say she is young and fit she should be glad to have an athletic body but it makes her feel so out of it she says she hates felling so tierd and 'dippy' then when she stands too long her BP drops and her HR goes up and up, homones seem to play a big part in all this, she always has underline problems but it is much worse 2 weeks prier to her monthlys, or when she is ill etc.

I think we need to find a Dr. that knows somthing about her electrical system!!

Thanks again,

Anna

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