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Caught The Rhythm!!!


cardiactec
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So finally caught "the rhythm" that i have been feeling for awhile now that i KNEW WAS NOT POTS/sinus tach. turned out to be a nonsustained polymorphic ventricular tachycardia......my cardio said he is STILL hesitant though at this time to do an EP study because he feels that the ventricular tachy is NOT from conduction abnormality but from autonomic troubles??!?!?!?!??!?!?!

argh!!!!!!!!!!!!!!!!

I actually caught the rhythm while at work - it was pretty short lived but caught the "remains" of it anyway......the rhythm started after I sat down, thus my cardio thinks that excess catecholamine release and postural venous instability is contributing to the ventricular tachy, which in turn is part of the autonomic dysfunction. I am baffled at this point that yet EVEN AFTER catching this rhythm, that my cardio is still saying that he feels it is connected to autonomic problems???????

ANYONE HERE EVER GO INTO V-TACH AND HAVE BEEN TOLD IT IS/WAS FROM AUTONOMIC DYSFUNCTION???????

my cardio says an EP study would be considered but that even if they did induce this rhythm and could ablate it, i'd still be left with pots and pots symptoms.......i really question sometimes how much the "symptoms" i get are related to POTS OR are from another rhythm disturbance, like the one we just caught! .......

my cardio really isnt willing to do anything until i see dr.grubb in december to see what he says. in the meantime though, my records have been faxed to a boston hospital and out to a NY hospital to docs who specialize in pots and BOTH facilities have said that they have never seen a POTS patient who goes into nonsustained v-tach with position change.....

just thought I'd share......

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I have been told my vtach is benign, which I must say, after 11 years of cardiac nursing, I had never heard before. Vtach and benign used in the same sentence.

My arrythmias were felt to be autonomic in nature, but that has shifted to other thinking. I'm not sure what to tell you, a second opinion? What does it do to your QTc? Anymore I am typically more confused by the lingo than helped by it. morgan

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hey morgan,

i have heard the same about SOME types of vtach -- which is a first for me in my four years of being a cardiac tech. though some types of VT quickly can progress to VFib, which is lethal so......

i think it depends on what type -- there is sustained, nonsustained, the long QT type of VT, brugada syndrome which triggers VT, monomorphic and/or polymorphic, WPW syndrome which can cause VT w/ underling afib to boot....the list really goes on and on......and the type is also dependent upon whether or not the person has structural heart disease/coronary artery disease/post-MI -- dependent on underlying pathologic states as compared to the patient with a structurally normal heart in regard to therapy and/or intervention and how to proceed with a VT patient. it also has a lot to do with symptomology -- ie: is the patient passing out left and right from it, hemodynamically compromised, etc.....

with me, of course, other than MVP/TVP, and and measly PFO, I have no underlying heart disease or structural defect or CAD.........and on top of that it was nonsustained VT, so i can see why he's not too frightened with what was caught, or that keen or jumpy to move into an EP study right off the bat.....

my QTc is normal.

but still, just makes me wonder if this is what i'm feeling for one to two minutes every five weeks or so -- which causes me to get severely symptomatic, much much more than the pots symptoms.

hey dari,

thanks for your support/concern. yes, i hope some things get sorted out with seeing dr.grubb as well.....until then, more waiting. you definitely learn PATIENCE with chronic illness! :oP

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cardiactec-

It just occurred to me that my TTT and EP study went hand in hand.

Having a positive TTT resulted in a practically "forced" EP study. The HEart Hosp. here generally does both at the same time.

I had no symptoms at that time (certainly not a documented V-TAC!) other than benign MVP and one near-syncope experience following an auto accident in which the air-bag popped me so hard it broke my nose. I think I was allowed the luxury of swooning!!!

This doesn't help you at all, but it is curious how different docs do things.

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Sorry Firewoman....

Vtach is when the heart beat originates in the lower part of your heart, the ventricles. Normally the beat originates in the upper right chamber( rt atria) zooms to a spot sort of between all the chambers, then down the ventricles, which is what causes the left ventricle to squeeze oxygenated blood into your system. Very rudimentary, but that's how it works. It's an electrical impulse in the heart and all the bumps and things on EKG's are showing whether the electrical wiring is working correctly.

Most of us have irregular beats, in fact, I would say every one on the earth has irregular beats once in awhile. You can't expect your heart to beat a zillion times in your life and never make a mistake. Most of us have PAC's, or beats that originate in the right atrium, but they beat too early, before the heart has relaxed and filled with blood and is ready for another beat. Then, because that one beat too early, the next one has a little extra time to overfill and then more than usual gets pumped out. That is typically the beat people feel when they feel an irregular beat. Not the abnormal early one, but the overfull next one. These are very benign and very common.

Abnormal beats that originate above the ventricles are called supraventricular. They tend to be very benign, although, sometimes they will take off and then you've got a heart going at 150-220 beats a minute. There are not many people that don't feel cruddy with that, as the heart doesn't have time to fill properly. This is called SVT or PSVT. This is different than sinus tachycardia. Much faster. Although there are doctors who call tachycardia svt.

Irregular beats that start in the ventricles can be much more problematic. PVC's or premature ventricular contractions are also not that uncommon and having them does not neccessarily mean you are in trouble. The heart has no chance to fill with blood with these types of beats, however, it's just a backwards beat I guess. On an EKG, these are usually big ugly beats that are hard to miss. Having them here and there is not an issue. When you have a whole bunch in a row, though, you can get into trouble.

These descriptions we were talking about are different types of PVC's. They originate from different parts of the ventricle, or you have "runs" of them. A whole bunch with no interruption. If they are coming from the same spot, the look alike, if not they can look very different, but all remain lg and odd looking. Non sustained means it stops itself. Sustained means it is not stopping and you will not stop without intervention...a code...in a hospital. You can't stay in vtach for a very extended amount of time without becoming very symptomatic. Because you aren't getting blood to your vital organs.

There are certain diseases of the electrical system, one being WPW...which can actually be quite curable with ablation. Some can not be fixed this way. VFib, is when the heart pretty much stops trying at all to beat, which is usually after sustained Vtach. It stops being big and ugly and just becomes a squiggly line on the paper.

Because my runs of vtach have stopped on their own, so far, the cardios have called them "benign" The problem with this thinking is, at some point, it may not stop on it's own and then I'm going to be in a very bad place, and no one can guarantee that won't happen. That is why I have problems with the term benign associated with RUNS of vtach, whether sustained or not. A PVC here or there is no problem to me and I never worry about those. I do not tolerate the runs, even though they have, so far, been relatively short. My PCP wants me to get an implantable defibrillator, but my cardio is balking at this. I'm not sure I want one, but I still balk at benign.

I hope this clears things up a bit. It's very simplistic and hopefully you aren't going well der, I do know things, but there are many people that don't understand any of it and it can get very complicated. QTc is the space on an EKG between when the node in the atrium fires and the heart is rested and ready for another beat. When these are too long, you run a higher chance of sudden cardiac death. It is called long QT syndrome, or can happen with problems like I have, which is potassium related.

morgan

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How would I know that I'm in v as opposed to sinus tach? Would it "feel" different to me? I have weird flutters that my ep cardio has chalked up to catechole overflow problems.

Nina

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I have had runs of VTACH, A-Fib, A-Flutter and Long QT all recorded with my heart. They believe that they are all related to Autonomic Dysfunction and Dysregulation of my Blood Pressure. Because I have the Hyperadrenergic form of POTS, my pressures go both very high (220/130) and very low (70/30) after or during an episode.

Erin

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Nina, I have distinctly different sensations. If I am having v stuff, it always is so annoying and pronouced, it makes me cough. Always, even if it's my pacer kicking my ventricle in, I will cough with it.

I usually don't feel my atrial stuff, if I do it's a much smaller kind of thump. Have you ever had that feeling your heart has flipped over? That may be ventricular or just a very full one from an early atrial beat. I discovered from monitors mine is ventricular.

The best way to tell, I think, is how symptomatic you are. You are going to feel really bad in a very short period of time if you are in vtach and it's not stopping. Where as with tacycardia, you get fatigued, maybe a bit of chest pressure, but you will probably, or do, tolerate it much better.

I have had a few patients that never felt anything with either and some feel horrible with either. But even the people that didn't feel their vtach didn't feel well very shortly after onset. Typically, you will get very symptomatic very quickly with a sustained vtach. Our bodies are not made to handle it at all. So if you get a rhythm and you aren't sure, but you know you are really going badly quickly, call 911. I'd rather find out I'm in an svt I'm not tolerating well that's just making me feel bad, then wait till I'm too sick to call.

This is when I wish I had one of those at home defibrillators, you could just stick it on there and see what's going on.......it's certainly not what they are for, but sure would come in handy sometimes!

Erin, I have all those too. Aren't they fun? Mine are related to potassium, which in turn affect my ans....they should be paying attention to your long QT! And I hope they are, but there are not a whole lot of doctors trained in that syndrome. I am hyperadrenergic too and when my heart is pounding, it doesn't matter whether it's slow or fast, it is still the worst I feel, and it really jacks up my BP, as opposed to lowering it. People will say, well it's not that fast, but it's not the rate, it's the force of the pumping....morgan

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mightymouse,

generally a sinus tachy isnt as "forceful" feeling as V tach. V tach produces a more prominent sensation since the rhythm is coming from the ventricles, which are much bigger and bulkier than the atria (where sinus tach comes from).....

...there are people that dont even know they are in V tach, so it all depends on how sensitive you are to the rhythm, also if it is a sustained rhythm (which tends to cause a drop out of BP) or nonsustained (which is short lived and generally doesnt cause hemodynamic collapse, doesnt drop your pressure out).......

also, sinus tach usually is a gradual onset offset rhythm disturbance and the sensation tends to come on more gradually, with Vtach it is very spontaneous (at least with me) and VERY abrupt - so you literally go from feeling absolutely nothing to WHAM, this hard thunking type feeling either in your chest or neck (with me, it's my neck) .........and then you feel it terminate as quickly as it came on .....with me, and with sinus tach and how it presents in general, it is a gradual onset and gradual offset -- and you can feel the rhythm subsided, slowly, gradually and it doesnt start or stop abruptly -- but slowly increase and decreases.

It's hard to say how you'd feel or how symptoms might differeniate between a sinus tach and v tach, because everyone is so different in how sensitive they are to specific rhythm disturbance.

morgan, EXCELLENT job at explaining everything. lol, sometimes i just get so wrapped up in the lingo, cuz i talk it every day, it just become "normal" talk to me and i forget that it is actually quite confusing talk to people not working in medicine! LOL. sorry firewoman! morgan said everything to the T correctly and I couldnt have said it any better.

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Angela,

in the UK we define "non-sustained VT" as runs of VT that self-terminate within 30 seconds. If the run lasts longer than 30 seconds it is termed "sustained VT" even if it sefl-terminates.

Are the US definitions different?

I know a lot of cardiologists are aware of the trial showing negative outcomes in POTS patients given ablations and now refuse to ablate any POTS patients. I think they have misunderstood the research, as my understanding is that ablation of abnormal pathways or arrhythmogenic foci is fine but we shouldn't let anyone attempt to modify out POTS sinus tachycardia? Perhaps your EP is not comfortable of the thought of ablating a POTS patient therefore would rather not do the EP to find the abnormality in the first place?

Hope you get something sorted soon,

Flop

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Okay, I've probably had v-tach, but relatively brief. It usually startles me when it starts and feels like my hearts doing flips, then I get a hard thump and returns to normal.

Nina

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It could well be that Nina, however, there is one type of of an svt which does start very suddenly and ends very abruptly. Paroxymal Atrial Tachycardia. That ending thump is a normal span, but since your heart hasn't been filling up well, it feels like a big thump.

It's just very hard to tell, unless on a monitor, but once you've seen it, and associated it with your symptoms or sensations, you recognize what is going on. Whether from the ventricles or the atrium. As cardiatech said, they can feel the same, and some don't feel them at all. When I was having 7 second pauses, I never felt my heart not beating, I just went down like a bag of taters. :blink: If I was lying down however, I could tell from the thump after the pause, something was happening.

If it's a fluttering sensation, it's typically atrial, as Angela said, vtach can feel quite forceful for a bit. But so can hyperandrenergic tachycardia.

Flop, I'm not sure what the accepted protocal is for sustained versus non sustained vtach. When I was working cardiac, vtach was vtach and you didn't mess around with it. They must have some sort of guidelines, but I am guessing the main one is how well it's being tolerated. I'll ask my cardio at my visit, which is coming up shortly and let you know. It used to be if someone had a run of vtach, you started a lidocaine drip...oh the times they are a changin.....morgan

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Morgan,

I guess you worked in a coronary care unit so mostly saw patients post myocardial infarction who are at high risk of going in to VF??

I must admit that if I had documented VT that I would want something doing about it. My signal averaged ECG showed late potentials which are an indicator of a propensity to VT. I'm pretty sure that the palpitations I used to feel (before I got POTS) were VT. Sudden onset, very fast, regular, strong punding in my chest, associated with breathlessness + chest pain + a strange strangling/tightness in my throat. Lasted about 15 secs then abruptly stopped.

Unfortunately?? when I was started on Bisoprolol the frequency of those palpitations plummeted. I had about 3 episodes during the time that my "Reveal" had a working battery in it. Unfortunately I couldn't get the reveal activator to work (it had "died") so we didn't get a recording of them!!

I guess I'm twitchy about VT as we have a family history of HOCM and my cousin had to be resuscitated from a pre-hospital VF arrest. My echo doesn't show HOCM but I still get a bit twitched!

Flop

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hey flop, yes that is what classifies sustained VT vs. nonsustained. under 30 seconds is "nonsustained" and over 30 seconds, whether or not it terminates on its own, is considered sustained VT.

I am totally with you flop when you say that if you had VT documented with you, that you'd want something done about it..... -- even though IT IS nonsustained in my case, i would think it could still pose a chance for it becoming sustained...... Never in my wildest dreams had I thought the rhythm that was going on was ventricular in origin.......thought it was a-flutter or something........I mean, I know it is very normal for many many many people to have ectopy (SINGLE PVC's and PAC's) but it IS NOT, as far as I know, common, or a "normal" thing for the majority of the population to have couplets, triplets, or more ectopic ventricular beats in a row -- especially when it is polymorphic (meaning electrical activity occurring at many different sites in the lower chambers of the heart, the ventricles, for those who arent familiar with the term).

I was told that monomorphic VT (meaning the rhythm is coming from one spot basically in the ventricles) is far less serious than polymorphic because monomorphic VT can be better controlled or terminated .......the rhythm I went into that we caught, though very short lived (I believe it was a four beat run) was polymorphic, not monomorphic - so a little more concerning.

I'd like to pursue EP study but I think my cardio is very concerned with the underlying POTS diagnoses as being the potential "cause for everything" ....that is what is so tough about having POTS or any type of chronic condition that isnt fully understood, because it seems like everything just gets blamed on POTS....and it becomes harder for docs to investigate or draw their attention to something ELSE that could potentially be going on that IS NOT pots, or IS NOT autonomic dysfunction, so it can be properly addressed.

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Hi again. I want to clarify... i actually have two different events that happen. One is the fluttery feeling, sometimes ending in a big thump... the other is a hard beating sensation in my chest, the one I described as it doing flips, and it's so forceful that it startles me when it happens and makes me sit straight up even if I'm lying down and drawn in a sharp breath b/c it's a really disconcerting feeling. The flutters will last a long time, a few minutes sometimes... the other one hasn't ever gone more than about 60 seconds, and is usually much shorter--maybe 5 or 10 seconds. The hard flipping sensation started within the past year; never had them before that.

BTW, I can't recall if i told folks that my stress test was perfect and my ep cardio said my heart looks 'beautiful'. :) And, because I was curious, he showed me all of my valves on the echo-- one was kind of shy (tricuspid), but was partially visible :blink:

Angela, did you get out to see Dr. Grubb? or talk to him? Just curious what his input might have been.

Nina

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When I get VT I can't breath very well and my heart feels as if it's jumping out of my chest. It's only happened a few times.

Morgan, they actually aren't really watching the Long QT because they only recorded a run on an EKG once when I was taken to the hospital after a pass out a little over a year ago. They attributed that to BP and ANS because it happened about 10 minutes after I passed out. Dr. Grubb has talked a little about an EP study, but we have never gone that route as I feel he truly believes it's ANS related. He wanted to watch me for awhile before he did that and it's just now been a year since I first got to see him. I go back in January again, so I'm sure we'll have that discussion again. Also, I'm wondering if you flush all of the time? Maybe that's an entirely different topic!

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I have runs of V-tach but they are short in duration. My pacemaker does record the number of runs and rates each month so the Dr's keep an eye on it but they feel it's ANS related.

I'm more concerned about it then they are. It often wakes me out of sound sleep and it's miserable when it happens and it also tends to set off ANS storm after it happens.

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I know most people with POTS have arrythmias, but for the most part they are atrial.

My mother had 2 episodes of sudden cardiac death, the first in her 40's :blink: and the second in her early 60's killed her. So it does make me a bit nervous. It's very hard to know what to do, when blown off by electrophysiologists.

I did work in an ACU for 11 years and we saw post infarcts, open hearts, and many many arrythmias. I actually worked on the end that dealt more with the arrythmia aspects of people, drug therapies, and EPS. We got all the internal defib patients. The other end dealt with transplants and more open hearts.

It was awhile ago, but we didn't sit around waiting for people to go into vtach to do anything. They were at least on meds. This sustained and not sustained thing has developed since I left the hospital and got sick. We had no rules that you had to be in vtach for a certain amount of time before it was a concern. When the monitor tech said so and so is in vtach, we didn't stand there and say, well has it been going on for 30 seconds? That is just so weird to me.

I had ablation in 2003. They did find an abnormal area, but it was not an extra node, it was just an abnormal area of tissue, which they ablated 27 times, and still didn't kill the whole thing. It was over the top of my right atrium. There was no testing for ventricular ectopy. I think when you have documented vtach, polymorphic, or whatever type, it desrves some type of investigation. Occasional PVC's, no problem, documented vtach, check it out. I don't think a doctor having runs of non sustained vtach would say, oh well, what ever.

My ablation was a huge mistake, but it wasn't for anything ventricular.....It's just hard to know what we have and ER's are not the place I want to go. 90% of the time, they don't even put me on a monitor. When I went to the Er for my long pauses, I was there 4 hours and they hadn't even run a single strip, let alone had someone watching it. We were lying there listening to my alarms going off for heart rates of 30 and below, not one person came in for 3 1/2 hours to see if I was okay. So i guess none of this should surprise me.

Sounds like WPW to me cardiatech, or something along those lines. You are in the age group and it's polymorphic. I can't see fixing WPW making your POTS worse, as they aren't messing with atrial rhythms. morgan

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lol, morgan, had to laugh when you talked about working, and waiting/watching the monitor to see if a patient hits the 30 seconds or more mark for them to take it seriously and if it didnt last 30 secs, have an "oh well no biggie" attitude. :blink: doesnt make much sense, and the way you put it, it REALLY sounds ridiculous huh! i had always been told, while first in training (four years ago) that VT was no light thing, to take it VERY seriously and NOT just to sit there and wait/watch for that 30 second or longer marker to do something about it. yeah, the nonsustained/sustained thing is fairly new i believe.

I often question WPW or some other funky condition.....ever heard of this condition --> Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) ??? I JUST stumbled upon it a couple days ago and though, as far as WE know, i have JUST recently, over the past year or so, started with these "events", this was nothing that was going on during my childhood days, so .....it might be a far cry from what the problem is, but, interesting to say the least -- more because my electrophysiologist is relating the VT to excessive catechol's. .....

nina, no, havent seen blair grubb yet -- in december - and i'm itching to see what he'll say...........though if havefaitherin says that he lumped in her VT episodes to autonomic problems, than he'll probably say the same about me ......havefaitherin, did you ever push for EP with blair grubb?

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thank you morgan!!!!!!!!!

i completely understood what you were saying that time and greatly APPRECIATE thefact that you took the time to explain it for me. that was VERY sweet of u.

my father has the electrical wiring prob u talked about, that clicked with me, cuz that's the way he described his prob to me(he's an electrician), and from your explanation i would say he had the ablation. he won't telll me that. doesn't want his little girl to worry about him. now i get it .

awesome, thanks again.

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Garsh, thanks ! My favorite thing to do, ever, was teach patients what was going on with their hearts. So many were so terrified, and felt so much better when they actually understood what was going on. I used to take a strip of a normal ekg and theirs and explain it to them. It was the best. I know many people do understand the ins and outs, but many don't, so I am always happy to explain, unless I don't get it either.

Nina, your symptoms sound very similar to mine. I know when mine is ventricular, because it just knocks me on my bum. Literally. It isn't even like it's painful, although it makes me feel sick, quickly, but it's just such a gross feeling! My heart looks okay on echo also, but structural is not always an indicator of electrical. You can have the greatest looking heart in the universe, but it doesn't mean it doesn't have "shorts" in the electrical system. That's such a large part of the problem I think. I had a heart cath that was "relatively" normal, so the cardiologist said he didn't want or need to see me again. But not having clogged arteries has never stopped the well documented arrythmias.

So there are many aspects to it. Coronary disease, (clogged arteries), structural problems (malformed valves, chambers that are too small or big, muscles wall abnormalities, etc) and the electrical system. One part can be fine, but one or both of the others not so fine. One doesn't neccessarily contribute to the other, but it can. So, it's important that your cardio take all aspects of function into account when evaluating problems.

And I do flush and can feel my BP skyrocketing when having problems. My hubby can always tell when I'm not doing well at all, because of the major flushing, and many medical people do comment on it. Makes my neck veins look like a rope a dope too. Yuck. Since I developed tachy-brady and required the pacer, I have taken the largest dose of a beta blocker I ever have. If I didn't have my pacer, however, my underlying rythym would be around 30. Off the atenolol, it's 140 and will drop to 30. Or vice versa, but the larger dose of beta does help a bit with the major BP surge that causes that flushed awful feeling. morgan

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