Possible POTS or Vagal AF?

Hello All! Grab some Ovaltine cuz it's story time!!!

I'm new to the AFIB community and sort of excited but slightly sad to be here. I'm only 26 and have been a natural bodybuilder/powerlifter for about the last 6-7 years of my life. Everyone thought I was perfectly healthy, yet here I am.

I always had an extremely slow heart rate, even back to elementary an middle school. Occasionally I had blips/very minor arrhythmias that began in college. I always chalked up to overtraining or marijiuana (only used it a couple times and don't plan on using again... get terrible anxiety!). Nothing ever seemed serious, just slow "athletic" heart rate is what most people called. it.

I was admitted to the ER my Junior year of college for palpitations after taking a pre workout supplement. The ER found nothing but that I was slightly dehydrated. I continued to use caffeine before workouts for years. Then last year I got extreme anxiety and palpitations from a combination of pre workout (caffeine/beta alanine) and yohimbine. Again, ER said I was fine. Stopped taking Yohimbine.

About three months ago I was feeling extremely tired after a nap, threw back a small amount of pre workout (probably only 50-75mg of caffeine) and convinced myself I needed to get to the gym. I usually force myself as I'm tired a lot (more on that later if you can bear with me). At the gym I started on the stairmaster. I was only about 30 seconds in when I noticed a lot of difficulty breathing. I don't usually do a ton of cardio, but 30 seconds of climbing stairs and I felt like I was going to faint. I COULD FEEL MY HEART BEATING HARD, BUT IT WAS NOT SEEMINGLY BEATING FAST ENOUGH. Scared that I was going to have a heart attack or faint, I hopped off the stairmaster. I noticed some slight irregularities, but my heart seemed to be okay after a few minutes. I almost went to the ER right then and there, but I brushed it off, and did some dynamic stretching and real light adductor work to finis the workout.

After I got back from the gym, nothing felt right. My heart seemed to be fluttering/fast,, I couldn't fall asleep in my bed, my blood pressure was high, and I couldn't seem to breath correctly. I called my family doctor and explained my symptoms and he recommended I go into the ER. AND IT WAS AT THAT ER VISIT, I WAS DIAGNOSED WITH AFIB . I also had couplets and PVC's. They injected me with a beta blocker, and in a near instant my blood pressure went from 170/100 to 135/65. That said, my heart rate still wasn't going down to its typical resting levels of 40 or so. It was hovering around 70 which (OF COURSE) they thought was fine and didn't care that I said otherwise lol.

Since that episode, I have effectively been on "pill in the pocket" approach with metoprolol. I have 25mg tabs and only have to take about 5-10mg for it to work. I AM VERY SENSITIVE TO IT. If I take too much, I feel like I got hit with a Mac truck and get labored breathing. I TEND TO GET EPISODES ABOUT ONCE EVERY TWO TO THREE WEEKS, AND THEY ARE ALMOST EXCLUSIVELY IN THE MORNING OR AT A TIME WHERE MY HEART RATE HAD BEEN DEPRESSED FOR A GOOD BIT.

SO... I KNOW WHAT YOUR THINKING. WHY DO YOU THINK IT'S POTS OR VAGAL AF, RYAN???!!!!!!

-Whenever I wake up in the morning, even the slightest of movement seems to cause my heart rate to speed up a lot (i.e.: sitting up on my bed... walking to go to bathroom, etc. I'm talking going from like 40/50ish to 80 in seconds). I sleep on my right side, as on my back I sometimes snore loud. I RECENTLY HAD A SLEEP STUDY THAT CAME BACK WITH ONLY VERY MILD SLEEP APNEA... about 3 events per hour, so no c-pap administered
-Gradually throughout the day my heart rate gets slower, even down into the 30's during my afternoon slump at my desk (seemingly par for the course for me)
-When I got to bend over and tie my shoes my heart seems to speed up too much, once nearly going into an arrhythmia (that one was also in morning)
-Big breakfasts don't seem to help.. not sure if there's a direct correlation there
-Previously had GERD issues from excessive caffeine intake over the years and a lot of burping at the gym (not near as much lately as I only take about 2 excedrin ~120 mg of caffeine for an entire day now)
-Events tend to to happen after sleep on in morning (did have one in evening after drinking and not eating for about 10 hours,and riding gokarts)
-Possible hiatal hernia from powerlifting? ...Have yet to see a GI doc
-Holter monitor came back with occasional PVC's, that's it
-Echo and stres test were clear

LIFESTYLE CHANGES SINCE BEING DIAGNOSED WITH AF
-Have lost 15-20lbs (went from 230+lbs to 210 ...keep in mind my BMI isn't too bad since I have muscle mass)
-Seem to sleep more consistently through the night
-Eat more veggies, notably kale (swiss chard bothers my throat)
-10K IU Vitamin D
-1200mg Magnesium Glycerinate
-~600DHA of Fish Oil
-198mg Potassium Chloride
-Limiting to around 100-150mg of caffeine a day

STATS/RISK FACTORS
-Avg morning blood pressure is ~145/70 on average (possible isolated systolic prehyper)
-Resting puse ~40 (substantially higher in morning)
-No other known risk factors at this time

If anyone has any advice I'd love to hear it as I have a check up with the EP coming up in about 10 days. Thanks so much in advance and hope I didn't bombard you all with too much info haha.

Ryan,

Welcome to the club nobody wants to be in!

A few thoughts:

1. Bodybuilding and powerlifting has a definite association with AF. Constant pressure in the mediastinum from lifting stretches the atria.
2. If possible, reduce or eliminate the caffeine. That's a lot, and it is very excitory to the atria,
3. You might want to reconsider the beta blocker if your normal resting HR is already on the low end. In vagal AF, betas can do more harm than good.
4. How does a 26-year old know what Ovaltine is?

LOL. I wondered if I was going to get a comment on the Ovaltine bit.

So as far as the Metoprolol, that's why the EP only has me on "pill in the pocket" approach (bc my low heart rate). I only take it if I start feeling an arrhythmia come on, which has been about once every two to three weeks or so since that initial really bad one. I try to take it as little as possible. The only thing I really know from my Echo is that my heart's walls are ever so slightly on the thick side. But EP said that's normal for a weightlifter. Also, just wanted to make a point that the episodes don't usually happen at the gym. Don't think there's any correlation there.

You really think only two Excedrin a day or an 8oz coffee is something to eliminate? I was abstaining for about 3 weeks post the initial episode but now I typically have what equates to a small cup of joe a day.

Normally a pill-in-the-pocket approach applies to anti-arrhythmic drugs such as propafenone or flecainide. Metoprolol is a beta blocker which slows the heart rate but otherwise does nothing to restore normal rhythm.

Honestly, I've been avoiding caffeine for so long I can't remember what's a small dose versus what's a large dose. It's the highway to PACs for me so I treat it like poison. Zero tolerance.

LOL on the Ovaltine. A warm glass is nice next to the AM radio on a Saturday night...

Ryan,

If you have a sympathetic trigger, the caffeine won't help. The PIP beta blocker makes sense. Sounds like you might have mixed triggers.

My motto is "if something isn't working, do something different."

In your shoes, I'd likely detrain, eliminate the caffeine, alcohol and eat as cleanly as possible. Sounds like digestion might be one trigger. My approach is to go to an endpoint and make something happen (or stop happening) then see what I can get away with.

George

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GeorgeN
Ryan,

If you have a sympathetic trigger, the caffeine won't help. The PIP beta blocker makes sense. Sounds like you might have mixed triggers.

My motto is "if something isn't working, do something different."

In your shoes, I'd likely detrain, eliminate the caffeine, alcohol and eat as cleanly as possible. Sounds like digestion might be one trigger. My approach is to go to an endpoint and make something happen (or stop happening) then see what I can get away with.

George

Hey George,

What do you mean by a sympathetic trigger? Like sympathetic nervous system? Sorry, since I'm new I probably won't always get the terms and or meanings off the bat.

Sympathetic nervous system = adrenergic/adrenaline
Parasympathetic nervous system = vagal/cholinergic

Basically, the sympathetic nervous systems is your heart's "gas pedal". You get excited, or do exercise, and it speeds up. The parasympathetic nervous system is your heart's "brake pedal". You eat a big meal, or sit down in the evening, and it slows down. Either one, or both, can be an AF trigger. Does your AF happen when you're exercising? When sitting down or after eating? Both? These are the patterns you need to establish, as best as possible, to guide your own treatment strategy.

Like Wolfpack says, see <[www.afibbers.org]

Hello, Ryan - You're receive a lot of important and good advice here...and you've done a good job of identifying your triggers; now the challenge to you is to do take steps to eliminate those potentials.. all of them including the Excedrin stimulant.

It isn't fun or popular to eliminate caffeine or alcohol or over-training/exercising, but many afibbers have done that and never looked back with regret. You should consider the sleep apnea connection as well....since if it's present, it's better to correct now as a long-term preventive measure rather than later on. At your young age, it's especially important to tone down your need for excessive stimulation because in the long term, there can be more consequences than just arrhythmia.

Were you tested for vitamin D deficiency and is your current dose of 10K daily recommended by your physician?


If not, you should be cautious about taking that much without at least an initial test to know your baseline. Also, when you take significant vitamin D quantities, it's important to use Vitamin K2 in the MK7 form... to help prevent circulating calcium in blood from being deposited in soft tissues such as arteries. The MK7 directs calcium into bones where it belongs. An example brand is Life Extension Super K... has 200 mcg MK7 [www.iherb.com]

I'm another one who remembers Ovaltine !

Jackie

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wolfpack
Sympathetic nervous system = adrenergic/adrenaline
Parasympathetic nervous system = vagal/cholinergic

Basically, the sympathetic nervous systems is your heart's "gas pedal". You get excited, or do exercise, and it speeds up. The parasympathetic nervous system is your heart's "brake pedal". You eat a big meal, or sit down in the evening, and it slows down. Either one, or both, can be an AF trigger. Does your AF happen when you're exercising? When sitting down or after eating? Both? These are the patterns you need to establish, as best as possible, to guide your own treatment strategy.

I'll def read up on the stickies/affibers.org to get more info on the basics and more of the lingo. Thanks again. I tried to do some research before posting info on hear and trying to recognize my triggers (though they aren't always the same).

What I can tell you is my arrhythmias come after times of depressed heart rate. ...either after sleeping (morning is the highest risk), sitting and resting after a big meal, after drinking in evening when I'm kind of tired, etc. ...So basically it sounds like the later, parasympathetic that triggers it. I don't think the caffeine is necessarily the trigger as most of those times I was waking up from a nap. I think that has more or all to do with that. Basically if my heart rate is depressed for too long, it seems get thrown off when it starts speeding up again. Hope that makes sense.



Edited 2 time(s). Last edit at 08/12/2017 05:08PM by RJS4.

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RJS4
Basically if my heart rate is depressed for too long, it seems get thrown off when it starts speeding up again.

I'm very vagal. When my electrolytes were not as balanced (too much calcium), I was subject to a lot of triggers that I'm not now. One of these triggers was the time after orgasm when the heart rate was dropping quickly. I could feel PAC's and if I did nothing, it would result in afib. I could usually ward off an episode by sitting up, standing, or getting up and moving around and increasing my heart rate. Also some vagal afibbers can convert an episode with exercise - increasing their heart rate. I could do this early in my afib career. Subsequent to my 2.5 month episode 13 years ago, I don't even try - I just take flecainide and chew it to get the quickest conversion action. I also have successfully followed this with a magnesium citrate powder "chaser." If I remember & I have some. Fortunately episodes are rare so I don't have to do it frequently.

Also, I've observed it isn't low heart rate per se, for me, it is vagal tone. In the orgasm example, my heart rate might go from 110 to 60. However resting HR is ~55 and during sleep it can drop to 45. Likewise it is reversing this high vagal tone that averts the afib, not the higher heart rate in and of itself.

Ryan,

Did your EP rule out SA node malfunction? Although unusual in younger people, it can be responsible for the bradycardia and variability in HR you describe, e.g., from sick sinus syndrome and its variants. It can also be hard to detect. If so, then supplementing with Mg can be counterproductive, due to its calcium channel blocking properties. Your use of beta blocker as PIP to treat some kind of transient tachy phase makes sense to me. And the fact that you react so strongly to it may have diagnostic significance. I would seek out an expert EP with broad knowledge of arrhythmias, and not necessarily follow conventional advice about afib prior to doing so.

Peter

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safib
Ryan,

Did your EP rule out SA node malfunction? Although unusual in younger people, it can be responsible for the bradycardia and variability in HR you describe, e.g., from sick sinus syndrome and its variants. It can also be hard to detect. If so, then supplementing with Mg can be counterproductive, due to its calcium channel blocking properties. Your use of beta blocker as PIP to treat some kind of transient tachy phase makes sense to me. And the fact that you react so strongly to it may have diagnostic significance. I would seek out an expert EP with broad knowledge of arrhythmias, and not necessarily follow conventional advice about afib prior to doing so.

Peter

Hey Peter. No, he did not bring up SA node malfunction. I will have to look into it.

That said, I did just hear back regarding my holter monitor results!!!!

I had a follow up with my EP scheduled for August 23rd, but it turns out I have to be at a work training out of town on that date. The earliest reschedule they could get me was October 4th!! So I told them I wanted to speak with someone about my holter monitor results (at the very least), since it had been 3 weeks since I had it done.

I was put on the phone with an RN at The Heart Group (Lancaster, PA) that had been there during my Afib/flutter that was caught on EKG. He went over it with me. He told me I had some of what they call "pauses." None of them were more than about 3 seconds, and he said they don't usually get worried until they are at least 4 seconds. There were also some PVC's and tachy/SVT stints in the morning, but none more than 10 beats long. He said he would sum it up with: my upper heart seems prone to beating out of rhythm for brief periods, but nothing long enough to detect the exact abnormality. He said there was nothing similar to the AFIB event I experienced when he took my EKG and caught it. He told me my EP reviewed it and said that I should continue the PIP metoprolol.

I felt like my heart was a little funky that day, especially in the morning... though I wouldn't say it was super out of the ordinary. Now I'm somewhat annoyed because again, there aren't any clear answers. Sometimes I feel like they're taking this lightly, considering I'm only 26.

You mention an expert EP. Are there any recommendations of an expert EP in the Southeastern PA area? I would prefer not to have to wait all the way to October 4th. I can't believe they're so backed up



Edited 3 time(s). Last edit at 08/15/2017 03:59PM by RJS4.

Welcome RJS4,

You have gotten a wealth of good advice/tips above including from GeorgeN, Wolfpack Jackie and SAFIB/Peter already.

They all have real merit and are important to digest and understand, including Peter's caution about ruling out a possible Sinus-Node dysfunction to some degree that could be a factor in your significantly Brady resting HR of 40bpm. As Peter noted, ruling out any Sinus node dysfunction issues will allow you to take magnesium (in reasonable doses) and even Beta blockers also at modest to small doses without exacerbating any possible sinus mode issues such as the deep Brady with uncomfortable 'existential feeling' pauses which are no fun at all as you no doubt have discovered.

For elite EPs to follow up with in PA , I can highly recommend Dr. Pasquale Santangeli at the renowned University of Penn Complex Arrhythmia group in Philadelphia which is one of the true high volume persistent and LSPAF centers in the US.

Dr Santangeli is very smart and very well trained with a gracious personality and manner as a cutting edge ablation EP who also very much appreciates life style risk management as part of the equation and was hand picked by Dr Andrea Natale, the single most experienced AFIB ablation EP on the planet at the largest/highest volume Ablation center in the world at St. Davids Medical Center in Austin Texas. Dr Santangeli worked directly under Dr Natale for his first few years after being brought over to the US from Rome Italy going on 8 to 9 years ago under Dr Natale's sponsorship and who helped place Dr Santangeli in the large program at Univ of Penn under Dr Frank Marchlinski there in their center that is closely collaborative and colleagial with Dr Natale and the St Davids Med Center group.

Dr Fermin Garcia who is also at University of Penn is truly an outstanding ablationist as well, and an AFIB expert who I can also strongly endorse.

Don't be shy in having to travel to Philly from where you are, as it is not that far from anywhere in PA and you won't been seeing your EP there that often in any event. In this field of EP, do NOT make the classic mistake of choosing an EP based mostly on convenience ... at all!! ... choose the most experienced and highly regarded EP you can possibly arrange for yourself and can reach, even with a bit of inconvenience, as doing so will most often pay big dividends over making what seems like the easy choice for the local EP in your neighborhood... unless you happen to live in Philly or best of all Austin or San Fran .

Best wishes,
Shannon



Edited 1 time(s). Last edit at 08/25/2017 09:21AM by Shannon.

Well after reading all these responses I went ahead and ordered Chocolate Ovaltine -- wow and so glad it is still popular!

My A Fib has been doing great since Dr Natale worked on it in March and now just having some PAC/PVCs after I had some laparoscopic surgery 5 days ago for the female track. Still no fun dealing with things yet once I got over being petrified and found it they were PAC/PVC is better. They just seem to go on forever these last 2 days. Meds are being reduced and off the Multaq now and reduced Toprol. Eloquis will be my friend for a while longer. Look forward to being completely back on track and at my 6 month checkup in a couple months! Take good care and thanks for all the info as I am really learning a great deal. Carol

Hi All!
I'm new to the forum also. My journey started five years ago with first, an episode of SVT with ectopics and a year or two later, a two and a half hour episode of a-fib. After a couple more years I started having nightly sinus tachycardia/atrial tachycardia episodes (about 3 am), which eventually were more a-fib. They usually go away when I get up.
This past week I had an EP study. I was hoping for some type of re-entrant tachycardia that degraded to a-fib, but it was just a-fib, so more complex to fix. I was told I went into it easily and I had to be shocked three separate times. My doctor didn't do an ablation. I was bummed! They put me on Flecainide and I don't like it at all. I woke up last night short of breath and a regular heart rate of 120 bpm.
I'm appreciative of the support this site offers.
Hi Ryan,
Heart wall thickness is also from high blood pressure. Your numbers are high, especially for your age. Left ventricular hypertrophy is a risk factor for atrial fib. You might be interested to read about methylation defects.
Best to you!
Libby

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libby
Hi All!
I'm new to the forum also. My journey started five years ago with first, an episode of SVT with ectopics and a year or two later, a two and a half hour episode of a-fib. After a couple more years I started having nightly sinus tachycardia/atrial tachycardia episodes (about 3 am), which eventually were more a-fib. They usually go away when I get up.
This past week I had an EP study. I was hoping for some type of re-entrant tachycardia that degraded to a-fib, but it was just a-fib, so more complex to fix. I was told I went into it easily and I had to be shocked three separate times. My doctor didn't do an ablation. I was bummed! They put me on Flecainide and I don't like it at all. I woke up last night short of breath and a regular heart rate of 120 bpm.
I'm appreciative of the support this site offers.
Hi Ryan,
Heart wall thickness is also from high blood pressure. Your numbers are high, especially for your age. Left ventricular hypertrophy is a risk factor for atrial fib. You might be interested to read about methylation defects.
Best to you!
Libby

Hey Libby,

Thanks for the response (and special thanks to Shannon as well for his wealth of knowledge ). I will most definitely read up on methylation defects. Your journey sounds slightly similar to mine. I tend to get tachy/occasional SVT in the morning, then occasional PVCs/PACs throughout the day as my heart slows down. But I am brady throughout most of the day.

And yes, I do have relatively high blood pressure though as of late it has come down a bit. My last two doctors visits it has been in the high 130's/60-70. And regarding thickness, the he EP said the echo shows a very slight thickness.. but he believes that has more or all to do with strength training. He said the little bit of thickness I have is common among strength athletes. I'm thinking the slight bp drop is from diet and losing pretty substantial weight since prior visits. I have a monitor at home but I don't like to take it too often for fear of stressing myself out. Slight hypertension isn't all that uncommon among heavy bodybuilders/weightlifters from what I've read. Especially isolated systolic bc of the elasticity of muscle tissue. Not sure what you all would think of this synopsis. [www.t-nation.com] ...But regardless, my blood pressure seems to be going down.

I still get occasional PVC/PACs but I haven't had an afib episode for about a month now, and haven't needed to take my beta much at all.. except for my continued blips of morning tacky.

A couple updates... Lipid panel came back:
Total cholesterol: 124
Triglycerides: 49 (apparently that's incredibly low/good)
HDL: 42 (good/average)
LDL: 72 (good/average)

EP says he has ruled out SA node dysfunction since my heart rate got all the way up to 190 on the stress test, and was back down to ~50 within a short period.

Blood pressure down the past two checks: Now averaging 138/65 (even though I was stressed and had an elevated heart rate both times)

I'm having a blood sugar check this weekend. GP and I want to rule out diabetes since my glucose levels were apparently off while in the ER. Also, just wanted to reiterate that I've never taken anabolic drugs or prohormones.