Can Anxiety Cause Heart Palpitations?
Symptoms of anxiety disorder are stomach upset, palpitations (feeling your heart beat), dizziness, and shortness of breath.
The heart needs its normal environment to work well. This is especially true for the heart's electrical system; changes in electrical conduction may lead to a decreased ability for the heart to pump blood.
Many of the substances that we put into our body can cause palpitations by appearing to act like adrenalin on the heart and make it irritable. Common stimulants include:
The use of some prescription medications needs to be monitored, since their side effects can cause palpitations. Asthma medications like albuterol inhalers or theophylline and thyroid replacement medications are common causes of palpitations.
Specific types of palpitations may be due to structural abnormalities in the heart. Narrowing of the coronary arteries that causes a decreased blood supply to the heart muscle can cause irritability and abnormal heart beats like premature ventricular contractions, ventricular tachycardia, or ventricular fibrillation. Structural wiring abnormalities can cause paroxysmal supraventricular tachycardias like Wolfe-Parkinson-White syndrome.
Heart valve abnormalities can also cause irregular heart beats. Up to 40% of persons with mitral valve prolapse complain of palpitations.
Women who are pregnant often experience palpitations and most often, no dangerous rhythm disturbance is present. However, for women who had underlying heart rhythm issues before their pregnancy, the frequency of the palpitations may increase because of the normal changes in hormone levels and changes in the blood flow that occur as the heart adapts to pumping extra blood to the uterus and developing fetus.
Changes in hormone levels in a woman's body before, during, and after menopause can also increase the frequency of palpitations.
Palpitations are a symptom in and of themselves. They can be associated with an isolated "skipped beat" sensation or, if the palpitations are prolonged, there can be a feeling of fluttering or fullness in the chest. Sometimes patients describe a marked fullness in their throat associated with shortness of breath, and it may be difficult to decide if the fullness is due to palpitations or due to angina (heart pain from heart disease). This is especially so if the palpitations have subsided and are not present when the affected person seeks medical care. Prolonged episodes can be associated with chest pain, shortness of breath, sweating, and, nausea and vomiting. Some types of heart rhythm problems can cause lightheadedness, fainting (syncope), or ventricular fibrillation and sudden death.
Extra heart beats are normal and most people are unaware that they have occurred. Every muscle cell in the heart has the potential to generate an electrical signal that can spread outside the normal electrical pathways and bundles and generate an extra heart beat. Many extra beats are normal variants and can be nothing more than an occasional irritant, but others can be dangerous, either acutely or chronically. Extra beats that originate in the atrium tend not to be as serious as those that come from the ventricle.
Abnormal heartbeats are classified by the location where they originate, if they happen occasionally or if they are clustered in runs, and if they resolve by themselves (self-limiting).
Premature atrial contractions (PAC) are just as the name describes. The pacemaker or SA node in the atrium decides to send a signal out before the heart is quite ready, and while it conducts normally and the heart beats, it is felt as a slight flop or thump in the chest as the heart beats a little earlier than expected.
A similar situation can occur with the ventricle if it becomes a little irritable and generates an extra beat, known as premature ventricular contractions (PVC). This beat fires the ventricle when there is little blood in the heart to pump, and again a flop or thump can be felt by the person.
PACs and PVCs in isolation are a normal variant. They can be asymptomatic, and an individual may not be aware of them.
If the electrical system in the atrium becomes irritable, it can cause the upper chamber to beat very fast, sometimes 150 beats or more per minute. The AV node senses each beat and sends it to the ventricle which itself responds with a beat. Because the electricity is generated above the ventricle and then passed down, the whole group of disorders is classified as supraventricular tachycardias (supra= above, tachy=fast).
Some supraventricular tachycardias are a normal response to specific situations. In times of stress, when the body wants to send more blood and oxygen to the body, like with exercise, trauma or illness, the heart rate rises in response to adrenalin that is secreted by the body to meet its physiologic demand. Caffeine, pseudoephedrine, and other stimulants can also cause this type of rapid heart beat. Because all the electrical impulses begin in the SA node and conduct normally (sinus tachycardia).
Some supraventricular tachycardias occur because of short circuits in the electrical conducting pathways in the atrium causing the heart to beat fast without apparent cause. Paroxysmal supraventricular tachycardias (PSVT) occur without warning and may last for seconds to hours. Specific types of paroxysmal supraventricular tachycardias have been identified because of recognized inborn wiring errors that can bypass the AV node. One such type is Wolfe-Parkinson-White syndrome (WPW syndrome). Precipitating factors for SVT may include caffeine or alcohol consumption, over-the-counter cold medications,electrolyte abnormalities, and excess thyroid hormone.
Atrial fibrillation and atrial flutter occur when more than one of the muscle cells of the atrium start acting like pacemakers and start firing on their own. This barrage of electricity does not allow the atrium to have an organized contraction. Instead, it jiggles like a bowl of Jello. Many of these electrical signals are passed on erratically by the AV node to the ventricle, and it tries to respond as best as possible, leading to a rapid, irregular heart rate.
There are a couple of complications with this rhythm. Since the atrium does not get a unified electrical signal, it does not pump. This allows blood to settle in the crevices of the atrium, and blood clots can form. They, in turn, can break away and travel in the bloodstream to block the circulation at other sites, causing strokes and other vascular problems. Moreover, without the atrium beating, blood flows by gravity into the ventricles and approximately 15% of the heart's ability to pump blood to the rest of the body is lost, making the heart less efficient in meeting the needs of the body.
Ventricular tachycardia (V Tach) is a potential life-threatening situation in which the ventricle starts firing quickly on its own. When people have coronary artery disease, the heart muscle can lack enough blood supply and become irritable. The electrical system doesn't tolerate decreased blood flow well and this abnormal heart rhythm may be a complication. V Tach may or may not allow the ventricle to beat in an organized way.
Ventricular fibrillation (V Fib) is not compatible with life since the ventricle has lost its ability to beat in an organized fashion, and the ventricle fibrillates or jiggles instead of beating, and the heart cannot pump blood to the body. This rhythm is what often causes sudden death after a heart attack.
Symptoms of anxiety disorder are stomach upset, palpitations (feeling your heart beat), dizziness, and shortness of breath.
The key to diagnosis is the patient's medical history.
Unless the palpitations are occurring during the visit to the health care practitioner, physical examination may not be that helpful. The health care practitioner will likely check the patient's vital signs such as pulse and blood pressure, and look for signs of underlying physical problems, such as a goiter (enlarged thyroid gland in the neck) and listen to the heart to check for abnormal sounds such as clicks or murmurs associated with heart valve abnormalities.
If the palpitations are present at the time of the visit to the health care practitioner, an electrocardiogram (ECG) and a heart monitor that records heart rate and rhythm may help establish the diagnosis. If the palpitations have already resolved, the ECG and monitor may not necessarily be helpful, however, there may be signs within the tracing that can provide direction in making the diagnosis. Most often, if palpitations are not present during the ECG, the test will be normal.
Blood tests may be ordered to check hemoglobin and red blood cell counts for anemia, to determine whether there are any electrolyte abnormalities, to check kidney function (since abnormal kidney function may affect electrolyte levels), and to check thyroid function. The levels of certain medications may also be tested in the blood.
For many people, there is a struggle to find out what heart rhythm is causing the palpitations. Inevitably, the symptoms do not always appear during the doctor's visit. Admission to the hospital is not usually effective, since lying in a hospital bed does not replicate the patient's function in their active world where the symptoms occur. A variety of outpatient heart rate monitoring devices can be worn by the patient to try to capture and record abnormal beats. These rhythm strips are computer analyzed and may give clues as to the underlying cause of palpitations. Some types of monitors are worn for one or two days, while event monitors can be worn for a month. Occasionally a patient may have a device implanted under the skin for even longer monitoring.
Since there are numerous types of palpitations, the treatment is usually specific to the diagnosis. In those people with a yet undiagnosed palpitation, minor lifestyle changes may help minimize symptoms. These include discontinuing the use of caffeine, alcohol, OTC cold medications, and vitamin, dietary, or herbal supplements or medicine.
Patients with palpitations should try to keep a journal of when, where, and what circumstances surround their palpitations. They should learn how to take their pulse and document their pulse rate, whether the palpitations occur in isolation or in a pattern, and what associated symptoms exist, including lightheadedness, nausea, sweating, chest pain, or shortness of breath. It is most important to note whether the heart beat is regular or irregular and whether it is fast or slow. It is helpful to know if the palpitations are associated with time of day, meals, lying down at night, or during emotional stress or anxiety.
Chest pain (or any other signs of heart attack including jaw pain, indigestion, or extreme fatigue), shortness of breath, or passing out should prompt the affected person or family member/friend/caregiver to call 911 and seek medical attention immediately.
In the acute setting, for a person with a supraventricular tachycardia or atrial fibrillation, the goal is to slow the rate and establish the diagnosis. Sometimes, attempts will be made to use vagal maneuvers to block the adrenalin forces in the body. One such maneuver asks the patient to hold their breath while bearing down hard as if to have a bowel movement. This stimulates the vagus nerve in the body, increasing the release of the chemical acetylcholine, which affects the heart by slowing it down. There are variations of this maneuver. Some doctors will ask the patient to breath through a straw. Others lay them flat and help them raise their straight legs as high as they can, bending at the hip.
Patients who have SVT that respond to vagal maneuvers can often be taught how to stop their palpitations at home with some of these techniques.
Medications may be used intravenously to restore a noraml heart rhythm or to slow a rapid heart rate. This is usually done in a hospital setting with the patient placed on a heart monitor, but paramedics may also use this medication in the field.
Adenosine may be given as a single intravenous injection that may reset the pacemaker cells and allow the heart to go back into a normal rhythm, or it may slow the heart rate temporarily to allow the doctor to diagnose the underlying heart rhythm causing the rapid heart beat. This allows the appropriate medication to be prescribed for control or cure. Other medications that may be used include beta blockers and calcium channel blockers that help slow the heart.
Some rhythms, like Wolfe-Parkinson-White SVT, have specific electrical short circuits that can be treated by the administration of high-frequency electrical energy ("burning") during heart catheterization and using high frequency ultrasound to ablate or destroy the abnormal electrical pathway and cure the problem. This procedure is used in rare situations, for example, in patients with WPW or atrial fibrillation.
If the rapid heart rate is associated with chest pain, shortness of breath, or low blood pressure, an emergent situation exists, and electrical shocks may be administered with anesthesia to convert the heart to a more stable and slower rhythm.
Longer term care for palpitations aside from the lifestyle changes is medication. Treatment is specific to each rhythm and must be tailored individually to each patient.
If a person is in ventricular tachycardia or ventricular fibrillation (VFib), call 911 immediately for life-saving medical treatment. VTach and VFib need immediate medical treatment to prevent death. Prognosis is very poor for V Tach or VFib without immediate medical intervention. If a person survives having ventricular tachycardia or ventricular fibrillation, they may need to have an implantable cardioverter defibrillator placed under his or her skin.
Most palpitations, like isolated premature atrial contractions and premature ventricular contractions, are normal variants and do not affect lifestyle or longevity. Other rhythm disturbances usually need medications for control, but the goal is to allow the patient to return to a normal lifestyle with minimal restrictions.
Medically reviewed by Joseph Palermo, DO; American Osteopathic Board Certified Internal Medicine
REFERENCE: Salem DN, O'Gara PT, Madias C, Pauker SG. Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133 (6 Suppl): 593S-629S
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