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April 25th, 2015
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I am 33, M, 160 lb with no family history of any heart disease. I wanted to run something by you. A year ago I had an episode of tachy heart was at 140-160 for about 15 minutes. I had a full cadio workup (stress, echo, event monitor, carotid scan) that all came out normal besides rare PAC's at peak exercise and PAC's day to day. For the past 6 months I have been waking up in the middle of the night and upon standing, about 20-30 seconds post standing my heart rate will jump to 120-135 and my heartbeat will be forceful, then it will seem to try to slow down, and then speed up again. This cycle repeats itself for about a minute or two. I feel anxious when this happens. I do not get this when I get up to work in the morning, or after taking a nap, it only seems to happen between 11-3 am. Is this something a test could miss, or should I be concerned. On the event all they said they found was normal sinus tachy, and nothing else alarming, but these episodes feel odd.
2012-09-28 Answered By : Dr. Dhanunjaya Lakkireddy, MD, FACC, FHRS.

In a condition called inappropriate sinus tachycardia, patients tend to have elevated resting heart rate and/or an exaggerated heart rate response to exercise. This is different from condition called postural orthostatic hypotension syndrome where patients tend to have normal baseline heart rates and exaggerated sinus tachycardia in response to changes in posture. Tilt table study to rule out postural orthostatic tachycardia syndrome can be performed. Increased heart rate might be due to suddenly standing up, but it is not clear why you do not have symptoms when standing during the day or when you are getting up in the morning. sometimes atrial arrhythmias that arise from the right atrium can look like sinus tachycardia and an electrophysiologic testing may be necessary to determine the exact nature of this arrhythmia.

I am female 67 years old. Ihave undergone 10 years ago a mitral valve replacement with a prosthetic one toghether with aMAZE cryo procedure to protect me from atrial fibrilation.The maze was unsuccessful,atrial.fib come back to me mostly as atrial flluter.I WAS VERY SYMPTOMATIC doctors changed all the timp for other antyarhythmic drug.on the last time i took dronedarone until it stoped working.Now i'm on CONCOR10mg twice a day DILTIAZEM 60mg 3times dayly valsartan 80ng Lipitor20 etct...NO rate control,most of the time the puls is irregular.Iam skeard that the combination of betablocker and calcium chanell blocker could made worser the heart problems(maybe to brink to CHF) I already had implanted a double chamber pacemaker(for what?).Dr Lakkureddy could you give me an advice maybe?
2012-09-28 Answered By : Dr. Dhanunjaya Lakkireddy, MD, FACC, FHRS.

Both CONCOR and valsartan have been shown to be beneficial in CHF. The combination of beta blocker and calcium channel blocker would slow down the heart rate. In your case, if your symptoms are not controlled with present dose of medications, it might be worthwhile increasing the dose of medications since the pacemaker would prevent the heart rate from dropping to very low heart rate. The other option would be radiofrequency ablation. Post maze atrial flutters can sometimes be challenging but most of them can be successfully treated with mapping and radiofrequency ablation. Contact an electrophysiologist who specializes in complex arrhythmia ablation in your vicinity and seek consultation. You have not been tried on other antiarrhythmic drugs like Dofetalide or sotalol which are worth looking into.

Hello Doctor, My husband is 50 years old and overweight. I recently had him undergo a Lifeline Screening in our town. His heart rate and cholesterol were good; however, the section on atrial fibrillation indicated st segment changes. I don't know what this means? kindly suggest me?
2012-09-28 Answered By : Dr. Dhanunjaya Lakkireddy, MD, FACC, FHRS.

From the information you have provided us , it appears that ECG performed for atrial fibrillation screening showed ST segment changes. The results of ECG are normally interpreted in context of symptoms and history which include presence or absence of chest pain, shortness of breath, palpitations, dizziness and exercise capacity (distance you could before you feel short of breath or experience chest pain). ECG is not recommended in patients who do not have symptoms or who have a low risk of coronary artery disease. ECG alone does not reveal much information in an asymptomatic patient apart giving information about the patient's rhythm. In your husband's case, ECG was performed to rule out atrial fibrillation ( irregular rhythm). I hope the test results showed that he does not have atrial fibrillation.

I was recently prescribed 20 mg Adderall for ADHD daily and just found out I have plaque buildup 25% in neck area. Is this something I should be concerned about and does the Adderall contributed to heart attack or strokes? I am 63, exercise several times a week and my focus and concentration has been finally improved with the ADHD medication but now concerned? Kindly let me know?
2012-09-28 Answered By : Dr. Dhanunjaya Lakkireddy, MD, FACC, FHRS.

A recent retrospective study showed that there was no evidence of an increased risk of heart attack, cardiac arrest, or stroke associated with the use of ADHD medications. The FDA also recently (in Dec 2011) relased safety information about a study in children and young adults exposed to certain ADHD medications which did not show any association of heart attack, cardiac arrest or stroke and ADHD use in that population.

Hello Doctor, I am being treated for atrial flutter with Tambocor, Micardis, Simvastatin and Atenolol, also warfarin. When sitting watching TV around 4PM I can feel my heart beating irregularly. My second dose of Atenolol and Tambocor for the day is due at 7PM. How is this situation? Once the Atenolol and Tambocor kick in around 8 - 9 PM I am usually fine again. Could anyone provide information about this situation..?
2012-09-28 Answered By : Dr. Dhanunjaya Lakkireddy, MD, FACC, FHRS.

The peak levels of Tambocor in blood is seen 1.5 to 3 hours, so the medication kicks in at 8-9 pm after you have taken the medication at 7 pm. Atenolol is taken once daily , in your case at 7 PM daily. It is likely that the levels of Tambocor in blood decrease towards the evening. The dose of tambocor may have to be increased. It is not clear whether you are taking 50, 100 or 150 mg of Tambocor. I recommend that you follow up with your doctor, who might consider increasing the dose of medication. The other possibility is that your AF is simply breaking through. You may need change of the drug or consider AF ablation.

Hello. My 86 year old mother had a heart ablation procedure done 4 days ago to treat her chronic and permanent atrial fibrillation. She was under general anesthesia for 7 hours and now has a very sore throat that appears to be getting worse. She is also coughing up a lot of bloody mucus still. Is this normal after 4 days? I am concerned that she is heading for about of pneumonia should this continue. Please help?
2012-09-28 Answered By : Dr. Dhanunjaya Lakkireddy, MD, FACC, FHRS.

Sore throat and coughing could be due to intubation during general anesthesia. In most patients , these symptoms resolve in two weeks. Also ulceration of esophagus may happen in few patients undergoing AF ablation , but the symptoms resolve over a short period of time. Lets hope that both sore throat and cough resolve in next two weeks. If she continues to have unresolving cough, painful swallowing or significant reflux it is worth mentioning this to her electrophysiologist who performed the procedure.

Hello Doctor, I am a healthy, 45 year old female; 5.6 147 pounds with no previous health issues. I am a smoker, perhaps 10 a day. I have for many years experienced mild twinges of what I can only call 'sharpness' in the area around my heart. I've had this for as long as I can remember and mostly it occurs when I lie down at night - don't notice it during the day. The reason I've now decided to question whether this is 'normal' or not is twofold; firstly, I've never experienced such twinges on the right hand side of my chest, hence not muscle related and b. My father died suddenly of cardiac arrhythmia 4 weeks after a major, unexpected heart attach (aged 71) and my mother has ischemic heart disease (aged 66) and a family history of blood pressure / stroke. My blood pressure is normal by the way. Is this something I need to investigate or are there perhaps less ominous reasons for the twinges I've been experiencing? Finally, the twinges are not painful, merely annoying and disconcerting. Always on left side of heart.
2012-09-28 Answered By : Dr. Dhanunjaya Lakkireddy, MD, FACC, FHRS.

It is not clear why you have popping sensation when you breathe in. If the pain or popping sensation increases with taking deep breaths, not associated with sweating, dizziness and not related with exertion, it is unlikely that it is related to heart. It could be either be musculo-skeletal pain (related to muscles and bones in the chest region) or a condition known as costo-chondritis. Treatment will involve taking anti-inflammatory medications like ibuprofen as and when needed. If the pain continues to recur, I would recommend you to follow up with your primary care doctor.

I had my fourth ablation at a major medical center about a month ago for afib. I have had no episodes of afib since then but I have frequesnt PVCs (every few heart beats). I have been advised this is not unusual and may improve with time. The experts seem to agree that while troubling they are not harmful. My options seem limited and I do not want another ablation. I am still on 225mg of Rythmol after the ablation. Do you agree that unless they become diabling with symtomps I should just learn to live with them. Ron Greenwood
2012-09-28 Answered By : Dr. Dhanunjaya Lakkireddy, MD, FACC, FHRS.

If you have had no episodes of Afib and A fib is under control, your doctor could consider stopping rythmol and re- assess if you have AFib recurrence and there is any change in PVCs frequency. Rythmol by itself cause PVCs in 1-2 % of patients taking it. Since you have undergone 4 ablations it is more likely that you may be one of those patients who may have extensive substrate changes with scar and require anti-arrhythmic medication for control of atrial fibrillation. If the PVCs are significantly impairing your lifestyle and your current antiarrhythmic drug is not doing the job, your doctor could consider changing to another anti-arrhythmic medication and reassess if there is a decrease in frequency of PVCs

There seems to be substantial excitement about the recently publicized Firm ablation technique. It sounds promising under the "less is more" school of thought, i.e. more precisely directed ablation will be safer and more effective than existing techniques. However the sample size so far is very small. At what point does the analytic and deliberate afib patient conclude this is the way to go (as opposed to essentially serving as a lab rat due to experimental nature of the technique)
2012-09-28 Answered By : Dr. Dhanunjaya Lakkireddy, MD, FACC, FHRS.

In the recently published study , Dr.Narayan and his group compared FIRM+ conventional approach to conventional approach alone and showed that FIRM techinque was able to terminate or slow down atrial fibrillation in 86 % patients before conventional approach. The early data is very thought provoking and warrants furhter studies. This study was a non-randomized study and did have limitations. This techique requires further validation in larger populations before the findings can be extrapolated. Also further randomized controlled studies are needed to demonstrate the overall safety and efficacy of this techique in all population groups. Like any other idea it needs work to tease out the details. If you are not willing to participate in the early phases of the research you may definitely want wait until we get further data.

Im looking for a specialist in using cryoballoon ablation in the San Francisco/Palo Alto area
2012-09-28 Answered By : Dr. Dhanunjaya Lakkireddy, MD, FACC, FHRS.

We have put out team to work to find which institution in this area provides cryoballoon therapy. We will have the names of a few specialists soon.

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