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Peter


4-15-99

Here is my story.

About 8 years ago I began to notice the first indications that my heart rhythm was showing signs of becoming abnormal. I am presently 38 years old, male and in otherwise perfect health. I have no family history of heart disease and have always led an active, healthy lifestyle. Aerobic activities such as skiing, running (including marathons), kayaking (raced at 5 nationals), mountain climbing etc. have pretty much dominated my life. The arrhythmia was first documented when I visited my family doctor who hooked me up to heart monitor and noticed the supraventricular tachycardia (SVT). Some peculiar findings were that the abnormal rhythm was usually initiated by the action of swallowing. I was told not to worry about it and that it was something not that unusual (sound familiar?). It generally intensified over the next few months, eventually becoming the focus of my life. The uncertainty of what was happening created a lot of anxiety. The idea of exercise was becoming almost impossible. After about 5 months of this it went away completely for about 2 years. During this time I resumed a completely normal lifestyle and ran about 50 - 60 kilometers per week. Everything was great until suddenly, for no apparent reason, it began to creep back into my life again.

I had a variety of cardiac tests done (ECG, echocardiogram, blood tests, etc.) that all proved negative. Well, things continued that way for 5 or 6 anxious months. The cardiologists again said not to worry. The fact that the heart beat would be normal until I swallowed seemed to puzzle the doctors. None (including a well known electrophysiologist) had ever heard of that correlation. Then again it went away for about a year this time. When it returned, a year later, I was becoming very frustrated and nervous. Basically my normal lifestyle went on hold while this was affecting me. I would go for a run with a heart rate monitor and watch my pulse beat happily along at 140 bpm. If I didn't swallow the beat would remain normal. As soon as I swallowed the rate would jump to 230 bpm instantly and then recover to 140 a few seconds later.

Unfortunately I suffered a prolonged occurrence (14 hours) of atrial fibrillation before meds converted back to normal sinus rhythm. The cardiologists were wondering if I had an accessory pathway and suggested an electrophysiology study. I was willing to do anything so I had the study done. I was put on heart meds to control the rhythm. The whole time I was on them (only a few months) I was sure something else was causing this problem. My exact words to my family GP were "We are missing something here". It sounds funny but after pushing my heart all my life and it serving me faithfully, I knew the problem rested somewhere else in my system.

The electrophysiology study proved negative. Unfortunately the irregularity of the beat, including the swallowing trigger, had gone dormant prior to the EP study. They told me my heart mapped out perfectly. They listed all the possible reasons to explain my problem, (which they called "lone afib")none of which were even remotely close to describing my situation. So I said, "Why do I have this?" Their response was "We don't know enough about this yet". "Great, but where does that leave me?" Well, I was told to stay on the meds for the rest of my life. I was also told that I may need a pacemaker sometime. NO WAY! So I began my search.

I spent days/weeks/months on the net exploring for any clues. I visited a homeopathic specialist who noticed problems with my digestive system. I was also told my liver had some trouble. All pretty unscientific but I pursued it anyway. I asked for an ultrasound of the liver and it turned out to be fatty (again I don't drink, smoke or eat poorly). The doctors couldn't explain this either. How many mysteries can one person have? Well it gets better... I asked for a Barium swallow to get a look at my esophagus. The doctors didn't want to do this test because I showed none of the typical symptoms of GERD. So I lied a bit and they did it anyway. To everyone's surprise I had significant reflux up to the hypopharynx.

In retrospect I did have lots of acute pains in my chest and back that I attributed to the heart condition or the stress, but I never had trouble sleeping or any of the typical heartburn symptoms. Actually I have always slept like a baby throughout all of this. Well they acknowledged the reflux and put me on Pantoprazole and Propulsid to knock it down. After a month of these meds ( I had no side effects) I was put on Pepcid 20 mg 2x day and before long the heart problem began to disappear again. That was about a year ago.

During the past year my lifestyle has basically returned to normal. I still have yet to resume my usually activity levels but I don't want to push it too soon. I have had some troubles with the stomach, probably due to poor eating habits or work stress. When I notice any hint of the rhythm problem returning I take some of the antacids and the problem goes away. On one occassion while engaged in a full day of hiking and climbing I suffered a short bout of afib lasting about 15 minutes. This caught me by complete surprise because I had been feeling no indication of any rhythm problem at that point. The afib actually occurred following a 60 minute, easy run with a light pack on my back. I noticed soon into that run that the swallowing trigger was happening. I ignored it and paid the price an hour later. I have noticed that the jarring action of running seems to aggravate this problem. If I bike or swim I can get my heart rate up pretty high without any trouble. If I run the bouncing seems to stir things up.

To this day no doctor has acknowledged that the connection between the heart rhythm and the digestive tract is a real one (other than the known effect of some foods like caffeine). I have had many people email me telling me of similar stories. A few doctors have indicated some support for the idea of a possible causative relationship. I still live with the fear of future rhythm problems. So what is causing all this - here is one possible theory based on what I have experienced.
The heart is controlled by the autonomic nervous system which has two basic mechanisms. Sympathetic nerves serve to stimulate or speed up the heart rate. Parasympathetic nerves do the opposite, that is slow the heart rate. During the day
most of us are in a continuous sympathetic tone. At night the parasympathetic response takes over. The Vagus nerve is a massive nerve that runs along the posterior part of the esophagus. It has many functions including a parasympathetic effect on the SA node of   the heart (Pacemaker). I believe that chronic reflux has caused an irritation of this nerve which, especially when I swallow , delivers an inappropriate parasympathetic stimulus to the SA node. The sympathetics will win out, especially during exercise, but the effect will result in a disruption to the normal sinus rhythm. At night the parasympathetic tone is dominant so swallowing doesn't interfere with anything (hence I sleep well). So why doesn't everyone with reflux have this problem???? Who knows, perhaps I have a slightly different anatomical relationship with the vagus nerve and the esophagus. As I reflect back on the many clues and pieces to this puzzle I can see that more and more of this possibly relates to acid reflux.

Recently I had a gastroscopy done. Mild to moderate esophagitis was observed along with the presence of significant amounts of bile in the stomach. This would suggest problems with gastric motility. Perhaps the acid itself is not the problem but some other mechanism. Could spasmodic peristalsis somehow act as the trigger? Could the bile itself be responsible?  I think the key to solving this mystery is isolating the trigger mechanism with regards to why the mechanical action swallowing causes the interruption to normal sinus rhythm.

I have probably left out many important parts to this puzzle but hopefully enough has been given to round out my story. When I talk to others with classic GERD I can't say that I have all the typical signs or symptoms. Actually if it were not for the heart beat problem I would have never considered it. But the facts are that when I targeted the reflux the heart problem did improve. I now eat properly and do all the typical GERD self-help things.

There are still many observations still unresolved such as:

1. The episodic nature of this problem. It has come and gone over the past 8 years.
2. Swallowing as the trigger mechanism (providing conscious control over when the beat is disrupted).
3. Positive esophagitis and the presence of bile in the stomach.
4. Effects are enhanced by the jarring action of running. Smooth activity such as biking      does not seem to create the problem to the same extent.
5. Why my nights are relatively peaceful with no interruption of sleep. Basically normal      sinus rhythm.
6. Gastric distress for several weeks prior to the onset of the arrhythmia.
7. Low intensity but specific pain in the epigastric area (not always there).

Test Results:

1. Thyroid test negative
2. Blood tests show nothing abnormal
    -Cholesterol normal
    -Low immunoelectrophoresis
    -Positive Billirubin count = Gilbert's Syndrome
3. Ultra sound shows evidence of fatty liver.
4. Echocardiogram done 2x shows nothing other than left ventricular volume on upper      border of normal.
5. Stress Testing (Bruce Protocol) well tolerated.
6. EKG's show a variety of abnormalities over several years including:
    - Right axis deviation (consistent finding on every ECG)
    - Frequent PAC's
    - Nonspecific intraventricular conduction delay
    - left atrial abnormality
    - possible right ventricular hypertrophy
    - sinus arrhythmia
7. Electrophysiology Study - normal / no mechanism found
8. 24 hour Holter monitor shows (see attachments for ECG strips):
    Dec. 1995:
    - 596 isolated SVT ectopics (only 48 of these occurred during sleep)
    - 189 couplets
    - 133 runs (Paroxsymal atrial Tach. fastest being 5 beats at 236 bpm)
    - sinus rhythm with occassional episodes of sinus tach. and occassional to frequent     episodes of sinus bradycardia.
    - occasional PAC's some aberantly conducted with rare couplets and bigeminy
    - min. rate 36 bpm
    - average = 70 bpm
    - max RR interval was 1. 87 secs after PAC
    Jan. 97:
    - 422 isolated SVT ectopics (only 24 of these occurred during sleep)
    - 217 couplets
    - 224 episodes of PAT 3 - 185 beats in duration at rates up to 247 bpm.
    - normal sinus rhythm with sinus bradycardia, sinus tach and sinus arrythmia.
    - min. rate 30 bpm during sleep
    -average = 62 bpm
    - max RR interval was 2.3 seconds due to atypical wenckebach AV block
    Apr. 98: (post Acid Reflux Treatment)
        - 5 isolated SVT ectopics
        - 0 couplets
        - 0 PAT
        - normal sinus rhythm with frequent sinus bradycardia
        - max RR interval 1.63 seconds due to sinus arrythmia

9. Barium Swallow (Upper GI) - positive finding for reflux up to hypopharynx
10. Gastroscopy:
    - mild to moderate esophagitis
    - bile present in stomach

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