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Author Topic: Heart Rate Varies at Rest; is it anxiety, medication, or something else?  (Read 465 times)

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Offline Andrew90

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I have some cardiophobia, and tend to take my pulse every day, more often than I probably should. But recently I've been noticing that while at rest, I will feel my pulse and my heart rate will go from around 67 to 85 in less than 30 seconds while sitting down. I use the Instant Heart Rate app on my android to take my pulse, in addition to feeling it on my neck. I'd like to note that I'm a 23 year old male, have been to the cardiologist recently, and have been told I have nothing to worry about, and that's it's my anxiety that's causing me to worry so much about my heart. I also had a 2 week holter monitor done about 2 months ago, and the results came back with nothing abnormal, save for a few PVC's and PAC's which I have been told are harmless in a structurally normal heart.

I would also like to add that I currently take 30 mg Remeron, 1 mg Klonopin daily, and 3 mg Guanfacine (spread throughout the day). My pdoc has prescribed me to start taking small doses of Dexedrine to get back on ADD medication, as I have some pretty bad ADD and have been off my ADD meds for several months to treat my anxiety. I have the medication, and was about to take it, but was a bit apprehensive when noticing how my heart rate varies at rest like this. Is this variation something I should really fret over, or should I just simply stop taking my pulse and get on with taking this ADD medication? I do have some xanax and ativan should I need it for any flare ups with anxiety, but at this point I am just wondering if I should stop taking my pulse and worrying about it.


Any insights about this would be greatly appreciated.
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Offline insights

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #1 on: January 11, 2014, 05:17:26 PM »
Is this variation something I should really fret over,

No. Even at 85bpm it is well within the normal 60-100bpm adult range. It is almost certainly 'white coat'  hypertension, or in your case its 21st Century manifestation 'Instant Heart Rate app' hypertension.

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or should I just simply stop taking my pulse

YES! All you're doing is feeding your anxiety without getting any benefit.

Ian
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NOTE: I'm not a doctor, and particularly not yours, so there may be factors I'm unaware of. Therefore all advice is of a general nature and you should consult your doctor before following any of it, especially before changing med doses.

Offline Abraham2007

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #2 on: January 11, 2014, 05:33:45 PM »

.... and 3 mg Guanfacine (spread throughout the day)...

Normally Guanfacine is taken once a day, usually before bed, not spread throughout the day.  Maybe if you took the full 3mg at night, and then checked your blood pressure in the morning, you may notice more stability in your pulse.   I also believe 3mg is the maximum dosage for Guanfacine, so this may explain why your doctor added the Dexedrine.  **

I also believe about a week or so ago, you were contemplating to completely drop the Remeron, or move to a lower dose at 15mg, and then taper off. You would go back on the Remeron (Mirtazpine), if you were to experience anxiety without it.  Given your cardiophobia, and your tendency to worry about your pulse, you are probably better to stay on the Remeron (Mirtazapine), or another anti-anxiety medication (like an antidepressant), than get off it.


_______________________________________ _______________________________________ __________
** Source:
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601059.html

How should this medicine be used?
Guanfacine comes as a tablet and as an extended-release tablet to take by mouth. The tablet is usually taken once a day at bedtime. The extended-release tablet is usually taken once a day and should not be taken with a high fat meal. Take guanfacine at around the same time every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take guanfacine exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.


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Offline Andrew90

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #3 on: January 11, 2014, 06:39:06 PM »
I take the Guanfacine 3 times a day, at about 6 hours apart. So I take 1 mg when waking up (usually at 8), 1 mg at 2 pm, and then 1 mg at 8 pm. My insurance company has approved covering the extended release brand formulation (Intuniv), but I have stuck with taking the immediate release version of Guanfacine (Tenex) because I feel comfortable with the ability to tweak the dosage if I wish. However, maybe I would be better off just getting the medication filled as 3 mg Intuniv, so that I would just take it once a day in the morning? Perhaps this would allow for more consistency with the drug levels in my blood?

Another thing I read is that mirtazapine potentially may oppose the action of the Guanfacine because Guanfacine is an alpha 2 adrenergic agonist, while mirtazapine is partially an alpha 2 adrenergic antagonist. This in effect could theoretically result in the Guanfacine not working as it should, and blood pressure rising...but is this something that I should be concerned about? My psychiatrist thinks the alpha adrenergic properties of the Remeron aren't significant enough to cancel out the effects of the Guanfacine.

I quote from the Mirtazapine page on wikipedia: "If a person is on the drug clonidine or other centrally acting alpha 2 agonists, even normal doses of mirtazepine risks a hypertensive crisis, this being due to it acting exactly opposite as clonidine on alpha 2 receptors."

Also, a reference to an article from medscape: http://www.medscape.com/viewarticle/409538_3
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Offline Abraham2007

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #4 on: January 11, 2014, 07:41:11 PM »
I take the Guanfacine 3 times a day, at about 6 hours apart. So I take 1 mg when waking up (usually at 8), 1 mg at 2 pm, and then 1 mg at 8 pm. My insurance company has approved covering the extended release brand formulation (Intuniv), but I have stuck with taking the immediate release version of Guanfacine (Tenex) because I feel comfortable with the ability to tweak the dosage if I wish. However, maybe I would be better off just getting the medication filled as 3 mg Intuniv, so that I would just take it once a day in the morning? Perhaps this would allow for more consistency with the drug levels in my blood?

I think most of the studies on the Guanfacine medication were with patients who took Guanfacine once a day at night, so you should follow suit as the participants took it once a day, and do the same, instead of taking it three times a day.  The reason why it's preferred to take it at night is due to sedation.   Patients are warned to not drive or operate machinery after taking Guanfacine, so a higher A.M. dose at 3mg (instead of 1mg at 8am) may cause you to be drowsy.  So there maybe safety issues when you drive, if you take Guanfacine around the start of your day, especially if you take classes in the morning at your local University.  Not to mention, you shouldn't catch yourself catchings some Z'sss in a 9:00 class, due to Guanfacine, because it makes you look bad in front of your professor.    :sick0002:


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Another thing I read is that mirtazapine potentially may oppose the action of the Guanfacine because Guanfacine is an alpha 2 adrenergic agonist, while mirtazapine is partially an alpha 2 adrenergic antagonist. This in effect could theoretically result in the Guanfacine not working as it should, and blood pressure rising...but is this something that I should be concerned about? My psychiatrist thinks the alpha adrenergic properties of the Remeron aren't significant enough to cancel out the effects of the Guanfacine.
I also found *some* evidence that Remeron and Guanfacine may impact blood pressure, when taken together, however you are also being monitored by a doctor.   The two of you should take note if the condition gets worse, however I wouldn't focus too much on it, because your constant attention to the Remeron and Guanfacine interaction will make you anxious.  And if you do choose to switch to another antidepressant, you may want to explore with your psychiatrist on another medication that can control your OCD tendencies about worry.

Possibly after two weeks, when you change your Guanfacine comsumption to 3mg, at night, this may correct the pulse issue.  If not, then definitely raise the issue again with your doctor.   If you don't mind, I hope you keep this forum updated about what happens, if you were to switch taking at once a day (preferably) at night, instead of originally taking it three times a day.

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Offline insights

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #5 on: January 11, 2014, 07:51:40 PM »
while mirtazapine is partially an alpha 2 adrenergic antagonist. This in effect could theoretically result in the Guanfacine not working as it should, and blood pressure rising...but is this something that I should be concerned about? My psychiatrist thinks the alpha adrenergic properties of the Remeron aren't significant enough to cancel out the effects of the Guanfacine.

Your psychiatrist is probably right, mirtizapine is a far weaker binding affinity - about 140Ki to a2 adrenergic receptors than Guanfacine does - about 30-50Ki (the lower the Ki value the greater the affinity/binding potency).

Whatever impact each drug is having on your blood pressure it would be fairly constant. This isn't the reason your BP is going from 67bpm to 85bpm is 30 seconds, your anxiety is.

Ian
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NOTE: I'm not a doctor, and particularly not yours, so there may be factors I'm unaware of. Therefore all advice is of a general nature and you should consult your doctor before following any of it, especially before changing med doses.

Offline Andrew90

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #6 on: January 11, 2014, 09:02:36 PM »
I will definitely ask my doctor about switching from immediate release Guanfacine 3 times a day to extended release 3 mg guanfacine once a day, either at night or in the AM. Guanfacine itself doesn't actually cause me any notable sedation, I've been on this dose of 3 mg for almost 2 months, and I have been fine going about my daily work without feeling overly sedated. I also think that it will just be easier to take it once a day instead of 3 times a day. 

I do have some OCD worry regarding this whole interaction ordeal between Remeron and Guanfacine, but from the binding affinity data that insights provided, along with the word of my psychiatrist, I suppose I should stop worrying so much. I look into things so intensely sometimes, that I recognize that they may be driving my anxiety higher.

I guess I'm wondering if it would be safe for me to take the dexedrine tomorrow? Probably a very small dose to start with would be wise. My doctors have given me the approval (including my cardiologist), I just want some additional support I reckon. Like I said, I look into things with a fine microscope at times, that it sends me into a whirlwind of worry. I probably should focus my mind on other things instead of just my medications.
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Offline Andrew90

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #7 on: January 11, 2014, 09:17:41 PM »
Insights,

What is your source of information regarding the binding affinity? On Wikipedia, it lists that the alpha 2a adrenergic receptor binding affinity is 20 Ki.
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Offline Andrew90

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #8 on: January 11, 2014, 10:16:27 PM »
WebMD, Medscape, and RxList all list a significant interaction between guanfacine and mirtazapine, in that their combined use can risk a hypertensive crisis. Could this perhaps explain partially why my pulse is varying to the degree that it is at rest? Unfortunately, knowing this is causing me additional anxiety. I am going to pop a xanax now.

I am thinking I may cut my 30 mg pill in half tonight and step down to 15 mg, and then after a few days go off of the Remeron. I will schedule an appointment with my pdoc for early this week. I don't anticipate it being too difficult for me to step down from the Remeron; I went down from 45 mg last week and did not experience any notable withdrawal effects. I will discuss with my pdoc an alternative antidepressant that doesn't antagonize alpha 2 adrenergic receptors, because I would rather stay on the guanfacine and allow it to work properly.

What do you guys think? If at the very least, at this point, it's all for cutting away at my anxiety, because even if it's not causing any real interaction symptoms, I'm now anxious about it. 
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Offline insights

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #9 on: January 11, 2014, 10:59:08 PM »
What is your source of information regarding the binding affinity? On Wikipedia, it lists that the alpha 2a adrenergic receptor binding affinity is 20 Ki.

From: P. K. Gillman, Mirtazapine, PsychoTropical Research, 2012 (table 1) and also his A systematic review of the serotonergic effects of mirtazapine in humans: implications for its dual action status which isn't online afaik.

Quote
WebMD, Medscape, and RxList all list a significant interaction between guanfacine and mirtazapine, in that their combined use can risk a hypertensive crisis. Could this perhaps explain partially why my pulse is varying to the degree that it is at rest?

No!

Quote
Unfortunately, knowing this is causing me additional anxiety. I am going to pop a xanax now.

This is!

Quote
What do you guys think? If at the very least, at this point, it's all for cutting away at my anxiety, because even if it's not causing any real interaction symptoms, I'm now anxious about it.

I think the only thing you should do between now and when you see your pdoc is to delete the heart rate app from your phone and never install anything like it ever again.

Ian

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NOTE: I'm not a doctor, and particularly not yours, so there may be factors I'm unaware of. Therefore all advice is of a general nature and you should consult your doctor before following any of it, especially before changing med doses.

Offline Abraham2007

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #10 on: January 12, 2014, 01:17:37 AM »
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Offline Abraham2007

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #11 on: January 12, 2014, 01:21:38 AM »



It's either the Xanax or the app, drop the app, my friend.  :yes:
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Offline Andrew90

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #12 on: January 12, 2014, 01:11:23 PM »
you guys are absolutely right. This app is driving me up the wall. I've had my cardiologist, psychiatrist, and cognitive behavioral therapist all tell me the same thing. It's in my best interest to stop taking my pulse.

On a side note, since dropping from 45 mg to 30 mg of the Remeron, I've lost 3 pounds! This was less than a week ago. This makes me very happy, because I had hoped all along I could pinpoint my weight gain to the remeron. I definitely feel that it slows metabolism, because my eating habits have remained unchanged.
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Offline dh1972

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #13 on: January 13, 2014, 10:39:07 PM »
I too suffer from some cardio phobia (especially since cardio issues run in my family although most of the people had unhealthy lifestyles when they had problems with artery blockage) so I can relate a bit to taking pulse and even blood pressure occasionally.  I also get PVCs and PACs occasionally, but several different doctors including a cardiologist said that is fine.  I have noticed a greater frequency of cardio exercise has significantly lessened the frequency of them.  Bursts of anxiety can initiate them.

When my anxiety reached a high point last spring and I had two panic attacks, it scared the daylights out of me as I thought I was having cardio issues.  Ended up getting a stress-echo and everything was normal.  That in addition to some other events in my life just created an anxiety ball that I never got out of and heart issues are still at the back of my mind.  I've learned to apply CBT to other aspects of my life, but still struggling in regards to the cardio fear - something I need to work on.

By the way, going to the Psychiatrist for the first time ever on Wednesday. :)
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Offline Andrew90

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Re: Heart Rate Varies at Rest; is it anxiety, medication, or something else?
« Reply #14 on: January 14, 2014, 12:18:40 AM »
Cardiophobia is a real drag...I try to block it from my mind, but that only makes it more at the forefront of my thoughts. It's tough, but I know there's a way to stop this freakishness if I change my behaviors and habits. Medications certainly help, as do therapy.

Let us know how your appointment goes :)
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