I’m presently enrolled in a University level Psychiatry course for existing healthcare providers which offers a discussion board as part of our learning process.  It’s a great way to share clinical experiences, hypothesis’ and make connections across specialties, conditions, and life experience.

I wanted to share a discussion and experience for the purpose of healthcare advocacy, because if I hadn’t been in medical school at the time of the past experience I’m referring to, myself, I would not exist to tell you about it.

So, here is a discussion, prompted by the question “What is Irritable Heart Syndrome”, with the context of stress and stress hormones exerting physiologic effects on the body, just as they do at the root of negatively effecting IBS (irritable bowel syndrome) and IBD (irritable bowel disease):

Classmate:

(paraphrased to avoid plagiarism)

“Irritable Heart Syndrome” is a term that connects to anxiety, as people often experience somatic symptoms like chest pain, increased heart rate, dizziness, or blurred vision, leading to emergency room visits assuming they have heart problems or heart attacks.

Discussion Response:

Hi (classmate name),

I appreciate the fact that you mentioned that a number of people frequently end up in the emergency room with cardiac symptoms or the belief that they are experiencing a heart attack when in fact they are experiencing anxiety as irritable heart syndrome.  This is something I saw frequently when I was an EMT in the field, in the ER, and on my PA student ER rotations.  One of my supervising physicians even intrigued me (some 13 years ago) with the correlation between mitral valve prolapse and anxiety felt as chest pain.  I vividly remember one woman in particular who I felt horrible for because she was noticeably struggling to breathe, and clearly felt this tremendous pressure on her chest which only made her more frightened with assertions of doom and death from what she was sure was an MI.  The physician was rather objective.  Not quite as reassuring as I would hope, especially if I were the patient in a crisis.  And he casually leaned over to me at the computer before reading the results of her echo and stated “How much do you want to bet she has a MVP (mitral valve prolapse: a condition in the heart where the leaflets of the mitral valve become enlarged or stretched) before I open this?” Upon reading the assessment, his prediction was confirmed.

This would have impressed me had I not been going through a cardiac work up of my own.  You see, a week prior, I had undergone my very first cardiac catheterization for an abnormality picked up on Doppler Echo of my heart.  I had been experiencing orthostatic hypotension, black outs, mild confusion, palpitations, and chest pain on top of the shortness of breath with exertion I had felt my entire life.  The dyspnea had been getting worse and prior to my ER rotation, I was rotating through Family Med with an Internist who also worked alongside a Cardiologist in the same group.  This cardiologist had observed me walking into walls when I thought I was walking into a patient room to take report.  They also noticed that I often appeared pale and blue when I would arrive in the morning after climbing a set of stairs from the parking garage.  I had a stress test done with peculiar and unpredictable results which made this cardiologist curious enough to order an Echo.  The results of the Echo showed the beginning of pulmonary hypertension, right sided dilation (changes made by more blood volume in one chamber of the heart than there is supposed to be) of my heart, and a big ol’ shunt (a hole in which oxygen rich and oxygen poor blood travel back and forth) between the atria.

Next thing I knew I was in the Cath Lab, getting prepped for the procedure.  Valium was administered as part of a twilight sedation and just prior to being rolled in, my surgeon came to meet me.  This is the part I will never forget and I want to share for the purpose of clarifying an overly used misconception:

An advanced age, Dr. Michael S. Marek came to my bedside and took one look at me, looked at my chart, saw that I had MVP (which is INCREDIBLY common in the general population) and spoke:

“Oh.  You’re only 25 years old.  Honey, the problem is not here (pointing to my heart).  The problem is here (pointing to my head).” 

I was too sedated to process and react but inside I was screaming that I did not consent to him performing the procedure as they rolled me in.

Needless to say, his overattribution of anxiety to what he believed was irritable heart syndrome (and his ego) prevented him from performing the designated “bubble study” (a specific study used to diagnose a hole in the heart on catheterization), and he entirely missed the atrial septal defect which occupied 1/3 of my atria, a pretty noticeably sized defect.

So naturally, when I witnessed the woman in front of me in the ER and the physician interacting with her, I felt her pain, and shoved down my own.  I was still concerned for her organic condition and the nonchalance of the provider was unsettling to me as I had learned earlier that year that intense emotions could, in fact, cause what physically resembles a heart attack.  This condition is called Takotsubo cardiomyopathy wherein transient left ventricular dysfunction is triggered by emotional or physical stress, accounting for up to 2% of Acute Coronary Syndrome (ACS) presentations.(1) It is more common in women, particularly post-menopausal, and its pathophysiological mechanisms remain unknown, though there is a catecholamine cardiac stunning (an inability for the muscle of the heart to properly contract and pump blood) evidenced.(1)

Long story short, my compassionate and brilliantly intuitive Cardiology Professor, Dr. Morton Diamond, who is no longer with us nudged me to seek a second opinion, as did the ordering physician.  I connected with an Interventional Congenital Cardiologist who properly assessed me and inserted an Amplatzer Septal Occluder within the month.  He saved my life as I would have needed a heart and lung transplant had I waited a few months more to graduation.

I still have arrhythmias and issues that flare every now and then.  Every other year I spend a couple weeks on a holter.  And every other year I’m prescribed yoga and self care (single moms don’t really have time for that, but with all the health based evidence arguing for self care, we really need to prioritize this just as we do showering or brushing our teeth!).  Talk therapy has helped.  And I’ve integrated coping mechanisms which have also improved the duration of symptoms.  I am fortunate to have a cardiologist who said without saying that it’s not my bundle branch blocks – but my anxiety which causes IHS.  He prescribed me a medication called a beta blocker which helps block adrenaline and decrease heart rate and force of contraction which is helpful high blood pressure, but is also used in other specialties, not limited to psychiatry for treatment of anxiety.

With self care and coping mechanisms in place,  I’ve found that I require less and less pharmacologic treatment over the years.

The point of this story is to share that: A) I have irritable heart syndrome. B) I also have ME/CFS (chronic fatigue syndrome), MVP, joint hypermobility syndrome, and chronic sinusitis. Interestingly, that’s four of the criteria correlated with panic disorder (2) which appears to overlap with IHS. C) I also have a history of a congenital heart anomaly and presently experience arrhythmias and palpitations daily.  D) I also live with a spectrum of anxiety symptoms.

I hope my story can serve as a reminder that both anxiety, IHS, and true organic cardiogenic conditions can co-occur.  Just because a patient has a history of one, does not mean that is the only isolated factor in the clinical picture.

And if you’ve read this far, I hope this story also serves as a reminder that you don’t have to be a healthcare professional to know when a diagnosis does not feel accurate or complete.  I tell all of my patients that second, third, and even fourth opinions have the power to save lives.  When I perform biopsies on patients in the outwardly observable specialty of Dermatology, I often find that two lesions exist in one, and I’m often glad that I aired on the side of biopsying because one of those lesions often requires further treatment.

Remember friends, we are not any ONE thing.  We are cells, tissue, systems, microbial colonies, hormones, neurochemicals, thoughts, lived and shared experiences.  We are whole beings who exist on a spectrum of varying realities.  While we may be similar in a lot of ways, we are equally different.  Ask questions and when you feel you need to know more, look for more experts and perspectives.  Somewhere in the answers, you are bound to find the ones that fit your needs and give you effective solutions.  Your health journey may be a long and sometimes frustrating one, but you’re every bit worth it!

1) Assad J, Femia G, Pender P, Badie T, Rajaratnam R. Takotsubo Syndrome: A Review of Presentation, Diagnosis and Management. Clin Med Insights Cardiol. 2022 Jan 4;16:11795468211065782. doi: 10.1177/11795468211065782. PMID: 35002350; PMCID: PMC8733363.

2) Black, Donald, and Nancey Andreasen. Introductory Textbook of Psychiatry. 7th ed., American Psychiatric Association Publishing, 2013. pp. 169-190.