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Suggest Treatment For Swallowing Induced Atrial Arrhythmia
Question: I am a 55 year old male that is experiencing constant atrial arrhythmia after each swallow. This originally flared up when I was 30. I had every test possible done including an EP study. All tests were normal but the swallowing trigger was obvious. Concurrent finding of acid reflux was treated with PPI medication. I remained on the PPI until three months ago. About 2 weeks ago the swallowing trigger returned with Vengeance. For the past 2 weeks every swallow regardless of food, drink or just dry, results in sinus pause followed by chaos for about 15 seconds while the rhythm re-establishes itself. This makes eating, drinking and exercise a very uncomfortable experience. I started the PPI meds about a week ago and hope they will work their magic again. Most believe this is an irritated vagus nerve acting inappropriately on the heart. The problem is at its worst during the day or when exercising. At night I sleep well. I believe this lends strong support to the vagal irritation theory. Recently I did a 2 hour steep hike in the mountains. I avoided swallowing so I could continue. When I had to eventually swallow I stopped and tried to relax before swallowing. All hell would break lose for 15 seconds then NSR and on I went.
I have not seen a doctor during this recent problem because I have already wasted too much of the medical systems time and money (Canadian). Having said that, I worry. Will it resolve itself like before. So what is my question? Has there been any new research into this phenomenon? I see posts all over the net from people with similar or exact issue. I am in the best shape and health of my life other than this one issue but it is a huge issue. Try to imagine every swallow causing such turbulence in your rhythm. Should is ask to see a autonomic nervous system specialist, do another EP study, have exploratory abdominal surgery? When I had the EP study the problem was in remission which was bad timing. Thank you.
I have not seen a doctor during this recent problem because I have already wasted too much of the medical systems time and money (Canadian). Having said that, I worry. Will it resolve itself like before. So what is my question? Has there been any new research into this phenomenon? I see posts all over the net from people with similar or exact issue. I am in the best shape and health of my life other than this one issue but it is a huge issue. Try to imagine every swallow causing such turbulence in your rhythm. Should is ask to see a autonomic nervous system specialist, do another EP study, have exploratory abdominal surgery? When I had the EP study the problem was in remission which was bad timing. Thank you.
Brief Answer:
Read below.
Detailed Answer:
I read your question carefully and I understand your difficult situation.
Swallowing induced atrial arrhythmia is a reported phenomenon. Its cause remains debated, with hypothesis involving abnormal vagal or increased sympathetic nervous system responses. Esophageal reflux and distention has also been implicated. Research is scarce though as it is a rare phenomenon, there are mainly publications of one or two cases without much research aimed at its management.
From literature reviews the only cases where a definitive solution has been found has been when electrophysiologic studies have identified an atrial source of the arrhythmia which can be treated by radiofrequency ablation. So given that you say the first time you were in remission I would say that it is worth to repeat EP studies in order to search for an atrial focal source. I wouldn't expect much from the other two options you suggested (autonomic nervous system specialist or surgery).
If EP studies find nothing again I would restart PPIs since they were successful before. Antiarrhythmics like calcium channel blockers, beta blockers have also been used with mixed effect, but if PPIs work I would stick with them as the ones with less potential side effects.
I remain at your disposal for other questions.
Read below.
Detailed Answer:
I read your question carefully and I understand your difficult situation.
Swallowing induced atrial arrhythmia is a reported phenomenon. Its cause remains debated, with hypothesis involving abnormal vagal or increased sympathetic nervous system responses. Esophageal reflux and distention has also been implicated. Research is scarce though as it is a rare phenomenon, there are mainly publications of one or two cases without much research aimed at its management.
From literature reviews the only cases where a definitive solution has been found has been when electrophysiologic studies have identified an atrial source of the arrhythmia which can be treated by radiofrequency ablation. So given that you say the first time you were in remission I would say that it is worth to repeat EP studies in order to search for an atrial focal source. I wouldn't expect much from the other two options you suggested (autonomic nervous system specialist or surgery).
If EP studies find nothing again I would restart PPIs since they were successful before. Antiarrhythmics like calcium channel blockers, beta blockers have also been used with mixed effect, but if PPIs work I would stick with them as the ones with less potential side effects.
I remain at your disposal for other questions.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dr Taka. Thank you for your response. I have started the PPI's and hope for improvement. Due to the fact that I am very active and enjoy many different athletic activities such as mountain biking hiking in the mountains and whitewater paddling, I feel a huge need to continue searching for the cause of this problem. As I said, other than this problem I feel in optimal health.
The reason I chose a neurologist was for two reasons:
1. I have done the cardiologist route with all associated tests.
2. The much agreed upon theory of inappropriate vagal reflex ales me think the neurologist could help.
Do you think I should try to be referred to a neurologist that specializes in such problems (if there is one)?
Are there medications that could potentially quiet an overactive vagus nerve (atropine) that would have minimal side effects?
It just seems that when I can consciously demonstrate the problem every time I choose to swallow, that the cause/solution could be discovered.
Thank you
The reason I chose a neurologist was for two reasons:
1. I have done the cardiologist route with all associated tests.
2. The much agreed upon theory of inappropriate vagal reflex ales me think the neurologist could help.
Do you think I should try to be referred to a neurologist that specializes in such problems (if there is one)?
Are there medications that could potentially quiet an overactive vagus nerve (atropine) that would have minimal side effects?
It just seems that when I can consciously demonstrate the problem every time I choose to swallow, that the cause/solution could be discovered.
Thank you
Brief Answer:
Read below.
Detailed Answer:
Thank you for the feedback.
I completely understand your logic regarding trying a neurologist since you have not amounted to much with cardiologist. It is true that there are centers dealing mainly with autonomic nervous system disorders.
However I still am more inclined toward the cardiology route. That is first because the vagal response thing is only a hypothesis, one among others, none of which has been proven.
Another reason is that even if it is vagus nerve related it is only certain nerve fibers dealing with heart rate, not the whole vagus nerve which is involved, would have other manifestations and I don't think a neurologist, even a specialized one, has many means to make the diagnosis of such a limited involvement.
Lastly from all my research of the last couple of hours, all the published papers on this subject, are from cardiology journals, none from a neurological source, which reinforces that it's the cardiologists who are more involved in the diagnosis and management of this condition.
That is why I suggested to repeat the EP given the fact you were in remission last time, if a focus is found ablation is reported to be pretty effective.
As for your question on medication like atropine, it has been shown not to be effective, which is one of the main arguments used against the vagus hypothesis.
Let me know if I can further assist you.
Read below.
Detailed Answer:
Thank you for the feedback.
I completely understand your logic regarding trying a neurologist since you have not amounted to much with cardiologist. It is true that there are centers dealing mainly with autonomic nervous system disorders.
However I still am more inclined toward the cardiology route. That is first because the vagal response thing is only a hypothesis, one among others, none of which has been proven.
Another reason is that even if it is vagus nerve related it is only certain nerve fibers dealing with heart rate, not the whole vagus nerve which is involved, would have other manifestations and I don't think a neurologist, even a specialized one, has many means to make the diagnosis of such a limited involvement.
Lastly from all my research of the last couple of hours, all the published papers on this subject, are from cardiology journals, none from a neurological source, which reinforces that it's the cardiologists who are more involved in the diagnosis and management of this condition.
That is why I suggested to repeat the EP given the fact you were in remission last time, if a focus is found ablation is reported to be pretty effective.
As for your question on medication like atropine, it has been shown not to be effective, which is one of the main arguments used against the vagus hypothesis.
Let me know if I can further assist you.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you once again for your response. Your advice makes perfect sense. Living in Canada, sadly I cannot quickly see an electrophysiologists to get another EP study done however I will certainly try. In all likelihood the PPIs will kick in and by the time I have an EP study the problem may well be in remission again. Of course that is crystal ball stuff.
A recent new twist to this story is the fact that my 27 year old son is showing similar signs of this issue. He had a positive diagnosis for Eosinophilic esophagitis found on an esophageal biopsy. He is now being referred for food allergy testing to see if there is a food he is sensitized to. Apparently there is a strong genetic connection with EoE and I will likely get the allergy tests myself. Perhaps that would explain the reflux / vagus nerve connection. There appears to be many documented cases where EoE patients report heart palpitations that have suspected vagal connection.
Do you have any knowledge or comment on this possible explanation?
Thank you for your help.
A recent new twist to this story is the fact that my 27 year old son is showing similar signs of this issue. He had a positive diagnosis for Eosinophilic esophagitis found on an esophageal biopsy. He is now being referred for food allergy testing to see if there is a food he is sensitized to. Apparently there is a strong genetic connection with EoE and I will likely get the allergy tests myself. Perhaps that would explain the reflux / vagus nerve connection. There appears to be many documented cases where EoE patients report heart palpitations that have suspected vagal connection.
Do you have any knowledge or comment on this possible explanation?
Thank you for your help.
Brief Answer:
Read below.
Detailed Answer:
Sorry for answering a little late, but due to time difference with Canada your question came during sleep.
Eosinophilic esophagitis has not been specifically related to swallowing induced arrhythmia which is very rare. However there have been publications linking it (and gastroesophageal reflux in general for that matter) to arrhythmia in general (atrial fibrillation) so it makes sense to extend the link for rarer subtypes.
The mechanism though remains unclear even for common type of arrhythmia, the vagus stimulation is a proposed mechanism along with several others like local inflammation and irritation of the neighboring atrium, the distension of the esophagus and compression of the atria, initiation of an autoimmune response with antibodies against heart muscle components, decreased blood flow in the coronary arteries etc. So it is still a matter of research and conclusions of any practical implications in your case can't be drawn.
Read below.
Detailed Answer:
Sorry for answering a little late, but due to time difference with Canada your question came during sleep.
Eosinophilic esophagitis has not been specifically related to swallowing induced arrhythmia which is very rare. However there have been publications linking it (and gastroesophageal reflux in general for that matter) to arrhythmia in general (atrial fibrillation) so it makes sense to extend the link for rarer subtypes.
The mechanism though remains unclear even for common type of arrhythmia, the vagus stimulation is a proposed mechanism along with several others like local inflammation and irritation of the neighboring atrium, the distension of the esophagus and compression of the atria, initiation of an autoimmune response with antibodies against heart muscle components, decreased blood flow in the coronary arteries etc. So it is still a matter of research and conclusions of any practical implications in your case can't be drawn.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I am reading your responses with much interest and appreciate your insight. It might be worth noting that in the past (about 25 years ago) when this first hit me, I did suffer 3 episodes of atrial fibrillation which required hospital intervention. This was prior to my use of PPI's. You suggest irritation of the atrial tissue as one possible mechanism. Are you suggesting that the inflammation caused by the reflux, regardless of its cause (Autoimmune or classic reflux) could extend beyond the esophagus to the heart itself? I have not read any cases where that was suspected. If in fact that we're possible I would think it prudent to rule out any possible cause for the irritation. It appears that one common finding with EoE is the absence of classic heartburn symptoms. In my particular case, heartburn has never been one of my symptoms. In fact I have always been able to sleep well through the night. Once again, those suffering classic heartburn typically suffer badly during the night when they lay horizontally. Thank you so much for your help on this matter. I look forward to hearing your final thoughts before this discussion gets closed. I will be pursuing this further and your suggestions will help guide me, hopefully towards a resolution of this matter.
Brief Answer:
Read below
Detailed Answer:
Thank you for your nice words. I don't know if I deserve them much as it being an uncommon issue I am offering more hypotheses than solutions.
I didn't mean inflammation of the atria itself, but inflammation in the adjacent esophagus causing release of proinflammatory substances and changes of the blood flow in the area which may affect cardiac cells. It is not a factor which I found mentioned in articles about swallowing related arrhythmia (they are very few, mainly case reports), but it was mentioned in discussions about the relation of esophageal conditions and atrial fibrillation.
There is no reason not to think it is not a factor in your case as swallowing may distend the muscle and add to the already present inflammatory changes, taking things beyond the threshold needed to cause the arrhythmia.
So the esophagitis track should be explored given your son's history and not typical picture for GERD. Hopefully it will yield more insight.
Until that I would stick with the tried and tested PPIs and if possible to have when process is active a repeat of EP studies.
Read below
Detailed Answer:
Thank you for your nice words. I don't know if I deserve them much as it being an uncommon issue I am offering more hypotheses than solutions.
I didn't mean inflammation of the atria itself, but inflammation in the adjacent esophagus causing release of proinflammatory substances and changes of the blood flow in the area which may affect cardiac cells. It is not a factor which I found mentioned in articles about swallowing related arrhythmia (they are very few, mainly case reports), but it was mentioned in discussions about the relation of esophageal conditions and atrial fibrillation.
There is no reason not to think it is not a factor in your case as swallowing may distend the muscle and add to the already present inflammatory changes, taking things beyond the threshold needed to cause the arrhythmia.
So the esophagitis track should be explored given your son's history and not typical picture for GERD. Hopefully it will yield more insight.
Until that I would stick with the tried and tested PPIs and if possible to have when process is active a repeat of EP studies.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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