AFib? But I'm only 38!

An episode of prolonged atrial fibrillation makes a young cardiologist take stock and make changes.

By Stanley R. Berger, MD
Cardiologist/Flourtown, PA

Suddenly, I didn't feel very well. I had returned from work tired, hungry, and late—as usual. After eating dinner alone, I had gone upstairs to visit with my wife and our three sons, ages 2, 4, and 9. I'd kissed the boys goodnight, returned downstairs, and poured myself a tall glass of iced tea. It tasted great—so refreshing that I'd had another and another. After the fourth glass, I'd felt satisfied.

Soon after the discomfort started, I took my pulse: It was an irregular 130 or so beats per minute. Still, I didn't panic. I'm a 38-year-old cardiologist, I thought to myself, and I'm in atrial fibrillation.

I'd experienced palpitations many times, but they would last no more than five seconds. But this sensation had already continued for two minutes, and I kept wondering when it would stop. Although I tried a Valsalva's maneuver, the discomfort wouldn't go away.

Feeling a little nervous, I went into my bedroom. "Honey, feel my heart," I asked my wife.

She placed her hand on my chest and said, "It's beating really fast; I can see it fluttering in your chest. What's going on?"

"It won't stop beating like this," I said. "Maybe we'd better make some plans—in case something happens to me."

My wife had also had a long day, returning from her solo legal practice to care for our sons single-handedly. When she heard my gloomy words and saw the way I was sweating, she screamed, "No! Don't do this to me! We've got to get you to the hospital!" She raced around looking for aspirin.

I had slumped to my knees, leaning my upper body on the side of our bed. Crazy thoughts were floating through my head. I do not want some cowboy ED doctor trying to shock me back into normal sinus rhythm. But what if I stay in AFib? Will I have to take Coumadin? No; I don't have structural heart disease, and I don't need anticoagulation.

Then I thought, maybe this isn't atrial fibrillation; could it be stable V-tach? Am I having ischemia without chest pain? Who will perform the angioplasty?

My wife shoved an aspirin into my mouth. I chewed it, congratulating myself that in this time of stress I'd remembered not to swallow it whole. But several minutes later, when the sweat kept pouring and the uncomfortable feeling remained, I agreed to go to the hospital.

I raised myself up and sat on the bed. It was now at least 15 minutes since this irregular heart rhythm had begun, and I was amazed that it had lasted so long. "Come on; we've got to take your dad to the hospital," I heard my wife saying from the hallway.

"What's wrong, Daddy?" my two older sons called in unison.

"I'll be okay, guys," I said calmly as I walked toward the stairs. "I'm feeling some fluttering in my heart, so we should go to the hospital."

I walked out the front door and peered into the clear night sky. As the cool air hit my face, I suddenly felt better. I checked my pulse; it had returned to normal. Boy! I remember thinking, that sure lasted long!

I went back into the house, where my wife was rushing the boys down the stairs, carrying the 2-year-old. "Where are you going?" she asked.

"It's all gone," I said. "I'm sorry I scared everybody. My heart is back to normal, and I feel much better."

"But we've still got to take you to the hospital," she screamed. "We are not staying here after all that!"

"If we go to the hospital now, it will be a waste of time," I explained in a monotone. "There'll be nothing for them to see. It's almost midnight; let's all get some sleep."

My eldest son decided we needed some wise counsel. "Dad, I think you'd better go to the hospital—to get checked out."

"You know your dad should go to the hospital," my wife exclaimed, nearly frantic with worry. "But Daddy has thought about what will happen when he gets there, and now he's trying to avoid going!"

"I'm not avoiding anything," I said. "I will need to be examined—but as an outpatient. There's no more emergency."

My wife fumed for another hour. By that time, I had changed into my pajamas, and she realized that I was resolute. She knows there's nothing worse than a proud, stubborn man who also happens to be a doctor.

The next morning, a bright and beautiful Saturday, I woke up feeling fine—though slightly apprehensive that the sensation might return. As I kissed my wife good morning, she asked, "How do you feel? What doctor are we going to today?"

"I feel fine," I responded. "When I go to work on Monday, I'll have the heart station put a Holter on me and ask one of the docs to examine me."

"No!" she said. "You are not waiting until Monday! I should have called 911 last night and let them drag you out of here in your pajamas!"

"They couldn't drag me anywhere," I said haughtily. "I'd simply tell them that I'm a cardiologist, I had some palpitations, and now I'm fine. Once they put a monitor on me and saw that I was in normal rhythm, they'd just leave. Baby, I'm all right! I just drank too much caffeine and triggered some irregular heart rhythm."

My wife was not convinced. "You're in denial," she said. "And I have to treat you like a patient—not like a doctor—because you obviously can't treat yourself!"

Just then, a friend who's an internist called to ask about my weekend plans. I chatted a little, and then described the past evening's events: "A little fluttering—no chest pain—it just lasted longer than I expected."

My wife took the phone. "He's not telling you the whole story. He was sweating profusely and talking about making final plans as if he expected to die," she said.

As they continued talking, I shook my head. All this because I'd been thirsty and overdosed a bit on caffeine. Finally, she gave me the phone. "Is there anyone at the heart station today?" my internist friend asked. "I think you should at least get a Holter monitor and an ECG. Isn't your boss on call? Maybe he can check you out."

I couldn't believe my friend's "doctor-to-patient" tone, but when I saw how distraught my wife looked, I realized I had to do something to calm her fears. "Yeah," I said. "I think they can hook me up today."

"I remember a patient with palpitations who had WPW syndrome," said my friend authoritatively.

Great, I thought. I'm the cardiologist, and he's suggesting a scary diagnosis I hadn't even considered. "I doubt it's WPW," I said. "But I'll get myself checked today."

Within a few hours, as I was being taped to a Holter monitor, the head of our practice, "Doc," as we all call him, came in. The echo technologist, who had generously suspended her busy day to attend to me, had tipped him off. "How are you feeling?" he asked me.

"Fine, now," I said. "I just had an irregular heartbeat last night. It felt like lone atrial fibrillation."

"This is like a board question," Doc explained to my wife. "A young guy with no heart disease comes into the ER with AFib, and it resolves; what do you do? That's called lone atrial fibrillation, and the answer is, you send him home because his risk is low—and you give him some warnings and instructions about what to do if it recurs."

I felt a lot better: Finally, a cardiologist—a colleague who realizes what this is—can reassure my wife and me that we can go home and forget about this whole thing. But Doc wasn't finished.

"Maybe we've been working you too hard," he said. "I want you to wear the Holter and go home and rest—no physical activity. Come back on Wednesday, and if the Holter's okay, and this doesn't happen again, we'll do a stress test."

I gasped. "What do you mean? You want me to stay home until Wednesday? Doing nothing?" This must be some liability thing, I thought. "I really think it was triggered by the iced tea," I said. "I drank four tall glasses."

"Maybe," he said. "Let's see your blood pressure." He took my pressure, frowned slightly, and took it again. "What does your BP usually run?" he asked.

"It's about 110 to 120 over 70 to 80," I said.

"Well, today it's 150 over 100," he said.

For the first time, I was truly taken aback. Although I never worried about my heart, high blood pressure does run in my family, and I'm extremely careful about my salt intake. Fortunately, my blood pressure had always been great—until now.

"It might be high because of all the excitement," he said. "We'll check it again later in the week. Now I want to look at your echo."

My mind was racing. I'll be out of work. My colleagues will think my heart's too weak for the stresses of cardiology. They want me to stay home and do nothing? But I'm perfectly fine. I won't take a stress test now, though, because I'm out of shape. Might as well wait a year, let me get in shape, then I'll go 25 minutes if they want me to. Why in the world did I drink so much iced tea?

Doc returned to the room. "Your echo's completely normal, and so is your ECG," he said. "So just take it easy. Rest and rejuvenate. We'll see you on Wednesday."

Those next few days were restful and joyous. I reconnected with my wife and sons, and realized they truly missed me all those late nights and weekends on call. And I realigned some priorities.

The day of the big stress test, my blood pressure was 118/82. I said to the senior cardiologist in our group, "I'm out of shape, so I think five to six minutes, tops, should be enough."

"We make the rules here, young doctor," he retorted. "I have an 80-year-old patient who goes 12 minutes every year."

I passed the test and went back to work. I do believe the combination of stress, excess weight, sleep deprivation, and caffeine precipitated my symptoms.

What has remained with me from this episode? I have far more empathy for the patient who tells me, "I keep having these palpitations, Doctor—and they scare me!"

I'm also determined to enjoy every moment of my life. But if I do have to face a more serious event some time in the future, I believe that I've learned a valuable lesson: When confronting hard realities, it is futile—and often dangerous—to practice denial.

 

Stanley Berger. AFib? But I'm only 38!. Medical Economics 2002;2:69.