Question: Hi there -

I'm 40, male, 6 feet, 190lbs, no history of health issues, former competitive athlete. Under a lot of chronic stress last couple of years, and in recent months started suffering from a lot of anxiety. One episode took me to ER which I feared was heart-related, but turned out to be an especially bad panic attack. I was given Ativan on a one-time basis after manual and stethoscope exams, ECG, blood and urine were all normal. My BP was high. Was measured 170s/110s at ER, but also 140s/90s same day at ER, few hours later. Then I went to see a GP who did their own blood and urine tests and chest X-rays. No pheochromocytoma. ECG so normal that they don't suspect left ventricular hyperthrophy, as it happens to athletes. No electrolyte or thyroid issues. No anemia, no kidney or liver issues. Stethoscope (both heart, lungs and abdomen) and manual (pressure) exam shows no murmurs, gallop or anything unusual. Resting heart rate 60. Total cholesterol under 200. I can walk 8-10 miles very briskly, getting my heart up to 115-120 and keeping it there for 2-3 hours, no issues. No shortness of breath, no chest pain. When I sprint and stop, the recovery factor (the number by which your heart rate goes down in 60 seconds once it starts going down again after exertion) is between 30 and 40 every time I measure. I was given a selective, slow release beta blocker (metoprolol), only 25mg, and within 10 days of beta blocker + taking up some breathing exercises and meditation again, my BP is now consistently down to 120s/80s. So I was inclined to consider this my "medical clearance", agree that there isn't any underlying medical cause, and go deal w/ the anxiety and the external stressors / life issues.



However, throughout this entire time (last few weeks), I've also been having an abdominal sensitivity. I've always slept on my stomach, and all of a sudden, I can't, b/c laying on stomach or the sides causes heart palpitations within seconds. By palpitations I mean the heart beats "hard", not racing (measures 70s, low 80s max), nor skipping beats or extra beats. It just feels like it has to beat "hard" to push against something. That is what would wake me up, and I suspect trigger a panic attack. My BP is now down to normal now, and I don't think it's just my "tuning into" it more and being more aware of the sensation/presence of my heart beating. In fact, when it beats hard, the BP goes up by 10-15 points (though that's not scientific b/c I can't measure the BP while laying on my stomach. By the time I sit up again and strap myself on, who knows if it's up b/c of the heart palpitation of b/c of the anxiety?) There is of course a strong possibility that subconscious thoughts and fears are triggering the palpitations when they happen on its own (wakes me up at night, or happens during day while standing, sitting, laying on back, etc.). Chronic activation of the amygdala is even known to cause permanent changes in the somatosensory cortex, and I know whatever you pay attention to can create a feedback loop and people seem to be able to "bring on" symptoms they fear. But, I'm concerned b/c I can reproduce this at will _mechanically_, regardless of my state of mind, by simply:

- laying on stomach or sides

- any vasoconstriction (morning after any alcohol consumption in sleeping in dry room, or tightening belt)

- eating a lot on empty stomach or eating fast while leaning forward

- forcing very XXXXXXX breaths inhale/exhale slowly, like 4 cycles or less per minute. This is the opposite of hyperventilating, these are XXXXXXX slow, diapgragm breaths into the abdomen and sides and back and should slow the pulse down, not speed it up

- manually pressing hard on region below solar plexus



In short, I'm really worried about AAA (abdominal aortic aneurysm) b/c I sometimes also get a stomach pulse w/ the palpitations. I also do have some lower back pain, but it has v. good alternative explanations, goes away when I stretch, and does not radiate. Aside from the higher BP, I have no other risk factors for this. Never smoked, no family history, no chest or abdominal pain of any kind. I should also mention that I went vegan overnight 6 months ago after a lifetime of standard American diet, and have been losing weight in a healthy, slow way naturally since, like most people who go vegetarian. I cut out all animal products, and now supplement vitamin B12. I'm almost down to my ideal weight of 187lbs, but still have somewhat of a distended abdomen b/c belly fat is the last to go, b/c I haven't been doing any interval or resistence training and b/c I'm likely "marinating" in cortisol due to the work stress.



I'm really worried about AAA. Is there a less ominous explanation for the stomach pulse? How about the palpitations when laying on stomach or increasing abdominal/thoracic pressure? I realize that the vagus nerve extends up when laying in that position and left lobe of lung, heart and stomach get compressed, so vagus nerve may be understimulated and cause palpitations. The GP advanced a vague theory re: the vagus nerve. Apical impulse has been suggested as an explanation. I did lose a bunch of weight, so perhaps the location of the apical impulse has changed and the diastolic BP is letting me feel it. But why is all this happening now, why won't it go away for weeks though my BP is now normal, and why is it mechanically reproducable at will? Do I need to get an ultrasound? In your view, what's the likelihood that I have AAA? And what's your alternative explanation? Many thanks in advance.