Heart racing/pounding upon waking up.

December 8, 2008 1:07 PM

Heart racing/pounding upon waking up. This happens in the morning and also when I take naps.

Relevant info: female, 34, no tobacco, moderate drinker, slightly underweight, no chronic physical issues. Blood pressure is usually on the low end of normal range. I almost always get 7-8 uninterrupted hours sleep/night and have no trouble falling asleep or waking up.

I am taking Lamictal, Zoloft, and Klonopin for anxiety/depression. Klonopin slows down the racing heart, but I dislike taking it in the morning because it makes me drowsy. I can't pinpoint when this started, but it seems like a few months ago. I do have panic attacks, but the racing heart has never been a symptom before. Besides, most of my panic is related to social phobia, so it doesn't make sense that I would feel that immediately upon waking. Note that this happens while I'm still lying down - I'm not getting up too fast.

I called my psychiatrist; he doesn't think it's related to the medication, and doesn't have any solid ideas. I got a pretty thorough workup in the hospital in July (was there for neurological stuff, not heart related, though they did do an EKG) and got a clean bill of health. Where should I go from here?

posted by desjardins to health & fitness (21 answers total)

Do you have an irregular rhythm during these events? That can cause your heart to race and can be something that occurs more often when reclining or lying down and can occur in the mornings. Alcohol can be a trigger.

You may want to talk to your doctor about getting a Holter monitor which is essentially a portable EKG machine that you wear for 24 hours or so. That way the doctors can actually see what is happening in the mornings.
posted by caddis at 1:20 PM on December 8, 2008

Seconding caddis on alcohol...

Try abstaining for several nights and see if there is any improvement. I have the same problem and I think, for me, it's a product of some sort of interaction between baseline anxiety and alcohol. You have my sympathy- it sucks waking up that way.
posted by hellboundforcheddar at 1:34 PM on December 8, 2008

IANAD (but am former EMT). Have you visited a cardiologist to investigate whether your panic attacks and early morning tachycardia might be due to heart-related issues? You may want to find out if you can be fitted with a Holter monitor, which records your heart rhythms over a 24- or 48- hour period in order to evaluate whether fluctuating symptoms might be related to heart-rhythm irregularities.

Also, you may want to ask your physician whether your symptoms could be suggestive of dysautonomia.

Lastly, keep a record of your food/drink intake each evening. Are there any foods or beverages that seem to precipitate next-morning tachycardia?
posted by terranova at 2:00 PM on December 8, 2008

This happened to me for a while. I went to the doctor and was told nothing was physically wrong. A bit later, I happened to mention this problem to a colleague who was in the military and was being treated for post-tramatic stress. I'll pass on his advice, which was helpful to me.

What is happening here is that you are stressed, and when you are awake your mind is putting up defences which fall when you drift into sleep... Essentially your brain is going (there is this... there is this... there is this... there is this... omg!). You start to breathe hard... your bodies' fight or flight mechanism is kicking in. Your heart beats fast.

So here is what you do about it:

First, go ahead and breathe really heavy for a while (breathe really hard, like you are running but just sit there)... and pay attention to what this feels like. You'll probably notice this feels really similar to what you feel like when you wake up suddenly - your heart beats fast and you feel a bit flushed and weird. Breathing heavy is how you got in this state - your body is working as it should; so you aren't sick.

Second when you wake up, say to yourself "this is not important". I would repeat this, like a mantra. When you relax, go back to sleep.

When I took this advice, the problem was gone in a couple of days and only occurred once or twice since.
posted by Deep Dish at 2:00 PM on December 8, 2008 [4 favorites]

Re: alcohol. My intake is literally 2-3 drinks/week at most. Usually one beer, one glass of wine, and maybe one mixed drink. I have not had any alcohol since Friday (which was one beer with a full meal), and I had the racing-heart problem on Saturday, Sunday, and today.

I am open to the possibility that it could be stress-related. I got married at the end of September, which was hugely stressful (though wonderful), and there have been other stressful events since then.
posted by desjardins at 2:22 PM on December 8, 2008

You might also consider taking your blood pressure first thing in the morning and at various times of day. It might be low in the mid-morning and afternoon (when people usually see doctors) but there is such a thing as early-morning hypertension that tends to cause a lot of problems for people who aren't aware of it. If you're really concerned and it persists, your doctor might suggest doing an echocardiogram as it's possible to spot the effects of high blood pressure on the heart in that way even if your BP doesn't run high in the office.
posted by threeturtles at 2:27 PM on December 8, 2008

Do you snore? Recent research has shown that snoring (even if just a bit) can be stressful to your heart.
posted by randomstriker at 2:32 PM on December 8, 2008

Do you feel any anxiety beyond your heartbeat (and any fears stemming from that)? Or is your head full of the things you need to do? My wife had her first major panic attacks start in this way (she was not medicated then) - we were out of town and visiting friends, when she woke up with hear heart racing to the point she feared she was dying. She would calm down a bit, and some thoughts triggered her heart again, and her fears of heart problems kicked things back up.

Afterwords, she thought most of her anxiety that weekend was from the list of things to do while with friends, and the things that were waiting for her return from the mini-vacation. Now she knows that her to-do lists can set off anxiety which will make her heart race, she can calm herself a bit (she's on medication, though I don't remember what exactly). Some weekends or naps end with anxiety and a racing heart, but she can calm herself down (or sometimes rub her back I sooth her).

O'course, if the to-do list or other impending events don't set you off, you can set all this aside and look elsewhere.
posted by filthy light thief at 2:43 PM on December 8, 2008

Seconding (or whatever we're up to) the suggestion of a holter monitor. Its diagnostic use is not simply to record your pulse (which you already know goes up sharply at times), but to look for anomalies in your heart function that can sometimes be detected even if you don't have the sort of event you described. It's not cumbersome or unpleasant, and you can take a shower with it on if you're careful and do a workaround or two. They usually have you wear it for 24-48 hours, which is just long enough for it to remain mildly distracting rather than annoying.

While this does not seem likely to be your case, I have known several people on whom benzodiazapenes "turned." (Previously.) They saw some tachycardia, though accompanied by the shakes and neurological symptoms that were essentially the opposite of the benzos intended effects (MORE panic, LESS sleep, etc.). If you see more of that (I highly doubt you will), then it's time to have a very different conversation about your meds with the psychiatrist and your GP.
posted by el_lupino at 2:53 PM on December 8, 2008

Along filthy light thief's comments, if your racing heart is set off by anxiety about upcoming things in your life, it might help to habituate yourself to some cues in your bed area that you associate with relaxation. This means doing focussed relaxation like a relaxation tape in your bed, or associating relaxation with a cue like a post-it note or a certain scent that you can put near your bed. If your body is more used to feeling relaxed in bed than feeling anxious, the pounding heart thing might dissipate. Worked for me.
posted by Dr. Send at 4:28 PM on December 8, 2008

IANAD, but I had this happen to me when I was having panic attacks. In my case, I had a lot of job stress and no effective strategy for relieving that stress. My body took over for me and began relieving the stress as best it could, involuntarily. In addition to the very unpleasant waking attacks, I also experienced the joy of going to bed somewhat relaxed and then waking in the middle of the night or in the morning with my heart racing, as you describe. Thanks, body!

My solution -- and it took some time -- was to exercise more, which gave my body a better way to release stress. Proper, regular aerobic exercise made a HUGE difference for me, and essentially gave me a handle on my panic attacks, eventually stopping them almost completely (I still get them once in a while if I'm stressed and not exercising). The change was not immediate, but once I started I began to see results over the course of 3-4 weeks, and the improvement was steady thereafter. And I'm not talking about training for a marathon: this was just regular aerobic exercise, mainly walking and biking with hills, an hour or so every other day.

Also, don't be surprised if your panic/anxiety attack symptoms morph over time. Your body is trying to release tension, and just because it's been doing X behavior for the last few months to release this tension, it can/will sometimes throw behavior Y or Z at you. That was always one of the scariest things about experiencing an anxiety-related attack, the feeling that my body was doing things that made no sense and which I couldn't immediately stop.

Good luck -- I hope you are able to get a handle on your symptoms and reduce your stress level.
posted by mosk at 5:19 PM on December 8, 2008

Agreeing with panic attacks as a big possibility. Just because you haven't had the pounding heartbeat as a symptom before, doesn't mean you aren't having panic attacks. It just means you developed a happy new symptom. Same thing happened to me.
posted by Coatlicue at 5:29 PM on December 8, 2008

To second what el_lupino said, may have been taking too much Klonopin (hence the drowsiness), and built up a tolerance, resulting in tachycardia.
posted by scottreynen at 6:46 PM on December 8, 2008

i've had the same experience, completely sans drugs. it hasn't happened in a long time, but used to happen often when i was in college.

i would get evaluated by a sleep therapist. you may have some apnea. your heart would start racing because you have stopped breathing in your sleep.
posted by thinkingwoman at 7:03 PM on December 8, 2008

My intake is literally 2-3 drinks/week at most.

It's not the alcohol.

It might be stress. The act of marriage is quite stressful, despite the enhanced joy, there is also enhanced stress, but then it usually produces a less stressful existence long term. You have always struck me as one of the more thoughtful and insightful commenters, especially on social issues. Everyone gets stress at times, but when they have your wisdom there is a natural balance. If it is stress, I think you will find it naturally dissipating over the next year as you both get comfortable with this new arrangement. Still, I would push things with the docs to make sure it isn't something else. Good luck and congratulations on your marriage. Your new husband is a lucky guy.
posted by caddis at 7:29 PM on December 8, 2008

Your marginally low blood pressure and the fact that this is happening when you wake up are making me think in terms of postural orthostatic tachycardia syndrome (POTS):

Postural orthostatic tachycardia syndrome (often referred to as just postural tachycardia syndrome or POTS) is a condition of dysautonomia, and more specifically, orthostatic intolerance, in which a change from the supine position to an upright position causes an abnormally large increase in heart rate, called tachycardia. This is often, but not always, accompanied by a fall in blood pressure. Several studies show a decrease in cerebral blood flow with systolic and diastolic CBF velocity decreased 44 and 60%, respectively [1]

Basically you need higher blood pressure when you stand up in order to be able to pump blood up to your now higher head, and your heart beats really fast to try to help achieve this. It's conceivable this could happen even before you are actually upright as a form of learned anticipation for the need for higher pressure.

I found a report of a patient who developed symptoms of POTS whenever he tried to lower his dose of Zoloft:

A patient receiving sertraline for depression developed dizziness and orthostatic hypotension on repeated attempts to discontinue the drug. ... After a variety of attempted treatments, the agent was discontinued successfully through an extended titration period.

Have you by any chance been trying to lower you dose, or changed prescription sources, or done something which could increase liver activity (and therefore clearance of the drug)?
posted by jamjam at 9:21 PM on December 8, 2008

POTS
posted by jamjam at 9:22 PM on December 8, 2008

I Am Not Your Cardiologist: Do you drink coffee or caffeinated soft drinks? My cardiologist advised to cut caffeine intake during a period of anxiety bouts that would result in tachycardia.

(switching to decaf was easy. Quitting smoking is not, damn)
posted by _dario at 12:12 AM on December 9, 2008

This always happens to me when I nap. Here's what I think is happening:

REM sleep is associated with increased heart-rate. My theory is that when napping I'd wake up (or be woken up) in the middle of REM sleep, hence the increased heart-rate. Antidepressants like Zoloft are known to mess with REM sleep (they have a suppressant effect, which may be one of the mechanisms by which they work). So when you sleep, your onset of REM sleep is probably delayed until later in your sleep cycle. Then you end up waking in the middle of a rem cycle, experiencing the associated autonomic effects.

Obviously this is just unqualified speculation, but I think it's plausible. A sleep study would probably determine whether it's really what's happening.
posted by xchmp at 2:14 AM on December 9, 2008

Medications: I have just restarted Zoloft after a couple years of not taking it. I have just increased (with doctor's supervision) my dose of Lamictal from 100 to 150 mg. Klonopin is the same, and I've been taking it for 2 years.

Caffeine: I have recently cut down to 40 mg/day (one coffee OR one soda) from 80-120 mg. I don't know that I'll ever stop completely, as I turn into a total bitch. Quitting smoking (4 years ago) was far, FAR easier.

I am going to call my psych and see if I can take my meds at night instead of the morning and see if that makes any difference. They immediately make me groggy, which does not optimize my workday. Then again, I'm a lot less anxious!

If this doesn't work, I'm going to call my GP and see what she says re: the holter monitor, dysautonomia, etc.
posted by desjardins at 10:21 AM on December 9, 2008

oh, and I meant to say - thanks for all your answers. Even though most of you probably aren't medical professionals, at least I have some starting points of conversation with my doctors.
posted by desjardins at 10:22 AM on December 9, 2008