ArcaMax

DEAR DR. ROACH: I'm a 75-year-old woman who, for at least 10 years now, has been experiencing a rapid heart rate. My blood pressure, however, remains normal. In fact, doctors are usually surprised at how good my blood pressure is since I am borderline obese and slightly diabetic.

During this past physical, my doctor did mention my rapid heart rate but didn't recommend treatment or referral to a cardiologist. Should I insist on a referral to a cardiologist, or would this only bring me to more unnecessary testing? -- M.R.

ANSWER: I unfortunately hear about people (more commonly women) having a potentially serious medical condition that gets ignored for many years, and I fear this is the case with you.

In a person with a persistently fast heart rate (over 100 bpm), an electrocardiogram (EKG) is an essential first step. I suspect you may have had this done, but if you haven't, this clearly needs to be done. Atrial fibrillation and some less-common heart rhythms need to be excluded.

It's likely that you have "sinus tachycardia," meaning that the impulse comes from the sinus node but is persistently too fast. The heart rate is supposed to be fast if you are exercising, and a fast pulse can often come on as a response to infection or loss of fluids. But I think that, after 10 years, you most likely have a condition called inappropriate sinus tachycardia (IST).

Since you are writing to me, I assume that this is bothering you. Most people with inappropriate sinus tachycardia note palpitations, but loss of endurance and decreased exercise tolerance are other common symptoms.

Before getting treated, it's important to make sure that there isn't some longstanding cause such as anemia or thyroid disease. It's also necessary to exclude the diagnosis of postural orthostatic tachycardia syndrome, which can overlap with IST and seems to be much more common now, especially after a COVID infection.

I have had some success in prescribing exercise for carefully selected patients with IST. The cardiology literature recommends beta blockers or ivabradine to reduce symptoms and improve exercise ability.

Referral to a cardiologist is appropriate given your 10 years of not being evaluated. Even if you decide against therapy, making sure that there isn't a serious problem is very wise.

DEAR DR. ROACH: I'm a 61-year-old male in excellent physical health. However, out of nowhere, I started having severe anxiety attacks when driving over 60 mph on the highway. I now have to frequently exit the highway in order to calm down, and I'm constantly worried about having additional attacks while driving. Do you have any insight on how to treat this? -- P.R.

ANSWER: According to the reading I did, some people will develop a fear of driving on the highway after an accident, but it also may come out of nowhere. Highway driving does tend to be more problematic as there is greater danger due to faster speeds but even more so because of a higher perceived danger, which is sometimes blown out of proportion.

From what I have read, cognitive-behavioral therapy is one treatment, while exposure treatment, sometimes using virtual reality, is another. The sooner you begin treatment, the more likely it is to be successful.

Since it sounds like you are having panic attacks, SSRI medications like sertraline may also be helpful, but some other medicines for panic attack are inappropriate for people who are driving.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

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