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Ep. 531 Your Heart’s Not Just Skipping Beats – The Shocking Truth About Palpitations in Women with Dr. Sanjay Bhojraj

  • Cynthia Thurlow
  • 3 days ago
  • 44 min read

Updated: 12 hours ago


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I am thrilled to reconnect with Dr. Sanjay Bhojraj today. Dr. Bhojraj is a board-certified interventional cardiologist who became a pioneer in functional medicine.


In our conversation, we dive into palpitations, which are a common complaint among perimenopausal and menopausal women. We explore red flag symptoms, the physiological effects of progesterone, estrogen, and testosterone as they relate to heart arrhythmias, EKG changes during the perimenopause-to-menopause transition, and wearable technologies. We unpack the differences between benign and more concerning arrhythmias, risk factors for atrial fibrillation, and the process of taking a thorough history, ordering the correct tests, and using imaging or sleep studies when appropriate. We cover treatment pathways, from lifestyle modifications to medications, channelopathies, and the genetic propensities for conditions such as Long QT, Brugada Syndrome, WPW (Wolff-Parkinson-White syndrome), and sudden cardiac death. We also highlight the importance of genetic testing for individuals with a family history of those conditions.


Today’s conversation with Dr. Sanjay Bhojraj is full of practical wisdom and clinical pearls, so you will most likely want to listen to it more than once.


IN THIS EPISODE, YOU WILL LEARN:

  • Why thyroid function should always be taken into account when assessing heart rhythm issues  

  • How stress and life circumstances can trigger palpitations 

  • The benefits of magnesium supplementation for supporting heart health

  • What ventricular arrhythmias (from the bottom chambers) and atrial arrhythmias (from the top chambers) are commonly related to

  • The value of monitoring for identifying the nature and severity of arrhythmias

  • How sleep apnea can increase the risk of arrhythmia  

  • The importance of exercise, stress management, and healthy lifestyle habits for supporting heart rhythm

  • Why certain arrhythmias may require procedural interventions

  • Why various types of athletic activity matter when evaluating arrhythmias

  • How genetic factors can impact specialized heart assessments

 “Lifestyle matters. Balancing electrolytes, stress, and sleep can make a huge difference.”


– Dr. Sanjay Bhojraj

Connect with Cynthia Thurlow  


Connect with Dr. Sanjay Bhojraj


Transcript:

Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. 


[00:00:29] Today, I'm joined again by the amazing Dr. Sanjay, who is a board-certified interventional cardiologist turned functional medicine pioneer. 


[00:00:38] Today, we spoke at length about the impact of palpitations, which are a common complaint of perimenopausal, menopausal females, red flag symptoms that clue Dr. Sanjay into more concerning etiologies, the physiology of progesterone, estrogen and testosterone as it pertains to heart arrhythmias and specific EKG changes that we can see in the perimenopause to menopause transition, wearable technology, differentials between benign versus more concerning arrhythmias including atrial versus ventricular arrhythmias as well as risk stratification for atrial fibrillation, practical evaluations for getting a really strong history, initial testing to use with working up palpitations, imaging as well as potential sleep studies, the impact of treatment starting first with lifestyle and then medications, what impacts treatment decisions for specific types of palpitations and last but not least, channelopathies and other genetic propensities for specific types of arrhythmias, including long QT, Brugadas, WPW and histories of sudden cardiac death, and the importance of genetic testing for these family histories. Again, a truly invaluable conversation, one I'm sure you will listen to more than once. 


[00:02:07] Dr. Sanjay, so good to have you back on the podcast. 


Dr. Sanjay Bhojraj: [00:02:10] Cynthia, it's great to see you again and just connect with you. Such a great time. Last time, I hope we had as much fun and are as informative this time for your audience.


Cynthia Thurlow: [00:02:19] Well, I can tell you as I was texting you over the weekend, there are a lot of requests to talk about palpitations, arrhythmias which are commonplace for perimenopausal, menopausal women. Let's start with palpitations. Obviously, you and I know there are things that are benign but annoying and then there are things that are more concerning. And it was purely coincidental when we were connecting that you mentioned this was an area of research that you studied during your training. So, for listeners, truly serendipitous that Dr. Sanjay and I are going to have this conversation. Let's talk about palpitations, let's unpack why they happen, let's start with the benign stuff all the way to the more concerning things that are out there. 


Dr. Sanjay Bhojraj: Yeah, perfect. So, you kind of intuitively said a classification system that I don't know if I came up with, but that I'd often talk about with patients. If you can imagine a two-by-two Punnett Square or matrix, on the top, I think of arrhythmias as either fast or slow, and on the side, annoying or dangerous. 


[00:03:19] Now, these are the arrhythmias, not the patients. I'm not calling a patient [Cynthia laughs] something that's not necessarily fatal or would not necessarily have consequences, but just you feel them and they just get you anxious and amped up. And so, with the framework of that matrix, we can really fill out all the different types of arrhythmias and things. 


[00:03:38] But before we even jump into that, let's talk about what a palpitation is because a lot of people might not be aware. And your heart is like the thankless organ in your body. It beats 60, 80 times a minute. 60 minutes an hour, 24 hours a day, do the math. I mean, it is hundreds of thousands of times per day. But you should never really be aware of it. You shouldn't have to think, beat, beat. [Cynthia laughs] It would be a big problem. You'd never get anything accomplished during your day. 


[00:04:05] So, we have this autonomous nervous system, autonomic nervous system that drives our heart rate up and down. But every once in a while, you will be aware or you can feel a heartbeat, whether it's early, whether there's a pause, whether it just is kind of beating out of your chest. And those are the sensations when you're more aware of the heart beating that people refer to as palpitations. They can either be a single beat, they can feel like a skipped beat, they can feel like “My heart is about to jump out of my chest.” So, a lot of different things fall under that monicker of palpitation. But again, with that framework, fast or slow, annoying, dangerous, we can figure out what's going on. 


[00:04:43] And the origin of these palpitations can come from a few different things. But generally, what's happening is there is an electrical system in your heart that starts in the top right and then sends an impulse down to the bottom left of your heart. And anywhere along the way you can get interruptions of that electrical system. So, you can have little short circuits that cause the wiring to go in a roundabout movement, we call that a circus movement. And that can fire fast, fast, fast heartbeats all the time. You can have a premature beat that starts in the top of the heart and sends the impulse down. You can have a premature beat from the bottom of the heart that sends electricity up. So, there's a lot of different things at play. And as a result, there are a lot of different ways that they can go wrong. And there's a lot of things that you can do to get them right. 


[00:05:29] But one of the things that I realized, and I think in our last conversation we talked about that little LDL bump that you get around perimenopause, what can happen is that as we see hormonal fluctuations that can actually affect the electrical system of our heart at a very microscopic level. And so inside our hearts, inside of these wires, we don't have little nine-volt batteries sitting there, but we have pumps that are moving ions back and forth like sodium, potassium, magnesium, calcium and all these different things. And as we get hormonal shifts, you can get dysfunctions of those pumps and that was the research that I did 100 million years ago in the hormonal fluctuations of these ion channels and so it stands to reason that a lot of women around the time of menopause, perimenopause are dealing with sleep issues, hair issues, joint aches and all these things. But one of the manifestations of that perimenopause can be palpitations from these ion channel problems that get created.


Cynthia Thurlow: [00:06:26] Yeah, you did such a beautiful job of illustrating how clinicians go about evaluating. And when I talk about clinicians, generally speaking, cardiology experts, how they go through the algorithm in their brains as they're talking to patients. There are benign things, but annoying and it goes all the way up to concerning ventricular arrhythmias that we never want to see. 


[00:06:50] And as a former cardiology nurse practitioner, every once in a while, I would get someone, we have a consult in the ER, and I would be talking to this relatively healthy patient, and they'd be talking about palpitations. And they're on a cardiac monitor, so they're hooked up and you can get a sense of what's going on between the atria and the ventricles. And every once in a while, someone would be talking to me and they'd say “That symptom that I was telling you about. It just started.” And there across the monitor goes a ventricular arrhythmia, and they're wide awake and talking. And the ventricular arrhythmias for listeners are the concerning things. And I was like “Oh, hang on a second. Let me get right back to you.” So always good to have these things evaluated and, in most instances, they are in fact benign. 


[00:07:31] And in my clinical experience, it would be things like someone was studying for an exam, or someone had really poor sleep and they were ingesting more caffeinated beverages than normal, or extra stress, losing more electrolytes than normal, low magnesium can precipitate and low potassium can precipitate a lot of things. And when you are evaluating patients and talking to them, what are some of your red flags? Like “Okay, this is less benign and this is more concerning.” 


Dr. Sanjay Bhojraj: [00:08:01] Yeah. And so that's when you go into that dangerous bucket from the annoying. So, lightheadedness, dizziness, passing out, feeling you're going to pass out, or actually passing out. We call those near syncope or syncope. 


Cynthia Thurlow: [00:08:12] Yep. I don't like those. 


Dr. Sanjay Bhojraj: [00:08:14] Those are always kind of scary. Episodes, like episodic symptoms that are unpredictable. So, I had a woman, female patient, this was probably about 10 years ago, who came to me for an unrelated issue. She came to me. Somebody had heard a heart murmur on her. And I'm just asking, “Anything else going on with your heart? Any fainting spell?” She goes, “Yeah. it's weird. Every once in a while, I just get a spell where I just pass out. My kids are just like whatever. [Cynthia laughs] [crosstalk] behind the wheel and here I am like jaw dropped. If this was a cartoon, my eyes will be popping up,” and I'm like “Oh, okay. So, you're telling me you have intermittent episodes of passing out where you can't predict them, and sometimes you're behind the wheel driving your kids. Hmm, let's get you on a monitor.” 


[00:08:54] And so, we put her on a third day monitor, and it was something like day 28, where she was going into something called intermittent complete heart block, where the top heart and the bottom of her heart were just no longer speaking to each other. And it turns out she’d had Lyme disease. And so, this was one of the late manifestations of Lyme. She never thought about it. And I was probably the fourth or fifth cardiologist that she had seen. I couldn't believe nobody else elicited that history or did something about it. And we ended up having to put a pacemaker in her.


[00:09:22] And she was young, she was in her mid-30s, but her spells went away. So, I think people oftentimes will accept a lot of things as normal that are not. And so, if there's something that just isn't working correctly, yeah, go get it checked out, talk to someone who knows because that could-- She could have been driving. Of course, I always think of the worst-case scenario as a cardio-- She could have been driving a bus full of orphans off over a bridge and fell out-- how many bridges and all that stuff. But you have to think about these things as the worst case scenarios and for her to have intermittent syncopal episodes because of heart block, not great. But luckily now she's had-- she had to go through a generator change and device change because the battery wears out over time on the pacemaker, and that was probably 10 or 15 years ago and she's still doing great. But had you not asked the right question, she wouldn't have given me the right answer. But yeah, these things can be annoying and dangerous, I guess, sometimes to know the right questions to ask or piece things together.


Cynthia Thurlow: [00:10:18] Well and this is where I used to always say to students whether it was a medical student, NP student, PA student, “This is why getting a really good history is so important. 90% of what you need, the patient will actually tell you when the physical exam is just backing it up for you because that gives you an idea of which direction to go in.” And to your point, I live in a state where Lyme disease and tick-borne illnesses are endemic. And I think the county that I practiced in when I was part of that cardiology group was the number one most reported cases of Lyme in the state. So, we saw more Lyme than anybody and we would have 16-year-old, 18-year-olds in the ICU with complete heart block. 


[00:10:59] Thankfully with treatment theirs resolved and went away. But I used to always say “When you see a young person in complete heart block, I automatically thought about tick-borne illnesses.” So, it really can be problematic. And kudos to you for listening to your patient and doing that event monitor so that you had a good sense of what was going on. 


[00:11:18] Now when we're talking about hormones, so like estrogen and progesterone, I know that estrogen can be involved in lengthening ventricular repolarization and progesterone and testosterone can shorten it. So maybe speaking to what an electrocardiogram is and kind of the basics about what's going on with the atria and the ventricle so that we can kind of unpack some of this information around these particular hormones. I'm trying to learn to not say sex hormones, because it then if I say sex hormones, then people think it's just about bikini medicine. And I want testosterone, estrogen, and progesterone as systemic hormones, because it's not just about bikini medicine. It's our entire bodies, including our heart. 


Dr. Sanjay Bhojraj: [00:12:03] Yeah, I missed out on that bikini medicine fellowship. I didn't know that was available. [Cynthia laughs] You realize that both men and women have estrogen, progesterone and testosterone. And I think when you say sex hormone, it automatically puts you in that mind of- 


Cynthia Thurlow: [00:12:15] Mm-hmm. 


Dr. Sanjay Bhojraj: [00:12:15] -men and women. So, in an EKG, you want me to go through an EKG? So, this squiggles and blips. And so, anyone who's ever had an EKG, that's where they put the stickers on your chest generally be a line across starting here and going-- Starting at the kind of upper right chest and going down around the left. And they might put some on your shoulders or on your legs, and that generates a series of squiggles. And all those squiggles mean things to us as cardiologists. 


[00:12:41] So there's an initial bump that's called a P-wave, that is the top chambers of your heart. That's the electrical impulse that comes from the top chamber of your heart. Then you have that big kind of up and down squiggle called the QRS complex, that is ventricular depolarization. So that's the bottom, the muscular chambers of your heart getting that electrical impulse.


[00:13:00] Now, there's a delay between the electrical delivery and the actual mechanical squeeze. But that's the relation there. And then there's a little bump afterwards called the T-wave, that is the recovery of the bottom chamber of the heart of the ventricle. Now, the upper chambers do recover as well, but they're just not as meaty. So, you don't see that electrically on the surface EKG as much. If you're doing wiring inside the heart, you can see that it's called the intracardiac echo, but that's a whole other ball of wax.


[00:13:28] And as we look at these intervals, as I mentioned, inside the wiring of your heart, you have different channels and different pumps that are pumping these electrolytes back and forth. As I mentioned, sodium, potassium, magnesium, calcium, these are the four that get pumped back and forth. And so, if you have a calcium abnormality, that can affect the length of some of these intervals, like the time that it takes electricity to go through can widen out. So, we look at things called a QRS interval or a QT interval. That's the space between these blips. Probably a little nerdy, but the point being is that these are all—these intervals are all affected by ion channels, calcium, magnesium, potassium. And think of those are like bouncers at the club that let people in and out. So, the sodium bouncer is the sodium channel, lets sodium in, and then there's somebody that kicks out the potassium. It happens in milliseconds at a very small scale. But what we see, not just with testosterone-- What am I supposed to call them now? 


Cynthia Thurlow: [00:14:29] The new terminology is PET because it's progesterone, estrogen, and testosterone. So, you can say PET hormones. And then this is like the-- I guess the way that we're kind of, I don't want to say it's being politically correct, I think it's just identifying that the hormones are important systemically and not just localized.


Dr. Sanjay Bhojraj: [00:14:47] Okay. So, as you look at the effect of these PET hormones, they can actually slow down or speed up how fast these ion channels are letting these electrolytes in and out. And that can have effects on the EKG on the surface, but more so internally what that can sometimes do is set up these kind of weird aftershocks, we call them early and late depolarizations and late potentials, where you can get, like if you've ever been surfing or you hear a sound wave that kind of bounce off and come back at you kind of fast or you see a wave, so you can set up these weird electrical phenomenon that confuse the heart muscle and cause them to beat early. And sometimes you can just get caught in the spin. So, with these PET hormone changes, then as you affect the ion channels, you can get a situation where you have less potassium but more sodium than you'd expect or magnesium is the calming-- it's like the aloe vera of the arrhythmia.


Cynthia Thurlow: [00:15:43] Aloe vera? [laughs] 


Dr. Sanjay Bhojraj: [00:15:44] Yeah. It soothes everything down. You’ve got a hot sunburn, you put the aloe vera on. And so, you can get changes in these relative ion concentrations, these distributions, and that can then set up for these early or late or sustained electrical impulses that eventually lead to arrhythmia. So, it’s a complex idea, but I think the idea here to extract and go back to the 10,000-foot level is variations in hormones, and these PET hormones can affect your heart rhythm system. And it's something that is not super well recognized. In fact, oftentimes--


[00:16:19] The only time in, when I was in my conventional mindset that I would ask about hormones would be when somebody would come with palpitations. I guess maybe another time with chest pain. But I would say, “Well, is there any coordination of these palpitations with your menstrual cycle?” And this is when women are normally menstruating. “Is it like before you ovulate, after you ovulate, when you're about to have your period?” And I would ask these questions, trying to sound all smart, I don't know what to put it together [laughs] but at least when you're-- when you're setting these things up and asking these questions and framing it in a certain way, women will be like “Oh, yeah. It's funny like every few days before I ovulate, I'd feel this funny palpitation.” Okay, well, I know that there's an LH and FSH surge and so that may be something that's going on here, but I think it becomes even more interesting in this time of menopause, perimenopause because now you're getting kind of wild swings of hormones. They may or may not be on a regular basis. 


[00:17:10] And so amongst many of the things that women are suffering, the vasomotor symptoms and all these other things, now you're getting palpitations on top of it. And man, you just feel like “Man, what else could happen? What else is going wrong?” But, a lot of therapies for this are tried and true. I mentioned magnesium as the aloe vera. So, one of my go-tos for these benign palpitations, so this would fall under the annoying bucket, either fast and annoying or slow and annoying would be to give people magnesium and oftentimes we'd see a pretty significant decrease.


[00:17:43] I'd venture to guess, in my practice, probably I'd say about 80% of people felt better. Not to say that, eradicated, they completely went away, but they improved their symptoms of that early heartbeat or heavy heartbeat or sustained heartbeat, because again, you're giving magnesium. Magnesium is the chill out element. 


[00:18:01] And interestingly, when you're stressed, you deplete magnesium. And so, you get into this feed forward cycle where you're stressed because of the arrhythmia, and now you're depleting your magnesium, but now the arrhythmias are causing you to feel stressed and you're depleting it again. So just something as simple as magnesium, super helpful. I do a lot of work with sympathetic, parasympathetic tone and so, breath work becomes really important. Doing things like cold plunge, if that is something that is available to you. I grew up in Chicago, I hate being cold. [Cynthia Laughs] So, I don't love cold plunges. I know that they're supposed to be therapeutic. Just for full transparency, I don't do them. But you can even just put your face in some cold water. When you're freaking out, what do they tell you? Splash some cold water on your face, that's that diver's reflex, it adds that parasympathetic tone. But, there's a lot of things that you can do with palpitations. 


[00:18:48] And I think-- Particularly again in the women dealing with menopause, perimenopause, there's so many other things at play. Electrolyte imbalances, stress, sympathetic drive, adrenergic tone, thyroid abnormalities, above and beyond, just the PET hormones being off. I like that, it's easy to-- It rolls off the tongue, PET hormones.


Cynthia Thurlow: [00:19:07] Yes. And it's very clear [crosstalk] about three specific hormones, and they're important for both men and women. And I so love how eloquently you described what an electrocardiogram demonstrates. And for listeners, the reason why I wanted Dr. Sanjay to explain this is that one of the ways that we as clinicians evaluate palpitations is doing an electrocardiogram or an EKG. And part of this is to screen out really serious things. 


[00:19:34] Like I mentioned earlier, I was seeing a patient in the ER and the ventricular arrhythmias went across the screen and it precipitates everyone moving very quickly to address said arrhythmia. But in most instances-- most premature beats, whether it's a premature atrial contraction, premature ventricular contraction, in most instances, I emphasize most, these are benign entities. I will say the exception is when someone has multiple premature ventricular contractions. We used to call them couplets or quadruplets. Like when you see three at a time, four at a time, we start thinking about more serious things. And typically, this is someone who's being hospitalized. 


[00:20:16] There was a very wise cardiologist that I worked with years ago. Unfortunately, he's no longer with us. And his name was Dr. Robert Herron. And I want to give him credit, I was a new nurse practitioner and he was very stern, but really invested time and effort in the nurse practitioners. And he was also an interventionalist. So, has the kind of background that you have, Dr. Sanjay. And I remember him saying, “Cynthia, I want you to think for the rest of your life when you see more than a couple PVCs, you think ischemic heart disease until we prove otherwise.” And so, I always tell people that sometimes it can just be, I had too much caffeine in the setting of low potassium, low magnesium, and I've precipitated these electrolyte disturbances. And in most instances, it is not ischemic heart disease, but important to just identify. There are times when it cannot benign. It might be a sign of something else. 


Dr. Sanjay Bhojraj: [00:21:06] Yeah, that can be the canary in the coal mine, right?


Cynthia Thurlow: [00:21:08] Right.


Dr. Sanjay Bhojraj: [00:21:08] If you see, a lot of those things you say, “Oh, my Spidey sense is up.” Something--


Cynthia Thurlow: [00:21:12] Yeah, walks a duck, quacks like a duck.


Dr. Sanjay Bhojraj: [00:21:14] There is a shoe about to drop let's get into this. So, yeah, there's a lot of subtlety here, but one of the things I will say-- I think we talked last time about agency and returning the ability back to patients to take care of themselves. And this is where I think wearables have been great. I've had several patients who have had a watch-based device or wristband that I thought would be completely useless, to be honest with you, when it came out, but we were able to diagnose and get them to therapy so much faster because they had the wearable device on. 


[00:21:43] So, there's one that goes out there and it says, “It's like having my cardiologist with me all the time.” [Cynthia laughs] That seems a little bit extreme, but these tools can be very useful and very helpful. And I think if nothing else, for reassurance that nothing really bad is happening here. I feel as a cardiologist, probably, I don't want to say, I don't want to overestimate, but let me say maybe 30% to 40% of the interventions I take are really just to help calm people down and prove that nothing bad is happening here. And so, I call it ART, aggressive reassurance therapy. [Cynthia laughs] So, sometimes having a name to something that you're feeling, but knowing that it's not that significant you are putting it into that slow and annoying bucket as opposed to the slow and dangerous bucket, can be really helpful for your whole mental, emotional, spiritual balance. So, I am a huge fan of those wearables, and I think that if you're suffering from these things, it's not a bad place to start. 


Cynthia Thurlow: [00:22:37] Absolutely. And I think the other thing to mention is that some practices have spread specialized arrhythmia doctors, they're called electrophysiologists. And I worked with four in the large practice I was part of. And the one thing I can tell you about the EP physicians that I worked with, very cerebral, very serious, because they see the worst of the worst. And their jobs are to put in devices like you need a defibrillator or you need a pacemaker or you need an ablation. So, they spend a lot of time in the lab. We used to call them lab rats. A lot of time in the lab. A lot of time looking for minutiae to kind of address arrhythmias or heart block as you mentioned. 


[00:23:18] And in some practices, cardiologists do both. They do general cardiology and they also do electrophysiology. So, if anyone's listening and they're familiarized with an electrophysiologist, they are the detectives of arrhythmias and heart blocks, and they deal with devices and other specialized procedures. And they are the lab rats because that's where they spend all their time. 


Dr. Sanjay Bhojraj: [00:23:39] Yeah, I used to say they're the electricians, we were the plumbers. 


Cynthia Thurlow: [00:23:41] Correct.


Dr. Sanjay Bhojraj: [00:23:42] But yeah, it's super subtle, I think, the field and they're the ones I mentioned before, these intracardiac echocardiograms. So now you're actually putting catheters inside the heart to map out the conduction system. And their ability to map that out unmatched. They would be like “Oh, my gosh, did you see that blip?” They'll be sitting there for 20 minutes staring at an EKG go by, and one extra blip will come and they'll be like “That was the key to the case.” It’s like watching one the of those murder mystery shows. 


Cynthia Thurlow: [00:24:07] Ectopic foci.


Dr. Sanjay Bhojraj: [00:24:08] I can see the shoe print matches the shoe of this person, and it must be Mr. Plum in the closet with a candlestick holder or whatever. They are smart people when it comes to the arrhythmia stuff. But yeah, that would be-- Ultimately, it doesn't necessarily mean but you always need an electrophysiologist for these palpitations, but they're the ultimate and-


Cynthia Thurlow: [00:24:29] Detective,


Dr. Sanjay Bhojraj: [00:24:30] -treater of these sorts of electrical issues of the heart. Yeah, absolutely.  


Cynthia Thurlow: [00:24:33] Yeah. I knew that I was not going to be an EP nurse practitioner when I sat in couple cases and I was like “I can't stand in one place all day with lead on.” I just felt by the end of the day I was like shrinking because the lead weights that you wear to protect yourself are very heavy, as I know you know. But by the end of the day, I felt like I had shrunk by about 3 inches because it was just. [laughs]


Dr. Sanjay Bhojraj: [00:24:52] Like, they need to like hang you upside down like an inversion table or something in the labs, but, yeah.


Cynthia Thurlow: [00:25:00] Exactly, exactly. So, when we're talking about palpitations evaluation, let's talk about atrial arrhythmias because I think in many instances, and for listeners, we have two atria at the top chambers of the heart and that's what we're going to start with. Let's start with really benign and go all the way to fibrillating atrial arrhythmias.


Dr. Sanjay Bhojraj: [00:25:20] Yeah. So, most common benign arrhythmia would be what's called the sinus arrhythmia, where just by breathing you're changing how much blood is coming into and out of the heart. That changes the stretch on the top chambers of the heart so you can see a little bit of a variation. That is normal physiology, but sometimes people will have an EKG done and--


Cynthia Thurlow: [00:25:40] They freak out. 


Dr. Sanjay Bhojraj: [00:25:42] Yeah, it's not completely on time. And I say, “No, actually, that's great. That shows that things are working really well. So that's normal.” Then you can have what are called premature atrial contractions. These names are very descriptive of what they are. Premature, early, atrial from the top chamber of the heart contraction, squeeze. And so that can be a situation where you would expect the beat to happen in a certain order and one comes a little bit before it's early, that's premature. That's again, a very benign arrhythmia. Some people will feel that though and you can be aware of that. And so that, as I mentioned, the distress of feeling it can oftentimes drive a lot of anxiety. But again, not a big deal. Nothing that we treat. We just say have a Coke and a smile and just relax. Maybe not a Coke, because we don't want to- [crosstalk] 


Cynthia Thurlow: [00:26:29] [laughs] Non-caffeinated beverage. 


Dr. Sanjay Bhojraj: [00:26:30] -have a non-caffeinated kombucha and smile. And then the more serious would be atrial fibrillation. And so, this is where rather than having one dominant area of what we call pacemaking cells and one dominant area that's telling your heart to beat, you have hundreds, if not thousands of areas. And so, this is a chaotic milieu. I think of this like a room full of toddlers just running around hopped up on Halloween candy, just kind of everywhere. And what happens is electrically, these waves will sometimes come together and crash and cancel each other out. Sometimes they come together in phase and they add to one another. And so, they send this really chaotic series of electrical impulses to the bottom chambers of the heart. 


[00:27:16] The bottom chambers are just like the worker bees. They just do as they're told. The top chambers are really the managers of the situation. So anytime there's a strong enough electrical impulse set from the top down to the bottom of the heart, the bottom chamber beats. And so that's the fibrillation is this irregularly, irregular aspect of beating. 


[00:27:33] Now in and of itself, a couple of problems with the ventricles is that sometimes when you're beating in this irregular pattern, they don't have enough time to fill, so they can't push enough blue blood out. It's like trying to breathe rapidly through a straw, so you're going [makes gasping noises]. You're not really getting a deep breath. You're not getting adequate gas exchange. So, people can feel lightheaded or dizzy or kind of clumsy. Particularly, this is a rhythm that happens as we get older. After the age of 60, it increases by 10% prevalence every 10 years. 


[00:28:01] So as we get older, you may have more of these sensations and your ability tolerate them becomes less and less. Just like our ability tolerate anything as we get older gets less and less. So, people can become lightheaded and dizzy and a problem. 


[00:28:16] In the top chambers, now remember, you have these thousands of electrical impulses happening. And what happens is the atria, the top chambers cannot beat that fast. They can't beat thousands of times a minute. So, they come to this very tense standstill. And what happens is they're just contracted and not really moving, and as a result, you're not able to wash the blood through, you're not getting movement. And so, what happens when blood just sits around? Well, it starts to clot and that's where clot risks come from. 


[00:28:43] So that's why when somebody goes into atrial fibrillation, we'll make a calculation. So, we call it CHADS-VASc score to see if you need to be on a blood thinner to prevent the risk of clot because that is oftentimes the most devastating aspect of atrial fibrillation is not the arrhythmia itself, but a stroke. Somebody will-- Probably 50% of the time, people who have stroke, that's their presentation symptom or presenting symptom of atrial fibrillation that was undocumented. 


[00:29:08] And the other question, what I forgot to mention about the bottom chamber is sometimes people don't feel it at all. Sometimes it's just sitting there buzzing in their chest and they're not aware of it, which if you're a patient, that's a blessing because you're not feeling your heart beating all the time, but from the doctor's side, it becomes a little bit more difficult because we don't know how long you've been in the arrhythmia. So, some people say, “Oh yeah, on Tuesday at 11:00 A.M. I was watching the Price is Right and boom, all of a sudden, my heart felt funny.” That is a great situation for the doctor because we know exactly when this happened. But people may have been in Afib for weeks or months, they don't feel it until they happen to get an EKG at a check or they happen to have a doctor listen to their heart and say, “Hey, I've never heard this before.” So, it can hide in plain sight. Oftentimes it doesn't need to be symptomatic. But that's why getting routine checkups become so important. 


Cynthia Thurlow: [00:29:54] Absolutely. And this is where like taking a good history, doing an EKG, in some instances we have 24-hour heart monitors. If someone's saying, “I get episodes every single day,” then a 24-hour monitor is reasonable, called a Holter. Event monitors are longer, up to 30 days. Like you mentioned that patient that you had, which can be helpful. 


[00:30:14] In terms of lab work for you, kind of high level, what are the labs you're looking at to help evaluate palpitations by history? And I think these are pretty straightforward from my perspective, but I think for listeners, if they're going to their internist as a starting point, what are the things that I think are most-- Or what are the things you think are most important that they should be following up on? 


Dr. Sanjay Bhojraj: [00:30:39] Yeah. So, I think first, electrolytes, you've mentioned that several times, and we've talked about that before, so getting what's called a complete metabolic profile. That's not just looking at kind of basic sodium, potassium, but it looks a little more deep. Calcium, magnesium levels, I think, are very important as well. Now, the thing about magnesium is it can be normal, but you can--


Cynthia Thurlow: [00:30:57] Mm-hmm. 


Dr. Sanjay Bhojraj: [00:30:58] It's like having all your money in your checking this account with no savings. So, if there is a lot happening, you have to look a little bit deeper into something called RBC magnesium, which is a better idea of how much you have available as storage. You can almost never get in trouble. I've said almost, never get in trouble with just repleting magnesium. 


Cynthia Thurlow: [00:31:17] A little bit of diarrhea and it goes away. 


Dr. Sanjay Bhojraj: [00:31:19] Yeah, 70% to 80% of Americans are deficient in magnesium anyway. So oftentimes, I would bypass a check, but that's because I'm a practiced practitioner. All the silver highlights in my hair [Cynthia laughs] certainly it's going to allow me to do that. But if you're not sure, younger patient can do on RBC magnesium, certainly thyroid has to be a part of that evaluation as well, because low thyroid or high thyroid, so either hypothyroid, low thyroid or hyperthyroid, high thyroid can activate arrhythmias and cause a lot of craziness to happen. 


[00:31:51] And looking at stress levels, cortisol levels that can-- Somebody's really in a sympathetic storm or this is where we start asking about what's going on in your life. “Oh, yeah, my house burned down, my dog ran away, my pickup truck broke. And I thought I won the lottery, but I lost the ticket.” All these kinds of stresses that happen in country, old country, western songs. Stress [crosstalk] can precipitate these arrhythmias sometimes as well, particularly the more benign arrhythmias. So, asking about that. 


[00:32:18] From a lab standpoint and then basics, just looking at a blood count, making sure nobody's anemic and has inadequate blood flow that's causing ischemia to the heart. Those are options and then from there, the further testing is really directed by what type of arrhythmia it is. You'd mentioned ventricular arrhythmias that come from the bottom of the heart. Those tend to be more insufficient blood flow oriented atrial arrhythmias from the top tend to be I think a little bit more hormonally mediated or stress mediated. So, it's not a one size fits all but yeah, generally complete blood counts, looking at electrolytes, metabolic profile and thyroid are at the very least what you should do. 


Cynthia Thurlow: [00:32:55] Absolutely. I also think about there's something called a CAGE questionnaire. I'm not sure if people are still using this, but patients-- I would ask them how much alcohol-- And you ask in a nonjudgmental way, but when they would say “Oh yeah, I have like three or four drinks a night,” we used to just double whatever patients would tell us. 


[00:33:11] So, if a patient was hospitalized, I would oftentimes check an ethanol level, looking at their alcohol level because I would see an uptick in atrial fibrillation in particular around the-- We just call it the holiday heart [crosstalk] Christmas, grandma had a little too much to drink or grandpa had a little too much to drink. And they would present with new onset or chronic Afib that was higher than the normal pulse rate than we would see. 


[00:33:36] So thinking about other things that can precipitate arrhythmias, I'm also thinking about untreated sleep apnea or inappropriately treated sleep apnea. I think for a lot of people, like my husband is a healthy weight and we used to walk into patients’ rooms and we would ask what their neck size was. Applicable to men, not necessarily women. And if their neck size was greater than 17 inches, we would automatically start asking questions about the potentiality of sleep apnea. And we know untreated sleep apnea can worsen high blood pressure, put you at greater risk for heart disease, put you at greater risk for arrhythmias. 


Dr. Sanjay Bhojraj: [00:34:10] Drop your testosterone, all the things. And yeah, I like what you said there because it's no longer-- We used to call it truck driver neck in [Cynthia laughs] Indiana. “Oh, a truck driver neck.” You can have thin people and I think a lot of this is from the mouth breathing and we're chewing softer foods and we don't have the same tone. And in fact, there's a device out there that's basically a pacemaker for the muscles of the pharynx and the hypopharynx. 


Cynthia Thurlow: [00:34:32] Floppy pharynx. 


Dr. Sanjay Bhojraj: [00:34:34] Yeah, it's an implanted device that increases the tone at nighttime. Seems like a crazy extent

to go know but if you have severe sleep apnea then that may be your only option. But, yeah, there's a lot of things out there. But, yeah, I do agree sleep apnea is a huge precipitant of atrial fibrillation as a cause. 


Cynthia Thurlow: [00:34:50] And that can also happen in women. I just did a podcast with Dr. Matsumura, who's a sleep specialist, and she was talking about how progesterone in particular can be precipitant for putting us at greater risk for developing sleep apnea as we're navigating that perimenopause to menopause transition. Makes complete sense because it's smooth muscle in our airways and elsewhere. And I was like, of course we're going to be at greater risk for sleep apnea as we're getting older. 


Dr. Sanjay Bhojraj: [00:35:19] I mean, menopause sucks. There's no way--


Cynthia Thurlow: [00:35:22] Men, andropause is not nearly as dramatic. I think you guys go through this slow and steady decline, and we kind of drop off a cliff, and then we're expected to pick up the pieces. 


Dr. Sanjay Bhojraj: [00:35:33] Yeah, how did women even survive? If you think about it.


Cynthia Thurlow: [00:35:39] Duct tape-- [crosstalk] 


Dr. Sanjay Bhojraj: [00:35:39] That’s a question for a different podcast, I’m sure.


Cynthia Thurlow: [00:35:41] [Laughs] for sure. Okay, so we've gone through the trajectory of how you evaluate patients. Let's talk about ways that you address palpitation. So, let's start with your algorithm of annoying and benign and work our way down, because I think we got so many questions around this. I think in many instances, people get an appropriate evaluation. I'm not being critical of having the evaluation, but I think a lot of people don't love the way they feel when they're on as needed medication or chronic medication to address palpitations. Let's talk about how you address it from a pharmacologic perspective. 


Dr. Sanjay Bhojraj: [00:36:22] Yeah. So, first thing first is really understanding the why. Like what is precipitating the palpitation. I think of this one woman who came to me with palpitations, and I don't know if I talked to you about this last time, but I just asked for some reason like the universe just kind of struck me and I asked the simple question, “Do you feel safe?” And she's like “What do you mean?” I'm like “I don't know. Just, do you feel safe?” And she goes, “Actually, not really.” And then she launched into this whole thing about her husband and her partner, whatever I'm supposed to say and kind of a not great situation and all these things. 


[00:36:52] The easiest thing for me would have been to just give her a beta blocker and just-- But there was just something that struck me weird about the situation. So, I think first of all, understanding the context of what's going on in someone's life. And perimenopause, menopause, andropause, all these things aside, like what's going on? What are the things that are weighing you down? Do you feel stressed? Are you stuck in, I call it the caregiver sandwich, where we're taking care of our aging parents and our stupid teenagers that need to age up a little bit more. They're doing dumb things. 


Cynthia Thurlow: [00:37:23] [laughs] Get with the program. 


Dr. Sanjay Bhojraj: [00:37:25] Yeah. And you're just caught in between. So that happens a lot to any of us in that 35 to 45, 50 age group, let's just call it. And so really understanding, are there things that we can do to implement there? Is there like maybe I can have you do a breathing exercise for 20 minutes a day and give you that relaxation. Maybe you need to extract yourself from a bad situation like this woman did. Because no amount of medicine for her was going to solve the underlying issue, which was not feeling safe at home, that's one of those core foundational needs. 


[00:37:56] So first off, figure out where the patient is in their life, what are really the precipitants, what are really the drivers of the situation, and then go towards the medical things. Okay, if your thyroid is high, thyroid is low, let's fix that. If your electrolytes are off, let's do this. 


[00:38:09] Again, one of my go-tos has just been magnesium. Magnesium glycinate, I think you can get into very little trouble with magnesium. You had mentioned, yeah, if you take too much magnesium, you might have a little runny poops. And if you really have too much, you get a little bit weak, but that's almost in an IV kind of really high dose situation, when we have women that we have to arrest their contractions. In Ob/Gyn, we use IV magnesium. But outside of that, very little downside to taking magnesium. and for most people, that just gets them better. 


[00:38:39] Certainly, doing a monitor or trying to capture the phenomenon of what's going on. I mentioned several times where I thought something was benign and something ended up being malignant. It went from that annoying to that dangerous and that changed the algorithm of what we needed to do, but really sorting that out. But magnesium, again, you can't go wrong with that. I think for most people a lot of it is just getting outside of nature and doing walks, just decompressing, just releasing some of the air out of the balloon is super helpful for again the benign arrhythmias that are exacerbated by stress. 


[00:39:12] Now when we talk about the more malignant things. So, the top chamber tends to be more benign. The bottom chamber can be a little bit more malignant. So, if you're having episodes of, as you mentioned, runs of these ventricular tachycardias, we call that non-sustained ventricular tachycardia. Certainly, if you're having V-fib, ventricular fibrillation, very different than atrial fibrillation, that’s a--


Cynthia Thurlow: [00:39:30] One, you are quite dead. [laughs] 


Dr. Sanjay Bhojraj: [00:39:33] Yeah. One, you’re quite dead. One, you’re just lightheaded. But again, those would precipitate evaluations of insufficient blood flow to the heart or sometimes you can have cardiac inflammation like in a post viral situation, a myocarditis. I've seen that particularly in these last few years.


Cynthia Thurlow: [00:39:49] Hearts can be irritable, they're cranky. 


Dr. Sanjay Bhojraj: [00:39:50] Hearts can be irritable. Hearts can be inflamed and cranky. And in fact, there was just a scientific statement released by the American College of Cardiology on inflammation and cardiovascular disease where they specifically called out pericarditis or inflammation around the heart as a something. So, there's a lot of different things. I don't know if I completely answered. 


[00:40:07] Oh, and then as we go to the more pharmacologic kind of therapeutic things to do, then we engage in some more conventional medications, things like beta blockers, which are medicines that help slow your heart rate down. They do drop your blood pressure. And the idea is that by slowing your heart rate down, again these medicines will affect those ion channels. Now we're making those early beats less likely to happen and so you can treat arrhythmias that way.


[00:40:32] Sometimes you do need to go in. We mentioned the electrophysiology doctors. So, there’re areas like little rogue spots in your heart that are causing these early episodes to happen, or little short circuits inside the heart, where the wiring bypasses the normal conduction system and is leading to early beats, they can actually go in and zap those out. In fact, my father-in-law had to have that done. He was having something called a premature ventricular contraction, which generally is benign. But he was having about 30% of his [crosstalk] PVCs and over time that can actually lead to weakening of the heart muscle. So, a buddy of mine did a PVC ablation. It was amazing. One little zap-- less than two second zap and he's been cured and that was probably seven or eight years ago. So, it's really remarkable what they're able do to do. But it can range from something as simple as balancing your life to balancing your electrolytes to going in and getting an invasive procedure. Again, it depends on what's needed in that situation.


Cynthia Thurlow: [00:41:30] Yeah. And I love that you touched on the lifestyle piece because I don't think there's enough conversation in traditional allopathic models of how impactful stresses and lack of sleep. And to your point about electrolytes, in the hospital I always say like “I'm the queen of electrolyte replacement,” because so much of my job was about that, either orally or IV. And so obviously in the hospital we do IV medications because generally it's just easier. I have a pretty narrow perspective of where I like to see potassium, where I like to see magnesium. 


[00:42:07] To your point, for anyone listening, you need a red blood cell magnesium. The other magnesium is not as accurate depiction of intracellular magnesium levels. And I cannot tell you how many patients we couldn't get their potassium-- and this is back when we didn't know better, couldn't get their potassium therapeutic and it was because their magnesium was also low. So, you need both. It's like peanut butter and jelly. You need to check both. The great thing about magnesium is the worst thing that's going to happen. That's why I never sweated it out. I was like “The worst thing that's going to happen. If you have too much magnesium, you'll have the loose stools and it's self-limiting, meaning when you stop the magnesium it goes away. So that's a temporary thing.” It's pretty hard in an outpatient setting or orally to take too much potassium. 


[00:42:52] Obviously the really hardcore potassium is kept in the CVICU, ICU environments that's generally not on the step-down units or accessible to most healthcare providers. I love that you talked about replacing thyroid if that is warranted, correcting iron deficiencies which can sometimes precipitate things. Really looking at inflammatory markers, thinking about beta blockers, calcium channel blockers, antiarrhythmics a lot of these drugs, especially if you have atrial fibrillation. We really want to get you back to normal sinus rhythm, that is the goal. Control the heart rate, get you back to normal sinus rhythm. Sometimes that's done chemically, sometimes that's done with a procedure probably outside the scope of this kind of podcast interview, but that is clinical decision making made with the cardiologist and/or electrophysiologist. So, beyond the scope of a general conversation, but just to let people know, there's different ways that we can address this. Also, managing your weight, eliminating alcohol, addressing sleep apnea all really, really important.


[00:43:53] I think that when I'm thinking about how to evaluate palpitations, we talked about red flags. We talked about the things. Obviously, some things, if you pass out, if you're dizzy, you get in a car accident, that's more concerning than someone saying, “I had five Cokes today and I feel like I'm having palpitations.” How about patients that present with supraventricular tachycardia? So, something that's above the atria, like at the top chambers of the heart. How do you like to address that? I know we haven't touched on it, but I did get a couple questions from people who I guess have had this by clinical history. How do you like to address SVT? 


Dr. Sanjay Bhojraj: [00:44:31] Yeah. So, there's the atria right on the top chamber and there's the ventricle. And in between, there's a little thin strip of conduction tissue called the AV node. And in there, I mentioned short circuits. So sometimes you can have short circuits in there or you can have short circuits called bypass tracks in that kind of thin demilitarized zone between the top and bottom chambers of the heart. And those are interesting, actually. Depending on what happens, you can sometimes even just do something as simple as a carotid massage, increased vagal tone, that can get people out. 


Cynthia Thurlow: [00:44:58] That needs to be done in the hospital. 


Dr. Sanjay Bhojraj: [00:45:00] In the hospital. It's not a DIY. 


Cynthia Thurlow: [00:45:02] Don't do this at home. [laughs] 


Dr. Sanjay Bhojraj: [00:45:04] Yeah, don't do this at home, but there are things that you can do, and that's a temporizing measure. But ultimately that is a great place for the electrical doctors to go in, map out the conduction circuitry of the heart, find out where this, we call it a bypass track. So, find out where this abnormal connection, the short circuit is, and then zap it out, so that's something. 


[00:45:22] But the rhythm that you feel there is, you're just sitting there and it's like “All of a sudden, doc, I just felt my heart buzzing in my chest.” And we did talk about this, but the speeds of the heart can actually give us some sense of what the rhythm is. So, we didn't talk about atrial flutter at all-


Cynthia Thurlow: [00:45:40] Yeah. Saw toothing.


Dr. Sanjay Bhojraj: [00:45:40] -which is another rhythm that can happen on the EKG. It looks like a saw tooth. And generally, that's going to be at about 140 to 160, 180 beats a minute maybe. But when you're getting past 160 into that 160 to 180 kind of 200 zone, generally that's going to be some sort of a supraventricular tachycardia or a bypass tract. So, there's, again, a lot of different ways that we look at this, a lot of different inputs that we get. 


[00:46:05] But yeah, if you're having a supraventricular tachycardia that can be precipitated by hormonal fluctuation, again in that conduction system, you're getting the ion channels changing in their affinities and so you can get these microcurrents and things that can happen, but generally that would be curative with an ablation. In fact, a girl I dated in college, she had an ablation for SVT. I didn't know what it was. I was like “What, they go through your leg and they fix your heart?” And I don't think that's what made me want to be a cardiologist because that relationship didn't work out. [Cynthia laughs] But the pretty most interesting to see, “Oh wow, that's really cool and you can do this and curate, meaning that once if you have SVT when they go in and unless there's--


Cynthia Thurlow: [00:46:47] Much better.


Dr. Sanjay Bhojraj: [crosstalk] it is remarkable. There's one woman I had who I tried to convince her for four years to get an ablation and she was just nervous, which I totally got, I said, “Okay, well one day you'll come to me- 


Cynthia Thurlow: [00:46:58] You’ll be ready. 


Dr. Sanjay Bhojraj: [00:46:59] -and you'll be ready.” So, four years later she had a pretty bad sinkable event where she went down and stuff in her church and so it was kind of scary. So, she got the ablation and now it's been like seven years and she has not had another episode since. 


Cynthia Thurlow: [00:47:11] Amazing. 


Dr. Sanjay Bhojraj: [00:47:12] It's great when you can actually fix someone.  


Cynthia Thurlow: [00:47:16] Absolutely, absolutely. And it's funny that those supraventricular arrhythmias, some of the things, because I would sometimes come down and consult on patients before my docs, who are probably in the lab or somewhere else, and I would say, “Okay, let's get you to bear down.” So, pretend-- you're increasing intrathoracic pressure. It's one of the ways you can stimulate the vagus nerve. There's a variety of different ways that you can do that, but for some patients, just bearing down or coughing or humming, I mean, sometimes it would be something as benign as that. They kind of taught themselves like, “Oh, when I feel this, because it's happened so many times, this is what I need to do to get me out of supraventricular tachycardia.” Again, I always say if you've never done that before, don't do that on your own. Do it in the company of a licensed medical provider. 


Dr. Sanjay Bhojraj: [00:48:00] Yeah, absolutely, absolutely. And again, the other thing about arrhythmia. My brain is working- 

Cynthia Thurlow: [00:48:05] Hard to spell, hard to say.  


Dr. Sanjay Bhojraj: [00:48:07] -faster than my mouth, which happens a lot. But let's not forget about the lifestyle component to arrhythmias. And as we look at these ion channels and mitochondrial dynamics and things like that is that when we are inflamed, when you're in a lot of oxidative stress, these are things that precipitate cellular dysfunction that lead to ion challenges or ion imbalances that can lead to these electrical things. I just did a whole talk for A4M a few weeks ago about the role of oxidative stress in a variety of cardiovascular conditions, like atrial fibrillation and arrhythmia in particular is when you're really inflamed, when you have a lot of oxidative stress, when you have a lot of peroxynitrite and superoxide and all these things going on that directly affects our cellular function and that can precipitate arrhythmias. 


[00:48:54] So oftentimes you're Living La Vida low inflammation. You're low inflammatory and getting your fish oils and all those things that can actually make it less likely-- If it's going to happen, it can actually make it less likely for it to go down. So that speaks to the importance of not just dealing with these arrhythmias and lifestyle issues when it's already happened, but living the right life, eating the right foods, having the right behaviors, all of these things can protect you from having to develop into these arrhythmias over time. 


Cynthia Thurlow: [00:49:22] Well, and I think that's really important because it all starts with lifestyle. And I think for a lot of people, maybe it's been over the last five or ten years that we're hearing more and more of this how important lifestyle measures are for maintaining health. I love to touch one more topic, and I recognize that some of the questions that came in were very specific. So, we're trying to talk in generalities, and then people can take the information back to their providers. I got a lot of questions around athletes that are women, as well as specific genetic propensities for arrhythmias. 


[00:49:57] Do you feel comfortable identifying like if you are meeting with a new patient, as a cardiologist, things that would be specific to a past medical history or family history about arrhythmias, that would be a flag for you to think about someone probably needs to escalate their care in terms of going directly to electrophysiology or involving electrophysiology in the discussions that you're having about the plan of care for a patient?


Dr. Sanjay Bhojraj: [00:50:30] So in general arrhythmias, we don't see a huge signal that they are hereditary, but there are some hereditary conditions that can cause arrhythmias. So, it's like not all things orange are oranges, but not oranges or whatever, you know what I'm trying to say? So, there are some. So, you can have what are called channelopathies, so ion channel abnormalities, we've mentioned these several times. But genetic ones that can predispose you. There're things like what's called long QT syndrome or short QT syndrome that are at play. There are certain bypass conditions that can be handed down, meaning short circuit conditions like there can be some Wolff-Parkinson-White and LGL, which is another bypass track that can happen. So, if you have a family history of people passing out or suddenly passing out, I'll always ask them, “Do you have a family history of anyone who died suddenly?” 


Cynthia Thurlow: [00:51:19] Yep. 


Dr. Sanjay Bhojraj: [00:51:19] Unexplained, like they're just-- You hear these stories of the kids at sports practice and all of a sudden someone goes down and CPR. So, “Do you have a family history of that at all? Or have your parents ever had passing out spells before the age of 60, 65 or so,” that can lead to thinking about these sorts of things. Any inherited or any abnormalities on their EKG. When I get an EKG, first question is, “Do your parents ever say they have funny looking EKG?” [ Cynthia laughs] Probably not politically correct now that you can't say it or you can say it now, but in the 1990s when I went to med school, I was in on a pediatric rotation with a geneticist and he said, “When you have someone that looks syndromic,” that's what we would say, “You always have to look at their parents first and see if they just look like their parents” because they could just look [crosstalk] parents. So, if you have a funny looking EKG, “Do your parents have a funny looking EKG?” That can be a metric. 


[00:52:10] For the athlete in particular, you have to ask about the type of activity and what's happening. I'm a lifter, so there's all these powerlifting videos where these guys are trying to lift a thousand pounds and they just kind of pass out, that's not really an arrhythmia, that's just-- We're just holding their breath so hard their hearts, they couldn't pump blood through, so that's called a vagal episode, I guess. So, they're just kind of holding, bearing down so hard, so that's not generally going to be something. 


[00:52:35] But if there's a runner, someone doing endurance work that they tend to have palpitations at a certain point in time or in the family they have it, that could be something of interest. A little fact, the most dangerous mile of a marathon, do you know where that would be? 


Cynthia Thurlow: [00:52:51] I'm guessing that. 


Dr. Sanjay Bhojraj: [00:52:52] It's 26.2 miles. [Cynthia laughs] They're all dangerous, but it's latter third is-- 


Cynthia Thurlow: [00:52:58] That's what I figured at the end. 


Dr. Sanjay Bhojraj: [00:52:58] So miles 18 to 26, because why? Because that's when you're sweating out, you're getting electrolyte imbalance balances, you're drinking water more than you're drinking sodium in, so you can get low sodium. So that last third can be where a lot of these arrhythmias happen. So that often times they'll have more aid stations and medics kind of at that point in a race as well. So, asking, “Okay, you are an endurance athlete, does that mean that you're a 5k runner,” in which case probably not a big deal. “Are you an ultra-marathoner where you're going 50 miles,” That's something, do you run a marathon distance? So, sorting out exactly what sort of athlete they are. 


[00:53:35] Sprinting. So, if you're someone who's doing basketball, football, soccer or something like that, you tend to, again, have this at the end of the episode, at the end of the sporting event, as opposed to during the middle. Unless there's some sort of arrhythmia that-- Some sort of a structural issue precipitated. So, again, it's tough to say. And speaking generally, I'd have to say, well, it depends which is the worst answer to have. But it really does because there's so many nuances because someone who's shooting archery is a very different athlete than someone who's doing the hurdles. So, you just have to take that into account and figure out. 


[00:54:07] I guess the questions would be, “When in the activity, is it happening? Is it consistently happening or is it intermittent? Does it happen in practice or is it in competition only?” Because there tend to be people a little bit more nervous during competition. “And how long has this been happening? Is this something that's happened in the last two weeks or is this something that's been going on for years?” And generally, with that framework and understanding what type of sports they're playing, we can figure out, okay, this is probably the type of arrhythmia that's having and then we can get them on an appropriate monitor because if you're a runner, we're not going to hook you up to all these wires, little stickers that we can put on your chest to give us an idea. 


[00:54:44] I live in Southern California practice here. We have a ton of surfers. So, we had to find a waterproof option. We had to put a patch over the device so that they didn't fry the circuitry. But there's ways that we can sort that out. So, I wish I could be more specific, but that's about as good as it gets, I guess. 


Cynthia Thurlow: [00:54:58] No, no, no, that was really helpful. And I didn't ask ahead of time if you felt comfortable giving that kind of broad base. But in all honesty, we get a lot of questions about these things, and I'm like “Listen, I'm not seeing this anymore in clinical practice, but we can speak from a broad perspective, but obviously, if you have concerns about genetic propensities for passing out, sudden cardiac events, inherited EKG abnormalities, this is an excellent opportunity to connect with a cardiologist and/or an electrophysiologist.” 


Dr. Sanjay Bhojraj: [00:55:30] Yeah. And they can do genetic testing for this. And so, you give a blood sample and they can check and see whether you have this gene or that gene. And one note on that is when we're doing, for example like calcium channel issue or sodium SENC5 or whatever sodium channel, we know what we know, but we don't know what we don't know. So, we might know the most common 10 or 20 genetic variances or SNPS they're called that lead to a channelopathy. But there may be others that we don't know. And so, I've had this several times with the gene testing where somebody will say, “Well, the test said, I don't have it, but I have all the symptoms of it.” And I said, “Well, we might just not know exactly what your variation is leading to this, but you may still have the condition. We just don't have the right question to ask yet.”


[00:56:14] So, it's very nuanced. But again, that is not something that you watch on YouTube or you go to labs by yourself and get it done there. You need someone to help counsel you, genetic counseling, a clinician who is comfortable in ordering the proper tests for this because believe it or not sometimes people come to me with second opinions and I'll be like “Boy, they didn't even order the right labs.” They're not even checking for what they thought they're checking for. So, you really need to have someone who is conversant with these genetic tests.


[00:56:43] And generally a good electrophysiologist, these guys and gals are awesome at this. But ask what are the genetic things? And see if they're comfortable. If not, go to an academic center or seek out someone in your community who does do a lot of these sorts of-- And there's message boards and things online that you can find physicians that are comfortable with this, that other people have used, but that it's a really intriguing area. It doesn't come up very often, but like in one week, I remember I had four or five different individual channelopathies and it was just channelopathy week at my practice. It was weird, but it can happen. 


Cynthia Thurlow: [00:57:15] Absolutely. Well, as always, a truly invaluable conversation, please let listeners know how to connect with you outside of this podcast, how to learn more about your work or listen to your podcast, which I have been a recent guest. 


Dr. Sanjay Bhojraj: [00:57:27] Oh yeah. So, number one, I apologize for the nerdiness of this.


[laughter]


Cynthia Thurlow: [00:57:33] People have been asking for this in particular. I think we had multiple requests just last week. So, I was like serendipitous, guess who I'm bringing on? We'll talk about it. 


Dr. Sanjay Bhojraj: [00:57:41] Perfect timing. So, you can find me. So, my podcast is called The Curious Cardiologist. It's on all the podcast places, so look me up. If you want to find me online, my handle is at @doctorsanjaymd. So, D-O-C-T-O-R-S-A-N-J-A-Y-M-D, because nobody can spell my last name.


Cynthia Thurlow: [00:57:58] Can't pronounce it either. 


Dr. Sanjay Bhojraj: [00:58:00] And my website is lagunamedicine.com so www.lagunamedicine.com. My practice is called the Laguna Institute of Functional Medicine. We focus mostly on cardiometabolics, all aspects of cardiology are at play and I'm actually launching a telehealth program as well. So, if you want to work with me one-on-one, for right now, just working with folks in California, but soon expanding everywhere. So, reach out, fill out the forms and I'll be happy to try to help fix whatever else is going on with you. 


Cynthia Thurlow: [00:58:27] Thanks again. 


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