Bradyarrythmia (Bradycardia) — Meaning Pathologically Slow Heart Rate, including in this Instance, a Noticeably Irregular Pulse — the Apparent Result of My Newly Developed Hypersensitivity (Allergy) to Ibuprofen (Advil^®) for Osteoarthritis — an Example of Lay Medical Analysis, Performed while Hiking a Colorado “Fourteener”

24 August 2012

Why this essay? —Four points of possible interest to older people

I occasionally write about aging, in hope that some of my personal experiences will be of informational value to others under similar circumstances.

This essay concerns the sudden development of a pathologically slow and irregular heartbeat at high altitude — most probably as the result of a newly developed hypersensitivity to ibuprofen, which I used to treat flare-ups of severe osteoarthritis.

I make four points:

(1) Medication that was once helpful and well tolerated can fall victim to the body’s suddenly formed hypersensitivity to it — with potentially serious, even fatal, consequences.

(2) Knowledge of one’s personal medical and family history sometimes unravels what might be going on.

(3) People differ in confidence in their analytical abilities — with some of us shortcutting medical investigations that others may think necessary.

(4) In the end, the uncertainty that is common in medicine combines with quality of life issues that only the patient can resolve.

What follows is not intended as medical advice — at most, it represents a framework of questions for your doctor, should a similar event happen to you

This anecdote exemplifies the application of common sense by someone with the experience and education to make guesses about the most probable cause(s) of a new personal medical ailment.

The essay’s reasoning might serve as a framework for questions that readers could bring their physicians under similar instances.

I am emphatically not recommending that people with weak or absent medical backgrounds end-run the medical profession. If you do that, you may end up prematurely dead or injured.

My personal medical anecdote — Bradyarrythmia (pathologically slow heartbeat) suddenly developed, while I was hiking Colorado’s Mount Shavano

The mountain’s summit is at 14,229 feet (4,337 meters).

About two-thirds of the way up, I had to stop every few paces because I did not have the muscular strength or energy to continue at an uninterrupted pace.

I found my difficulties curious because I am moderately fit. My pack weight was only 26 to 30 pounds (11.8 to 13.6 kilograms). When I was young, I routinely carried packs weighing 70 to 110 pounds (31.8 to 54 kilos). Struggling under the tiny load was an eye-opener.

Initially, I dismissed the symptoms as being due to the lamentable physical deteriorations of age.

Then, when muscular fatigue was compounded by problems with light-headedness, I recognized that my brain was not getting enough oxygen.

Checking my carotid pulse, I was surprised to find that it was both irregular and ridiculously slow at approximately 40 beats per minute:

slow one, two — long pause — slow one, two — long pause

slow one, two — long pause —slightly faster one, two, three, four — very long pause — slow one, two

one — 2 second pause — one

And so on, in apparently unpredictable weavings of those three basic themes.

Notable was the larger than normal (for me) high volume of the one and two pulses. My heart was obviously trying to make up for its exceedingly slow rate by ejecting more blood with each beat.

This slow and erratic pulse explained my fatigue

Ordinarily, my resting heart rate is 50 to 52 at 6,000 to 7,000 feet (1,829 to 2,134 meters) altitude.

At 13,000 feet (3,962 meters) — carrying a pack up a steep hill and trying to walk at a moderate rate — my heart rate should have been between 120 and 140 beats per minute.

The irregularly pulsed, much too slow 40 beats per minute explained the fatigue and light-headedness.

So, what did an allegedly smart guy do in this situation?

Continued on to the top of the mountain.

My reasoning for temporarily ignoring these pathological signs

If we seniors are going to be afraid of every deterioration in our physical capacity during the coming years, we are probably going to have to stay at home and next to a telephone.

On Mount Shavano, I recognized that I would be unlikely to make a return trip because there are so many other hikes to take. So, I figured I might as well complete what had I set out to do.

What tipped the safety balance in my mind was the probability that the bradyarrythmia (a second word for slow heart rate) was due to a newly developed sensitivity to ibuprofen (Advil^®).

Note

Recently, I have been using Advil^® at the beginning of each hike to control the difficulties that wide-spread (sometimes severe) osteoarthritis, and its neurological complications, get me into.

Examples of these joint and nerve problems are briefly presented in accounts of hikes on Blodgett Peak and Pikes Peak.

On Shavano, my pulses, though pathologically slow and irregular, were strong. And I was experiencing none of the usually painful or scary symptoms that accompany so many men’s heart attacks.

Memory indicated that the majority of arrythmias are not life-threatening. And even if this one could be, I concluded that it was more important (psychologically) for me to make it to the top of the mountain, than it was to only slightly improve my chances of taking a living route down.

Analytical components of my tentative self-diagnosis

Given my exceedingly slow way up Shavano, I had time to analyze the probabilities:

(1) Altitude sickness was not likely, given that arrythmias are not associated with it.

(2) Arrmythias, infrequently including bradycardia, have been associated with NSAID use, including ibuprofen, in some people.

(3) Hypersensitivities (meaning allergies, some occasionally deadly) to pharmaceuticals can develop suddenly, even after years of previously safe use.

(4) I had twice before experienced anaphylaxis (in those instances, difficulty breathing), due to the sudden development of intolerance to two prescription NSAIDs — even after using them on and off, as most people do, for months to years.

That kind of severity is why physicians usually insist that people subject to anaphylactic reactions carry an epinephrine injector (syringe loaded with epinephrine/adrenalin). For example, EpiPen^®.

(5) My two previous NSAID allergic reactions had escalated radically in severity over the space of only two doses.

The first reaction in each case was noticeable, but mild enough to leave me questioning the accuracy of my perception that something was amiss.

The second reactions were so physiologically significant that their potentially life-threatening implications could not be missed.

This pattern is not uncommon. Its surprising rapidity explains why some people die as a result.

(6) Thinking back to a Pikes Peak hike earlier this year, and the disconcerting difficulty I had doing it, made me think it was likely that the Pikes effort represented a mild first warning about ibuprofen sensitivity.

(5) In diagnostic contrast, because I have never experienced heart-related problems due to heavy exercise, I thought it less probable that I had suddenly developed age-related cardiac conduction problems.

Was this rationalization or sound sense?

Another clue, when I got home

My heart rate and rhythm had returned to normal, when I got home at 6,200 feet (1,890 meters).

The return to a normal cardiac rhythm was, most probably, due to either of two causes:

(1) My bradyarrythmia might manifest only under the low oxygen physiological stress of altitude, which somewhat parallels exercise-induced cardiac problems.

(2) Or my body had metabolized (gotten rid of) the ibuprofen that had caused the suspected hypersensitivity problem.

I checked online medical information sources to verify my recollection of medical literature

As I had thought, the online survey eliminated the three predominant forms of altitude sickness as possible causes of bradyarrythmia.

On the other hand, online sources verified the correctness of my recollection that NSAIDs have been associated with arrythmias — including abnormally slow heart rates in a minority of affected arrythmia patients.

For example, as of 23 August 2012, eHealthMe quantified the relationship between ibuprofen and bradycardia at slightly less than 1 percent of patients — 503 people in a 50,384 person sample.

So, I decided to test the ibuprofen possibility first

The following day, without ibuprofen in my system, I used our elliptical trainer to get my heart rate to 120. My self-detected pulse rate and rhythm was appropriate for the moderate level of exertion. If there was a problem, it was beyond my at-home means to detect it.

The day afterward, I did bicycle sprints outdoors at full blast. Cardiac response appeared to be what it normally is for me under those conditions.

A couple of days later, as the “ultimate” test, I hiked three connected “fourteeners” — Mounts Democrat, Cameron and Lincoln. Again, my self-evaluated cardiac rate and rhythm appeared to be normal.

However, I noticed the presence of mild acute mountain sickness, in the form of significant headache and noticeable nausea.

Somewhat conveniently, this bit of mountain sickness tended to further rule altitude out as being the primary cause of the heart problem that I had experienced on Mount Shavano.

Here, I reasoned that, if:

(a) mountain sickness was present on Mounts Democrat, Cameron and Lincoln, where I experienced no obvious heart problems,

and

(b) mountain sickness had not so noticeably occurred on Shavano, where I did have cardiac problems —

then

Not definitive, of course — but good enough for me, in light of my previous history with NSAIDs

Certainty in medicine is often scarce.

As my professors said a couple of times (here paraphrased):

We train you to find the zebras in a herd of horses, but remind you that what you are looking at is most often simply a horse.

Meaning that, in clinical practice, common medical problems predominate over rare ones.

This translates into the importance of knowing (a) what is common in the population and (b) what is common in a specific patient’s medical and family histories.

The above analysis and crude experiments were good enough to indicate (to me) that I probably have developed a serious hypersensitivity to ibuprofen.

It makes the third NSAID that I have developed a serious sensitivity to. Given my body’s penchant for mounting self-destructively massive immune response attacks on some foreign substances, there is nothing clinically surprising in the development.

“But Pete, why didn’t you see a doc?”

Here is where older, medically knowledgeable, and autonomous people may relate.

My experience has been that medicine, when it is out looking, often finds abnormalities that are not now or going to be, functionally problematic. When these are not immediately related to the medical issue at hand, they are called “incidental findings.” Meaning that we stumbled across them by accident.

Detected abnormalities, whether related or unrelated to a manifesting medical problem, frequently lead to a long and expensive chain of statistically unnecessary follow-ups, some of which continue for a lifetime.

The problem here is not thoughtless doctors. It is the scientific uncertainty that underlies so much of the medical discipline.

Abnormalities in perfectly healthy people are common. But we cannot tell that these are harmless, until that person has lived a full life span. So, when confronted with potentially serious medical issues, physicians necessarily go looking for answers.

In my bradyarrythmia case, there may indeed be something not quite right with my heart. Or, alternatively, with my ability to properly metabolize ibuprofen. And we already know that my immune system is operating slightly outside the desirable range.

Nevertheless, from my perspective — given that I had no obvious cardiac problems in the absence of NSAID use, and have been physically active for more than 65 years — I see no need to go looking for abnormalities that are probably not going to kill me tomorrow.

But, even with that said, can you imagine a responsible physician saying:

Yeah, Pete, that’s a great idea.

I’ll let you go back up into the very same environment that gave you a very concerning heart irregularity — based simply on your suspicion that ibuprofen caused it.

Have your wife call me, when you come home dead.

I’ll put a note in your file, documenting the fact that we were wrong.

This hypothetical physician’s dilemma is exacerbated by the fact that some medical organizations do not have continuity of patient care, and virtually all see far too many patients, much too quickly, to provide ideal service.

Not knowing one’s patients arguably necessitates running standard, appropriate spectrum tests, when medical issues crop up.

For example, the military system where I am a patient has — for reasons of medical provider deployments and “permanent changes of station” — bounced me from one doc or physician’s assistant to another every few months.

Not one of these medical professionals knows me by name, and none remember anything at all about my health. Nor do they have time to read my medical file. And most are too busy even to have a solid clue as to why I’m there.

I also know, from personal experience outside the military system, that this is the way most American primary and specialty medicine performs these days.

The unavoidable professional “sloppiness” that accompanies our perversely incentivized medical system is a primary reason that I left my own training at the end of my third year.

Note

None of what I have said is a slam at physicians.

Most of them are trapped in a flawed and expensive health care delivery system that gives them little choice as to how they operate.

The more competently caring they are, the harder they have to work (metaphorically uphill), often sacrificing their own health in the care of their patients.

With these facts in mind, and from my analytical autonomous person’s perspective, there are times when it is best to leave the “system” initially out of it.

With my background, I was certain that I could eliminate the more obvious bradyarrythmia diagnostic possibilities myself and avoid undergoing probably unrevealing tests and insurance company costs.

And I was relatively certain that I could do this, without putting a well-meaning and wisely cautious physician on the spot.

For everybody else — see a doctor

For less knowledgeable and less autonomous people than I, under the above described circumstances, going to see a medical professional makes mandatorily perfect sense.

“So, Pete, if you stop using ibuprofen — how will you control your arthritic inflammatory response?”

You got me.

This week’s “trek” on the test fourteeners (Mounts Democrat, Cameron and Lincoln) confirmed the reason that I had started with Advil^®. I re-experienced the significant (un-medicated) mobility problems that had me in such difficulty on Blodgett Peak.

But what to do medically is not as obvious as it would be for a patient who is just discovering her first hypersensitivity. I am now seriously allergic to three anti-inflammatory medications in two different chemical families.

And I have experienced no benefit from two to three more in the selective COX-2 inhibitor group. This is the family that contains:

rofecoxib (Vioxx) — which has been voluntarily withdrawn from the market

and

celecoxib (Celebrex) — currently subject of an FDA alert for potential cardiac problems.

The commonality among NSAIDs is that they cause cardiac problems in some people. Yet, it is impossible (today) to forecast which people are going to be negatively affected.

For me, this raises implications about the long-term safety of what there is left to try. Two NSAIDs have “tried” to kill me by stopping my ability to breathe and a third, less dramatically, by directly impacting my heart.

Given that we know that NSAIDs cause cardiac-related problems, the fact that one has so visibly done exactly that in me indicates that caution might be in order.

This raises the balancing question that aging people often have to confront:

Is it better to treat a medical condition with something that is probably going to be harmful over the long-run — however long that works out to be for people already quantitatively near the end of their life span,

is it preferable to leave the condition untreated?

No one has the answer to this because the question blends (a) medical uncertainty with (b) people’s varying psychological orientations toward quality of life issues.

The moral? — Medicine’s uncertainty affects us at the personal level

Sometimes the only reasonable answer is, “I don’t know.” And sometimes the only reasonable response is to flounder.

My guess is that I am probably more likely, than not, to develop significant allergies to most, perhaps all NSAIDs.

This raises a specific version of the older person’s balancing question:

Do I —

Give up hiking mountain peaks — as the price for reducing the probability of un-medicated and serious falls?

Or, do I try a new medication — and run the risk of having a sudden, or drawn out, fatal response to it?

I have dodged the NSAID fatality bullet three times. Perhaps now is a good time for to stop flirting with my now obvious propensity for developing hypersensitivity to them.

I don’t know yet, how I am going to come down on this question.

Giving up mountain peaks is a psychologically difficult thing — even though hiking them is painful and physically dangerous for me, even when medicated with an NSAID.

On the other hand, accepting losses is what graceful aging is predominantly about.

One nice thing, about having lived a long while, is that we often recognize that medical dilemmas like these, insofar as they affect only us, are not particularly important.

PeteFree.com