Dear Dr. Roach:

A couple of weeks ago, I had a sudden fast heartbeat with a very irregular and erratic pulse (approximately 150-161) for about six hours, along with a very low blood pressure, ranging from 74/59 to 79/52. I first felt a strange thumping in my neck area. I am treated for high blood pressure with amlodipine, losartan and HCTZ. My BP usually is in the normal range, and I have never had an episode like this. I called my doctor’s office a day later, and he ordered a Holter monitor (I will have it tomorrow). I was feeling some anxiety before this happened, but this has been an entirely new event for me. My other medications include thyroxine. I am 90 years old, in good health, mild arthritis, alert and oriented. What could possibly cause such an episode?

—E.P.

Answer:

A sudden, fast heart rate without exertion can be caused by anxiety or fright; however, that doesn’t sound like what happened to you. Your report sounds very much as though you had an episode of atrial fibrillation. The atria are the top chambers of the heart, which fill with blood passively from the veins of the body (on the right side) or the lungs (on the left), and contract to fill the ventricles. The right atrium also normally provides the electrical stimulation for the heart. In atrial fibrillation, instead of, say, 60 beats a minute, the atria may put out a thousand impulses a minute. The heart cannot possibly respond to all those impulses (there is a safeguard built into the electrical system), so the heart rate becomes highly irregular and variable. The rate might be normal, but more frequently it is too fast. One of the goals in atrial fibrillation is to control the heart rate, to protect the heart from going too fast. A rate of 160 in a 90-year-old is not safe, and the fact that your blood pressure went down is concerning: I would have considered admitting you to the hospital in this situation, and certainly would have recommended that you be seen and get an EKG at the time.

People with atrial fibrillation also are at risk for blood clots forming in the heart, and these can travel to the brain, causing a stroke. The other major goal of treating atrial fibrillation is to reduce stroke risk. This requires anticoagulation. The erratic nature makes me think atrial fibrillation is the diagnosis.

Dear Dr. Roach:

You recently wrote that 1,200 calories a day is not enough for most people, but 1,200 calories will support a 120-pound person. Most diets recommend 2,000 calories. That is enough for a 200-pound person! And we wonder why we have so many obese people in our country? The answer is portion control!

—Anon.

Answer:

I must disagree with your numbers. According to the Office of Disease Prevention and Health Promotion, a sedentary adult woman of 126 pounds requires 1,600 to 2,000 calories to maintain her weight. People with normal or high levels of activity will require more. Estimates of how many calories are actually consumed in the U.S. vary, but most estimates are that the average intake is close to 3,500 calories per adult per day. I agree with you that portion control is key, but telling a person that 1,200 calories is adequate is not supported by the data.

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