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Diagnosed with LBBB after fainting. Prescribed Angiotensin Receptor Blocker. ER and ECG showed sinus Rhythm with PVC. Remedy?

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I am a 54 year old female - 5' 2", 115 pounds. No health history until 6 months ago (no illness, no medications, no problems) diagnosed with LBBB after fainting in Feb. Continued to have several episodes of near syncope. Had positive tilt table test. Prescribed 25mg of Angiotensin Receptor Blocker - this evened out the erratic blood pressure (was dropping very low and then going very high). Echo was low normal 55% EF and Grade 1 Diastolic Dysfunction in addition to the LBBB. I have had numerous ECGs during the past 6 months - they always show , Normal Sinus Rhythm, LBBB, Abnormal ECG. My heart rate was usually between 50 and 60 at each of my many dr.visits. I did have a 3D Cardiac Ct Angiography with contrast that creates a 3d image of the coronary arteries and the report says they are clean with no blockages seen on this test. Two weeks ago, I felt a distinct change in my heart rhythm along with exhaustion and chest pain. Went to ER and the ECG now said this: Sinus Rhythm with PVC or fusion complexes, Low Voltage QRS (76) T Wave Abnormality, Abnormal ECG. I was told in the ER that this was normal and nothing to worry about. Since then, my heart rate is no longer in the 50s and now is anywhere from 62 to 80. I insisted that my Cardiologist do another Echo (6 months after the first one) and he said the Echo was normal - I have not seen the copy of the report yet. He also thinks the low QRS voltage is due to the LBBB but it does represent a change as my previous 8 ECGs did NOT show this. I am not overweight - am very petite, so it is not due to obesity. For the past 2 weeks, I am experiencing a very sore front of neck and middle of chest along with uncharacteristic exhaustion. I am going to pursue a Gastric consult to see if it could be from a gastric issue but I have a nagging concern that it could be cardiac related. My cardiologist does not think I need to see him again for 6 months. In your opinion, could the change in the EKG be responsible for my increased symptoms? In your opinion, is the change in the QRS duration meaningless or could it mean something in my heart is progressing? Previously the QRS Duration was 134 (one month ago) 132 (3 months ago), 110 (4 months ago), and 132 (6 months ago). It is now 72 as of 2 weeks ago. Should I seek a second opinion from a new Cardiologist? Mine doesn't seem very interested.
Posted Mon, 15 Jul 2013 in Heart Rate and Rhythm Disorders
Answered by Dr. Sukhvinder Singh 23 minutes later
Respected Ma'm
I need more information before I can explain the whole picture to you.
1. What happened to your episodes of fainting and near fainting? What was and what is your PR interval in ECG. You may upload your ECGs through a facility on right hand top corner of this page. That would be a great help. Have you consulted an ELECTRO-PHYSIOLOGIST (a specialist for rhythm disorders) for your fainting attacks?
2. A QRS duration of 72 ms now, means your LBBB has disappeared! Something, not easily acceptable, unless I see the ECGs. However a reduction in QRS duration is not likely to be responsible for any symptoms. A low voltage QRS is different entity than a low QRS duration. You have mentioned both. Is it a typing error? Please confirm.
3. Do you feel the sore neck & front of chest at rest or is it associated with exertion? Is there any relation to meals? Does these symptoms come up with running/ using stairs/ carrying weights? For how long they last? What are accompanying symptoms? How you get relief? Have you undergone a stress test ever?
4. Your ECHO and angiogram are normal. Hence progression of a structural heart disease is not in question; I am more concerned about the electrical events and your attacks of near-syncope.
Waitnig for your next mail.
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Follow-up: Diagnosed with LBBB after fainting. Prescribed Angiotensin Receptor Blocker. ER and ECG showed sinus Rhythm with PVC. Remedy? 1 hour later
Thank you for such a quick and thorough response. Here is the additional info. I can't scan the paper ECG copies at home. Here is what they say: XXXXXXX 2013: Sinus Rhythm, freq. ectopic vent. beats, LBBB and left axis. Rate 78; PR 126; QT/QTc 392/425 QRS Axis -27; QRSD 132; P axis 69; T Axis 71; This was first ECG done after going to Cardio due to nearly fainting while driving home one night.

2nd ECG also XXXXXXX 2013 Done at ER after nearly fainting: Sinus Rhythm, occasional PVC; LBBB; Vent Rate: 86; PR Interval 120 ms; QRS duration 132 ms; QT/QTc, 374/447; PRT Axis, 76, -29 87;

3rd ECG also XXXXXXX 2013: Done at ER after nearly fainting: Sinus Rhythm, occasional PVC and fusion complexes, Incomplete LBBB; Vent rate 75; PR interval 144; QRS Duration 110; QT/QTc 392/437; PRT Axis 76, -8, 73;

4th ECG Feb 2013 at Cardio Office: Normal Sinus Rhythm, LBBB Vent
rate, 75; PR interval, 124; QRS duration, 132; QT QTc, 400-446; PRT axis, 77, 39, 75;

5th ECG Apr 2013 at Cardio Office: Normal Sinus Rhythm, LBBB; Vent rate 72; PR Interval 126; QRS Duration 134; QT/QTc 386/422; PRT Axis: 74, -22, 84;

6th ECG XXXXXXX 2012 ER because of chest pain; Sinus Rhythm with PVC and Fusion Complexes, Low Voltage QRS, T Wave abnormality, consider Anterior Ischemia; Vent rate: 64; PR Interval: 140; QRS duration: 76; QT/Qtc 404/417; PRT Axis: 65, 53, 40;

You are right - this last one does not say LBBB. At the Cardio, his assistant told me he thought the ER reversed two of the ECG leads and that this ECG was a mistake. The actual Cardio looked at my paper copy and said he could explain it. He said what could be interpreted by the machine as a past MI was actually a result of the LBBB so he was not concerned.

As for the near syncope episodes - there were 3 in Jan/Feb and Cardio thought it was an issue of my bp randomly dropping. It always happened in the car while sitting - either driving or as a passenger and once it started in the car but continued while sitting in a meeting. I did see ElectroPhy and had 30 day event monitor in Feb - HR went to 40 while sleeping but was told it was neither too high or too low. Do have multiple PVC runs but no real concern. In March, tilt table test was positive so near fainting was diagnosed as neurocardiogenic or vasovagal syncope. In April bp went to 200/100 on two occasions - and I nearly fainted as a passenger in car Was told this was stress related. Never had bp issues before this year. In April was prescribed the low dose of bp med to help even out the highs and lows. No more near fainting since then.

Have not had a cardiac catherization but the 3D test showed clean arteries. Electro guy doesn't think there are any XXXXXXX arrhythmias. No stress test has been done. I do have greatly reduced exercise tolerance but my recent chest pain does not seem worse when running up house teps or vaccuuming. When doing the heart monitor, my rate did go up when carrying food bags, etc. but not over 100 I don't think. I do get tired very easily the past 2 weeks. I am wondering if I may have developed a thyroid issue due to throat/neck pain - not sharp more of an ache - not like reflux I had that before losing weight but no issues now. Could a thyroid issue be responsible for low QRS voltage 2 weeks ago? My neck pain is pretty constant but it does get worse after I have been active. It is somewhat better after sleeping. The chest pain is middle of chest, near bottom of breastbone. One ER doc thought possibly liver related. I am going to look into whether it is digestive related but I need to feel confident that the cardiac workup is sufficient and stable.

I appreciate your time to consider this long request. I want to be informed when following up with Cardio or seeking a second opinion. I understand you can only go on the info provided here. Having always been healthy with two healthy parents the LBBB is concerning to me. A relative does have a pacemaker due to sick sinus node. My bp seems better controlled in the past two months so there have been no near fainting spells but the intense neck pain and heavy fatigue is new and possibly not heart related.
Answered by Dr. Sukhvinder Singh 24 minutes later
Respected Ma'm
1. There is no substitute of actually looking at ECGs because the reports generated by computers is only based on the algorithms we feed. They can not think beyond those algorithms. So the disappearance of LBBB is controversial and I would like to see the ECG, even if you upload it after a day or two.
2. A low voltage ECG can occur in hypothyroidism, but I would like to reconfirm it by looking at the ECG. Why should it be so that only one ECG showed low voltage and others did not?
3. Good to know that your 30 day event monitor did not show any "heart block" and your PR interval is also normal. This was the main "electrical" concern. In view of overall information, LBBB seems to be only a cosmetic change in your ECG.
4. Since your angiogram (CT scan based) shows normal coronary arteries and your symptoms are not increased or precipitated by exertion/ exercise and your neck pain is a constant one, Current symptoms are unlikely to be angina related.
5. Regarding second opinion- I would like to see your ECGs before a final comment on this.
However, the possible logical sequence would be to see your XXXXXXX medicine specialist; if clinically indicated, get your liver/ thyroid/ stomach/ other investigations done. Even if by that time, we do not reach a logical conclusion, seek a cardiologist opinion and also get a stress test done after discussing with him. In the meantime, if you have a new symptoms or you feel symptoms are too bothersome or your internist also opines in favor of seeking a second opinion, please see your cardiologist on priority.
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